Provider Overview
Advanced Health Network and Recovery Health Solutions, operating in affiliation.
AHN/RHS is an independent practice association (IPA) and behavioral health network that comprises 46 New York State licensed agencies that provide comprehensive community-based services to individuals and families throughout New York City and Nassau and Suffolk counties. The providers in the AHN/RHS network share a goal of improving the health and wellness of individuals experiencing behavioral health disorders, which are often further complicated by medical and social determinants of health issues. AHN/RHS is dedicated to improving immediate access to quality care and empowering individuals to better manage their health and healthcare needs. AHN/RHS supports a person-centered, integrated healthcare model that focuses on early detection, prevention, and treatment with the goal of avoiding unnecessary emergency department visits and hospital admissions, by connecting patients to integrated routine care.
Challenges that needed to be solved
Individuals are utilizing the emergency department (ED) to address primary care and behavioral health needs that could better be addressed in the community. In New York State in 2019, almost half (48%) of ED visits were for non-emergent and primary care needs or were otherwise avoidable. At the same time, hospital resources are strained, in part due to treating individuals whose needs could be better met in the community. This problem presents an opportunity for community behavioral healthcare providers to better coordinate care and improve individual health. Actionable, measurable data can be used to enable this effort.
Barriers
Behavioral health providers lack access to data tools providing actionable, measurable information essential to meet the needs of their patient populations. The resulting information gap imposes an administrative burden on staff, who must track data manually and rely on self-reported information from patients. Even if such data tools were accessible, behavioral health providers do not have dedicated project management staff to improve clinical and operational workflows and workforce development. Due to the lack of complete, timely, and actionable data, providers may be unaware that a patient is repeatedly visiting the emergency department, and such patterns of behavior may go unidentified and unresolved.
Solutions
In partnership with the Bronx Regional Health Information Organization (Bronx RHIO) and individual behavioral health network providers, AHN/RHS developed a suite of data analytical tools that identify patterns, trends, and insights to inform care delivery interventions and support providers and patients. These tools are intended to improve patients’ engagement in medical, mental health, and substance use disorder treatment and address social factors that may impact patients’ health. They can also be used to inform quality improvement initiatives to develop workflows that support equitable, high-quality, patient-centered care.
To support AHN/RHS network providers in implementing the suite of data analytical tools, AHN/RHS partnered with Primary Care Development Corporation (PCDC) to offer coaching. The coaches engaged providers in establishing workflows for utilizing ED Alerts and ED Patient Registry tools. Workflows for utilizing the ED Follow-up Report are forthcoming as funding becomes available.
Results
The goals for developing and testing the data analytical tools were to:
Engage patients in their behavioral health treatment, including referrals and linkages for primary care and social care services.
Prevent and reduce avoidable ED utilization by coordinating care to improve quality of life.
Utilize data to demonstrate the impact of engaging individuals in comprehensive care treatment plans, including improvement in the overall cost of healthcare.
Demonstrate the value of transitioning from a fee-for-service payment model to a value-based care model that supports adequate reimbursement for comprehensive behavioral health services.
One provider in the AHN/RHS network reported that use of the ED Alert tool led to a 62% increase in overall outreach to patients, other than for scheduled appointments, from May to September 2023. Follow-up visits within seven days of an ED visit increased by 16% during the same period, and 67% of patients who received outreach remained active in treatment one month after their ED visit. Staff reported discussing a patient’s ED visit in follow-up appointments in 79% more cases than at baseline.
Another AHN/RHS network provider reported that their patients’ 30-day ED readmissions decreased from 66% in January 2021, to 42% in September 2023 following the implementation of the data analytical tools. Patients receiving a follow-up call within 24 hours of an ED visit increased from 0% in January 2021, to 90% in September 2023. The remaining 10% of patients received a follow-up call within 48 hours of an ED visit. Patients expressed gratitude for the follow-up calls they received after an ED visit.
Future Plans
AHN/RHS and its network providers will continue their work with the ED and Inpatient (ED/IP) Alerts, and with developing patient registries. With continued investment, they will look to enhance and optimize data capture, quality management, and data monitoring along with performance reporting supported by workflow redesign. This will involve:
Collaboration with the SHIN-NY and Qualified Entities to capture accurate medical diagnosis data from hospitals, primary care data in support of integrated care, and emerging social determinants of health data via the approved Social Care Networks (SCNs).
Collaboration with PCDC to support AHN/RHS providers with ongoing investments in workflow redesign, optimizing the implementation and use of ED/IP alerts and patient registries with focused community- and evidence-based best practices.
Continual investment in performance reporting for providers, NYS, health plans, and funders.
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