Tuesday, 27 September 2016 06:03

Notification Service for Care Coordination in Value-Based Payment Models

Written by Larry Wolf, Strategic Health Network

A timely list of where a patient has been for care is valuable in many contexts. In value-based payment models, it is essential. This article outlines a notification service that can provide that list, and more broadly, supports care coordination.

We are in a new era of value-based payment. For a wide range of reasons, from improving care outcomes to reducing costs, there are many new payment programs in various stages of trial and implementation. There are also both public and private sector initiatives being organized.

As an example, in early August 2016, the Centers for Medicare & Medicaid Services (CMS) issued a notice of proposed rule (NPRM) for “Advancing Care Coordination Through Episode Payment Models (EPM): Cardiac Rehabilitation Incentive Payment Model and Changes to the Comprehensive Care for Joint Replacement Model” (to read the proposed rule in its entirety, click here.)

The various bundled payment programs are focused on episodes of care that begin with acute-care hospital admissions. The anchor hospitalization places a patient in a bundle based on discharge diagnosis. However, that diagnosis is not finalized until the claim for the hospitalization is submitted, often days or weeks after the discharge. Effectively managing the patient with respect to the bundle requires the hospital to make assumptions during the admission and communicate those assumptions to the subsequent care provider upon discharge. Furthermore, keeping the downstream providers updated after discharge is important, because those providers need to know that their patient qualifies for the bundled payment program. A notification service could be an essential component of this process.

There are other complications for the beneficiary care inclusion criteria, based on patient or physician participation in other value-based payment initiatives. The exclusions in the new EPM program include: (Federal Register, Vol. 81, No. 148, Page 50834)

  • Not aligned to an ACO in the Next Generation ACO model or an ACO in a track of the Comprehensive ESRD Care Initiative, incorporating downside risk for financial losses.
  • Not under the care of an attending or operating physician, as designated on the inpatient hospital claim, who is a member of a physician group practice that initiates BPCI Model 2 episodes for the EPM participant for the MS–DRG that would be the anchor MS–DRG under the EPM.
  • Not already in any BPCI model episode.
  • Not already in an AMI, SHFFT, CABG, or CJR model episode with an episode definition.

Managing the exclusions will require information about the providers the patient is seeing and the payment models they are already participating in.

Information Architecture Entities

The standard architecture for care and payment is built on three primary entities:

  • Patient
  • Provider
  • Payor
  • Coordinator

While there is variability in the program design, there is a clear need for a care coordination role.

The care coordinator, who may be an individual or an organization, is charged with managing care across the many silos of providers and payors. Multiple care coordinators may be associated with multiple providers involved in care delivery and payment.

The care coordinator may be part of provider or payor organizations. Family, friends, health coaches, and others may act as care coordinators for patients. The care coordinator may be a freestanding entity, offering services to other entities. Knowing where the patient is at any point in time is essential for this person.

Besides knowing where the patient is, it is also important to know what programs, clinical or financial, that the patient is associated with. 

There are many payment models with their own rules for inclusion. Patients may be in a program because they are a member of a managed care plan. They may be assigned to an ACO because of the physician they saw the most in the past year. They may be in a bundled payment program because of their acute-care hospital discharge diagnosis. In order for providers to know how they will be paid for their services, they need current information on each relevant payment model. In this architecture, that is the patient’s program.

Each of these entities must keep track of what the others are doing and their constantly changing relationships with patients.

Notification Service

The notification service addresses the need to share information. By receiving updates from all relevant entities (providers, payors, care coordinators, and the patient), it can track the relationships between patients and programs as well as patients and the various other entities. Based on the established relationships, it can then notify the relevant entities of any updates that apply to them. By tracking these relationships, it can also enforce privacy rules that only allow for the informing of entities with a relationship to the patient.

The notification service must be able to manage the identities of the entities and match them across the updates it receives and the information it already has. While this is not necessarily easy, there are best practices to improve the accuracy of any matching strategy. In addition, for purposes of notification services, often the payor-associated identifiers, along with paying attention to accurately collecting names and other demographic information, can greatly improve the ability to match entities. (See the Sequoia Project white paper for a compelling example of the value of data quality for matching patients across organizations). Also read about the CHIME National Patient ID Challenge). 

Existing Notification Services

Notification services currently exist in several forms. This service is offered by several regional health information exchanges (for example, the Indiana Health Information Exchange (IHIE), and the Colorado Regional Health Information Organization (CORHIO). The service is additionally available from dedicated notification providers (for example, Patient Ping). It is also available from payment clearinghouses (for example, MemberMatch from Experian Health).

There are many ways the updates and notifications can be transmitted, ranging from real-time HL7 Admit/Discharge messages to periodic file transfers to web portals with manual forms.

There must be very high levels of participation in the notification service for it to be of value to the participating entities. At the present time, these services depend on local markets for which a single service can have high adoption across providers.

Given the evolving nature of notification services and the specific local problems they are solving, it will be a while before the key attributes of a successful implementation emerge.

Combined Architecture



In summary, a notification service can facilitate care coordination and communication across entities. It can also be the trusted agent to manage the privacy controls for sharing information.

Notification services are an important component for value-based payment models.

About the Author

Larry Wolf is Principal at Strategic Health Network, a health policy advisory service. Larry has forty years of experience in health IT with an emphasis on clinical systems across a wide spectrum of care settings. Larry has a strong foundation in the development of clinical systems and a track record of strategic use of data. He is exceptionally able to work across traditional boundaries, bridging the technical, clinical and business worlds; ambulatory care, acute care, postacute care and longterm support services. He builds consensus and shared vision, even among the conflicting positions of members of Federal workgroups.  Larry is a national leader using health IT to improve care coordination. He is a member of the Federal Health IT Standards Committee and chair of the HIMSS Public Policy Committee. He is an organizer of the annual LongTerm/PostAcute Care Health IT Summit and an author of the biannual LTPAC HIT Roadmap. He provides advisory services on strategic direction and information systems architecture.

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Last modified on Wednesday, 28 September 2016 03:39