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ConcertoHealth® Achieves Double-Digit Improvements in Decreased Admissions and Readmissions, and Increased Primary Care Visits for Michigan’s Most Vulnerable Patient Population

DETROITMich.Sept. 24, 2018 – ConcertoHealththe leading full-risk provider of specialized primary care and supporting clinical services for vulnerable, frail and elderly patients, announced today that 84 percent of the patients it manages in Michigan have seen a primary care physician (PCP) in the last year, well above the national average of 51 percentThe company also has achieved an 11 percent and 21 percent drop in emergency department (ED)ii and hospital use, respectively, and reduced its overall readmissions rates by 35 percent, year-over-year, for Michigan’s most fragile patient population.  

ConcertoHealth provides field-based care teams and “wraparound” support services to Michigan Complete Health and Meridian health plansRather than replace or compete with the health plans’ PCPs, ConcertoHealth supports their performance with an array of clinical resourcesincluding social workers, care managers, pharmacists, clinicians, and nurses, to care for patients when they are most in need, in any care setting.  

“We developed our Primary Care Support Platform with a deep understanding of the challenges involved with managing vulnerable patient populations,” said Richard L. Brown, M.D., MPH, ConcertoHealth regional medical director. “Results show we are on the right path to providing comprehensive care with improved health outcomes for these patients. 

In addition to improved health outcomes for patients, the Primary Care Support Platform has also helped ConcertoHealth achieve a 19 percent improvement in medical costs for its health plan partners.iv 

Improving the Health of Michigan’s Most Vulnerable Residents One Patient at a Time  

To facilitate effective collaboration with health plan PCPs, ConcertoHealth utilizes a proprietary population health analytics platformPatient3Dwhich provides PCPs with a 360-degree view of each patient’s status and care needs. As a result of this increased visibility, two in three ConcertoHealth patients discharged from a care facility receive PCP follow-up, half of them within seven days of discharge.  

More than 52 percent of ConcertoHealth patients have three or more chronic medical conditionsAs patients’ health care needs become more complex, ConcertoHealth relies on field-based interdisciplinary care teams to manage patients’ myriad needs, identifying avoidable hospital admissions and readmissions. 

ConcertoHealth deploys an ED intervention program, in which its medical directors closely monitor potentially avoidable hospital admissionsFor each would-be hospital admission intervention, medical directors partner with ED clinicians to determine the most appropriate care plan and setting. The program has proven effective in increasing the percentage of would-be hospital admissions diverted to other settings. Since its early health plan partnerships, ConcertoHealth reports: 

  • Potential hospital admissions that were diverted to Skilled Nursing Facilities increased from 19 to 24 percent and, 
  • potential hospital admissions that were changed to Observational Stays increased from 37 to 45 percent. 

One recent example is a patient who visited the ED five times in 90 daysShe has an extensive history of uncontrolled hypertension and is on hemodialysis for endstage renal disease. After her most recent discharge, the case manager-led care team ensured regular home visits from an on-staff home-visiting PCP and included pharmacist to reconcile her medications. The care team secured additional supports, including referrals to a nephrologist and a psychiatrist, and implemented telehealth solution to prevent further would-be hospitalizations. ConcertoHealth was successful in minimizing her admissions and readmissions over a period of six to eight months, and the patient’s health has significantly improved. 

“This patient’s experience demonstrates our ability to deliver the personalized care necessary for patients with multiple conditions, and impact both hospital admissions and readmissions,” Brown said. “Here at ConcertoHealth, our goal is to continue to develop innovative solutions that result in better healthcare outcomes.”  

Full Article (external)

About ConcertoHealth

ConcertoHealth Inc. is the leading provider of specialized primary care and supporting clinical services for vulnerable, frail and elderly patients. ConcertoHealth provides high-touch, individualized care for patients and also deploys “wraparound” clinical resources to extend the reach of primary care providers, operating exclusively in value-based agreements. The ConcertoHealth care model, elevated by Patient3D, improves overall health quality and outcomes for high-need patient populations. The ConcertoHealth care model is proven to reduce admissions by 30.3 percent and readmissions by 17.1 percent, benefitting patients, payers and their provider networks alike. The company is headquartered in Aliso Viejo, California.

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