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ConcertoHealth® Achieves Double-Digit Improvements in Hospital Admissions and Readmissions for Washington’s Highest Risk Patient Population 

SEATTLEOct. 15, 2018 – ConcertoHealththe leading full-risk provider of specialized primary care and supporting clinical services for vulnerable, frail and elderly patients, announced today that it has achieved a 29 percent reduction in hospital admissions and 12 percent drop in readmissions in the state of Washington. The health services organization has also reduced overall emergency department (ED) readmission rates by 6 percent, year-over-year, for Washington’s most fragile patient population.  

ConcertoHealth provides field-based care teams and “wraparound” support services to Washington state Medicare Advantage health plans. Rather than replace or compete with the health plans’ primary care providers (PCPs), ConcertoHealth supports their performance with an array of clinical resources, including social workers, care managers, pharmacists, clinicians, and nurses, to care for patients when they are most in need, in any care setting. 

Knowing that patients with complex medical needs can easily slip through the health care system is exactly why we developed our Primary Care Support Platform,” said ConcertoHealth Chief Care Transformation Officer Christopher Dodd, M.D., M.S“Our care model enables ConcertoHealth to stand shoulder-to-shoulder with primary care providers as partners in caring for Washington’s most complex patients, many of whom are dual eligible for Medicare and Medicaid.”  

In addition to improved health outcomes for patients, the ConcertoHealth Primary Care Support Platform has also achieved 19 percent savings in medical costs nationally for its health plan partners.  

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

More than 52 percent of patients under ConcertoHealth care are diagnosed with three or more chronic medical conditions. The company reports the following disease prevalence rates among patients in Washington: 

  • 83 percent have a behavioral health diagnosis, 
  • 71 percent are diagnosed with cardiovascular disease, 
  • 51 percent have been diagnosed with congestive heart failure (CHF), and 
  • 41 percent are diabetic.

As patients’ health care needs become more complex, ConcertoHealth relies on field-based interdisciplinary care teams to help health plans’ PCPs manage their patients’ myriad needs, identifying avoidable hospital admissions and readmissions. To facilitate effective collaboration with PCPs, ConcertoHealth utilizes a proprietary population health analytics platform, Patient3D, which provides PCPs with a 360-degree view of each patient’s status and care needs.  

ConcertoHealth deploys an ED intervention program, in which its medical directors closely monitor potentially avoidable hospital admissions. For each potential hospital admission intervention, ConcertoHealth medical directors partner with ED clinicians to determine the most appropriate care plan and setting. The program has proven effective in reducing the percentage of would-be hospital admissionsby diverting patients to more appropriate care settings such as a skilled nursing facility  

One example is a 48-year-old patient from Kent, Washington, who visited the ED more than 91 times in 2016. At the time of ConcertoHealth’s first encounter with him, the patient’s primary medical issue was a set of nonhealing wounds from a 2015 surgery. In addition, he has an extensive history of issues with pain medication. The patient has developmental disabilities, anemia and lives with his father, who was struggling with his own health issues. Since the patient engaged with ConcertoHealth in April 2017, the field-based care team established:  

  • regular home-based wound care and biweekly visits with key members of the care team, including a PCP, pharmacist, and a registered primary care nurse, 
  • pain-management plan, including a medication adherence agreement, 
  • communication and collaboration with the patient’s family caregivers, 
  • case coordination with Department of Social and Health Services caseworkers to ensure patient care and safety, and 
  • behavioral health services treatment plan to initiate a substance abuse assessment, as well as counseling for opioid dependency.
     

Since engaging with the ConcertoHealth care team, the patient’s health has improved, with decreased ED utilization in 2017 and no ED visits or inpatient admissions in 2018.

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.

www.concertohealth.com

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