case study
Complex Care Optimized: A Closer Look at How Innovation Care Partners’ Complex Care Team Leverages HELIOS to Enable Effective Value-Based, Collaborative Care Across the Continuum
Background
In October 2022, Innovation Care Partners (ICP), a physician-led clinical integration network and accountable care organization (ACO) serving more than 220,000 members in Phoenix, Arizona, launched a new program within their longitudinal care model to better support members with complex care needs.
Seeing a need to offer more comprehensive and frequent support for some members, ICP formed a new Complex Care Team with licensed registered nurse (RN) and licensed clinical social worker (LMSW) that could be tapped into by any part of the ICP team that needed follow-up or intervention on a patient. To empower other teams and contacts within ICP’s care ecosystem to leverage the Complex Care Team, ICP looked to HELIOS to provide a centralized resource and referral pathway.
ICP leveraged the configurability of HELIOS to develop a customized referral form that could be processed through workflows in HELIOS to generate a daily report of patients in need and enable other care coordination ICP teams to easily connect with the Complex Care Team for critical interventions or redirections. As a result, the Complex Care Team can jump in and provide additional support, resources, education, guidance, and interventions as needed to help get these patients back on track, healthier, stronger, and more self-sufficient.
Using HELIOS as a centralized referral and care coordination resource, ICP has been better able to identify and serve complex-care patients. As a result, ICP has been able to reduce readmissions, improve health outcomes, improve overall health and quality of life, and close critical gaps in health-related social needs for these individuals.
Confidently Identifying & Serving Patients in Need
The Complex Care Team can be brought in at any stage along a patient’s journey, from primary care to acute and post-acute settings. This helps ICP better support high-risk and complex patients, and keep or get the patient back to a more independent level of care. At this point, the Complex Care Team can step back and let the care coordinator manage the patient’s needs again.
To enable this, the ICP team first needed the ability to accurately identify which patients needed their attention. This included having a centralized path which other ICP teams and contacts to refer a patient to the Complex Care Team, and an accurate picture of what cases required the Complex Care Team to step in on. Leveraging HELIOS as a single source of truth, ICP was able to create a streamlined referral process that worked across their care model, accurately identify patients in need, and leverage unified, comprehensive patient views where information and updates could be shared and viewed in real-time by ICP teams for accurate care coordination and support.
“We were getting emails, phone calls, texts, all with patient information and needs, but no tracking method attached,” said Roberta Kafora, Director of Care Coordination at Innovation Care Partners. “Bonnie would get all this information coming to her in a variety of ways, and we were worried about patients getting lost, so we needed to create a single pathway for this. Within HELIOS, we created the Complex Referral Form, so all this information can be captured and a report is generated daily to let us know which patients need attention. This report comes in every morning with the patient referrals submitted the day before that we need to address, and we’re able to use the platform to review a patient’s recent care activities and histories to determine what is needed, where to meet the patient, and how to help them succeed with improving their health.”
Patients can be referred to the Complex Care Team from another ICP team, or they may come from a doctor or other healthcare provider, from an insurance phone call, or even outside home healthcare organizations. ICP also has an out-of- network transitional care manager who tries to locate ICP patients who end up at unaffiliated health hospitals and redirect them back into the network via the Complex Care Team.
The Complex Referral Form gives ICP’s Complex Care Team a starting point to look at why a patient is being referred and to prioritize those who are most at risk. Following a review of the form and patient’s profile in HELIOS, the Complex Care Team can determine what interventions or supports are needed to get them back on track.
“When I start working with patients, I go into HELIOS first thing,” said said Complex Care Manager, Bonnie Boyle, RN. “Everyone has their own assessments and tools for different settings. acute, post-acute, etc. – so we really rely on reviewing those assessment results, documentation, care setting notes, and more in the member’s profile in HELIOS to see what’s going on. For example, when I follow a patient, I look first for what our Acute Care Managers are saying, and if the patient has gone to post-acute, then I follow up with what the post-acute team is saying and then review what the care coordinators are documenting, so I can easily gather from each angle what’s going on and where I need to step in next. Then we’ll execute the next steps, which is often a super visit with a patient. These visits can take place anywhere, anytime, and the goal is to get a better picture of what gaps or obstacles are keeping this patient from getting healthy or are causing their condition to worsen or to be readmitted to a hospital.”
Sometimes, Boyle notes super visits involve going to the PCP office and meeting with the patient’s care coordinator and the physician. Other times visits take place in a post-acute facility, a skilled nursing facility, a recovery house, a halfway house, or even a specific street by a restaurant. The goal she notes is to begin the process and then step in wherever a need is identified. The team may provide additional education or a piece of equipment (wheelchair, mattress, etc.), help communicate and coordinate with the patient’s doctor for home health orders, guide the care coordination team, or help identify and address health-related issues and other care gaps that are inhibiting the patient’s progress.
“Wherever the patient is that needs me, I go, and whatever they need we are going to work on getting it for them,” Boyle says. “We’re going to consistently follow up until they’re on the path they need to be. If a patient needs a food box, we have the care coordinator go out and get it. For our homeless populations, communication and tracking where they are is a big barrier, so sometimes it’s about tracking this patient down, equipping them with a cell phone, and working with them on how to stay in touch so we can properly support them. Other patients I have helped can’t take care of themselves because they’re caring for a spouse, or they’re lacking a bed, or need help getting into a bath, or caring for basic needs. A lot of times, it can seem like a little thing or a small fix, but it makes a huge impact.”
And the program is always on. The Complex Care Team handles the patients who are most at risk and more likely to be readmitted to the hospital or suffer an adverse health incident. ICP has care coordinators who work in tandem with the Complex Care Team, and who work on weekends to reach out to and provide an additional touch for high-risk patients when clinics and providers are closed. For example, for complex patients recently discharged from hospitals, the team will be in contact and maybe provide additional resources or alternatives if a patient thinks they may need to go to the hospital or ER and first try to work with them to deliver health support and care to their home.
ICP also partners with Dispatch Health for complex care patients to address acute needs that need immediate attention, utilizing HELIOS to provide real-time information and updates to help update dispatch health and the care coordinators on the patient’s health status and to address the patient’s needs properly.
“What we want to avoid are those readmissions, so the quicker we can wrap our hands around the patients and have that face-to- face, the better,” Kafora said. “And our team picks up on the weekend, which is especially important for urgent and critical cases.”
The Value is in the Transformation
With HELIOS, the Complex Care Team is more easily able to keep track of complex care patients, and review where patients are, what’s been done, and, if the team can graduate them back to care coordinators in the clinic or if they need to follow and support them more. Sometimes interventions can take weeks, months, or longer.
“Every patient is different, but nothing happens overnight,” Boyle notes. “We always go in with the same goal; we’re here to help make your life work, and execute a plan to accomplish that, and then go from there. We want to let them know our faces, and that we mean it when we say we are here for them along the way. And the reward is seeing these patients trust us to do this, and then the transformations to their lives and health as a result….that’s everything.
My favorite example of this is a female patient who called us for help because she was immobile and unable to support herself at home. She had recently had X-rays, and we knew nothing was broken, but she’d reached out asking if we could get her into another care setting because her husband has dementia, so she couldn’t leave to get food from the store or see the specialist she needed. So, our team worked to get her into rehab so she could be successful when coming back home, got her equipment, transportation to appointments, and home health set up for her husband, and now she’s back with her husband, at home, healthy and succeeding.”
With an interconnected team and singular resource in HELIOS, ICP has been able to keep more high-risk and complex-care patients on track and be faster to identify when an intervention is needed and to execute it. The results ICP has seen include reduced readmissions, improved health outcomes, and improved health and quality of life for patients.
Enabling a More Empowered Population
For ICP, the Complex Care Team is still evolving. Kafora notes that as ICP continues to expand its staff, this team will grow to be able to provide more support and touches that can help ICP continue to empower its population to be more independently self- sufficient about their health.
“Our goal is to give them the tools and resources to empower themselves to return to a healthy state so they can manage their own care,” Kafora explains of the Complex Care Team’s role within ICP’s model. “But a lot of them don’t have the tools or the resources that they need that little bit of extra support to get them over the hump to get them to that point where they need to be. Bonnie and the rest of our team are working daily to review the reports in HELIOS, look at the patients’ histories and health needs, and get out there in front of our patients to understand how we can help. And our team continually meets to ask how we can provide a variety of interventions to work with these patients, to keep them safe and healthy, to resolve issues at home that are keeping them from improving their health.”
