3-minute case study: A ‘one-stop shop’ seamlessly connects the dots for treating the chronically ill

By Carley Thornell | September 9, 2021


Across the athenahealth network and beyond, healthcare organizations are designing and implementing simple interventions with outsized impact on outcomes, satisfaction, and success. Here's another.

The challenge

It’s no secret that controlling costs and spending is one of healthcare’s greatest hurdles. One of the biggest contributing factors for most geographies is chronically ill patients — Maryland being no exception.

The innovative Maryland Primary Care Program (MDPCP) allows primary care providers to play an increased role in the prevention and management of chronic disease while preventing unnecessary hospital utilization. MDPCP provides funding and support for the delivery of advanced primary care throughout the state.

However, while physicians often focus on improving conditions, they rarely have time to combat contributing factors to those conditions such as nutrition, exercise and social support systems.

The solution

Privia Health’s Siobhan Kirksey, MSN, RN, is the Senior Manager of Clinical Programs for MDPCP. Her diverse care management team of 26 coordinators has a “boots on the ground” approach to working with patients. Those professionals including social workers, pharmacists, nutritionists, mental health providers and more pride themselves on a high-touch, communicative style. That communication is not just regulated to patient care, however. Giving physicians all the information that they need in real-time from various sources, when they need it — or in advance — offers up impressive results.

Supporting it all is Privia’s proprietary care management app, which is built on athenahealth’s adaptable cloud-based platform. That platform supports interoperability between the app, Privia’s EHR athenaOne, and the state’s health information exchange CRISP (the Chesapeake Information System for Our Patients).

The app’s built-in tool allows care managers to easily build out care plans, which are linked with problem sets and interventions. There are free-text fields for managers to leave additional notes for providers or others on their team, and they can also ping doctors to ask questions.

“Providers have direct access to everything we document and do because we share our documentation platform, which translates directly into athena,” explained Kirksey. “We only push pertinent communication to the providers that we need them to weigh in and have impact on.” If a patient is adhering to their care plans, providers can review that information on their own accord without prompts; they are only notified of non-adherence when that could affect patient outcomes. The quality tab within the EHR identifies open care gaps, and physicians have even more visibility into closures because quality measures are closed directly in the EHR.

MDPCP can also close out more measures thanks to CRISP, says Kirksey. Unlike many other states, “in good, old, little Maryland, CRISP will pull everything from most of our laboratories. So for us, it's just one place to look,” she explained. “Usually, if I see that you have an open gap for a mammogram and I see that the doctor ordered one, because I can see the order in the chart, then I just look you up in CRISP and pull out what’s available there.” The lab work is then easily uploaded into the EHR to close out the measure.

The outcomes

Kirksey calls the user-friendly technology a “one-stop shop” that helps enhance speed, transparency, and ease for those who deliver care. “Everything is where you can see it,” she said. “Because all of our documentation is housed in communicating systems, you get almost everything back right away when we're working together with the patients. Your pharmacist did an evaluation, but you don’t have to wait for the front desk staff to send it over, things like that. We're already embedded in your EHR so you're getting everything back right away when we're completed with it. There's usually not much of a lag.”

The efficiencies give Kirksey’s team more time to spend on their direct-outreach strategies to patients, like phone calls. Those are traditionally more effective for MDPCP versus automated outreach, she said. The result is also a proactive approach to Medicare's Transitional Care Management (TCM) services that tees up TCM templates for care coordinators; the answers they garner from patients benefit providers, who can then bill Medicare. The impact on primary care practices is multifaceted, as they benefit from increased shared savings with less administrative work.

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