Advanced Health Network/Recovery Health Solutions Independent Practice Association

“To transition to using data for better care, providers need new infrastructure and training to incorporate data review as a part of daily patient care,” said Isaac Kastenbaum, Managing Director of PCDC’s Clinical and Quality Partners. “PCDC has a deep understanding of safety net providers’ work and challenges, and a strong track record in supporting organizations to change the way they work with data to improve patient outcomes.”

When data are used to improve care, providers are more effective and can measurably improve health outcomes. But, in a busy practice environment focused on patient care, making these changes without support can be a struggle.

In 2021, PCDC worked closely with 20 behavioral health organizations who are part of the Advanced Health Network/Recovery Health Solutions Independent Practice Association to better utilize health information exchange data to drive improvement. PCDC’s coaching team used a rapid-cycle quality improvement model to help providers to address critical challenges, breaking down each step into feasible actions and manageable time frames, resulting in more clients with a primary care provider and a reduction in readmissions and emergency department visits.

In one collaboration, PCDC worked with VIP Community Services (VIP), a Bronx-based center providing comprehensive services in medical and behavioral health, housing and wraparound services. PCDC helped VIP explore what was driving their clients to the Emergency Department (ED) and consider options for intervention. When clients use the ED unnecessarily, it is disruptive to their lives, does not support their health goals, and is costly to the system. With PCDC’s support, VIP:

• Reevaluated their client scheduling to offer more appointments and shorten the timeframe for getting in to see a therapist. Clients with pressing needs were able to see their therapist sooner.
• Developed interventions to: improve access to integrated health care services; reduce ED visits; and increase connections to social determinants of health resources (e.g., services to address housing, education, employment, legal needs).
• Created a decision tree for clients to use to decide whether to go to the ED. Staff focused on supporting clients in addressing medical and social barriers before they reached crisis levels. Making decisions based on their data, VIP was able to change their approach with these clients and reduce preventable ED use and admissions.

By the end of the project, VIP reduced preventable visits to the ED for seven clients. Seven clients went from 12 ED visits before the intervention to only one ED visit that was deemed necessary after the intervention.

PCDC’s individualized coaching enabled AHN/RHS to establish quality improvement approaches leading to improved care among 40% of its members that had not been possible through usual activities (i.e., newsletters, provider communications). AHN/RHS data show that, during the project period, 80% of participating practices experienced measurable improvements in primary care provider engagement, and two-to-three-point reductions in readmissions and ED visits. Ultimately, incorporating continuous quality improvement structures will enable these providers to adopt approaches that enable their success in alternative payment models that more fully cover the cost of providing care.