Allegheny Health Network team enhances transitional care management

Transitional care management is a set of services – conducted after a patient transitions to the community following discharge from the acute or post-acute setting – aiming to improve patient transitions back into the community, reduce avoidable emergency department visits and hospital readmissions, and minimize gaps in care.


Transitional care-management components include interactive contact and certain face-to-face and non-face-to-face services. Interactive contact is one transitional-care-management component in which the discharging provider must contact the patient or caregiver via phone, via email or in person within 48 hours post-discharge in order to set up a face-to-face follow-up visit and bill for transitional-care-management services.

Patients discharged from acute care hospitals, inpatient rehab hospitals, long-term acute care hospitals, and skilled levels of care qualify for an interactive contact within 48 hours post-discharge. If contact with the patient is not made within this required time frame, the provider cannot bill for transitional-care-management services – and the first provider to make contact is the only one that can bill for the services.

Allegheny Health Network, a Highmark Health Company, sought to optimize its transitional care management services to reduce avoidable emergency department visits and hospital readmissions, and to close gaps in care. Specifically, its transitional-care-management program goals included increasing transitional-care-management encounters post-discharge, increasing seven-day follow-up visits post-discharge, improved medication reconciliation post-discharge and an optimized transitional-care-management revenue stream.

“The platform provides us with the contextual information we need, in real time, to better monitor patient transitions across the continuum of care.”

Dr. Bill Johnjulio, Allegheny Health Network Primary Care Institute

Allegheny Health Network handles more than 80,000 discharges and observations per year, but lacked comprehensive, interoperable data to efficiently identify all transitions of care – particularly discharges from non-Allegheny Health Network acute and post-acute providers. Allegheny Health Network faced challenges in identifying and contacting patients that qualify for transitional-care-management services, including post-discharge interactive contact (phone calls) and subsequent face-to-face visits.


As part of Allegheny Health Network/Physician Partners of Western Pennsylvania’s Practice Transformation initiative, the Allegheny Health Network team, led by Dr. Bill Johnjulio, medical director of Physician Partners of Western Pennsylvania and chairman of the Allegheny Health Network Primary Care Institute, sought to increase transitional-care-management encounters post-discharge from an acute inpatient hospitalization or from a post-acute facility within 24 to 48 hours.

“To improve the timeliness with which practices are notified of a transition of care, in order to commence the transitional care management process – and to ultimately improve outcomes, reduce inefficiencies and optimize revenue – Allegheny Health Network needed a solution to better identify patient transitions of care in real time,” Johnjulio explained. “Allegheny Health Network turned to CarePort Health’s care coordination software solution, CarePort Connect, which provides real-time visibility into patient transitions across the continuum of care.”

CarePort’s platform bridges acute and post-acute EHRs, allowing all providers – including hospitals and health systems, payers and ACOs – to better track and manage patients across the continuum and provide coordinated care, he added. The platform provides a more comprehensive and automated mechanism to identify transitions of care, he said.


The platform flags patients at the time of discharge from acute and post-acute care who fall within Allegheny Health Network’s Clinically Integrated Network and notifies providers in real time of these discharges. Using the platform, Allegheny Health Network can quickly identify patients who require transitional-care-management services within 48 hours of discharge and schedule follow-up office visits seven to 14 days post-discharge, Johnjulio said.

The platform’s real-time, actionable information enables a more holistic view of patient transitions of care, so helping avoid unnecessary utilization of health services, improve overall patient care coordination and reduce the likelihood that patients will return to the hospital, he added. Additionally, the software fits into current workflows, making it easy to use and adopt across different locations, he said.

“The platform takes away all of the manual detective work in transitional-care-management,” Johnjulio said. “The platform provides us with the contextual information we need, in real time, to better monitor patient transitions across the continuum of care.”

To date, the CarePort platform has been implemented at 119 primary care offices within the Clinically Integrated Network (Physician Partners of Western Pennsylvania), 65% of the network’s offices, with future plans to roll out CarePort across the entire Allegheny Health Network provider base. CarePort Connect is used by more than 600 active users, including nurses, nurse navigators, pharmacists and physicians, to help manage patient transitions.


“After implementing CarePort Connect to augment the practice transformation initiative, the Allegheny Health Network Primary Care Institute and Physician Partners of Western Pennsylvania generated improved value-based program performance through increased care coordination,” Johnjulio explained.

Additionally, Allegheny Health Network has achieved the following results:

  • 49% year-over-year increase in transitional care management encounters.
  • 44% year-over-year transitional care management revenue increase.
  • 10% increase in medication reconciliation compliance post-discharge in one at-risk entity within the Clinically Integrated Network.


“With the adoption of technology solutions that foster increased communication and transparency, we will realize a more effective integration across the continuum – PCPs, hospitals, post-acute care and rehabilitation facilities, and at-home care – breaking down silos among what have historically been disparate care settings,” Johnjulio said. “Though healthcare providers may be hesitant to adopt new tools or solutions because of implementation or onboarding challenges, or for fear that they will disrupt current workflows, there are solutions that fit within existing current workflows and minimize administrative burden.”

Technologies that help break down healthcare silos and provide a holistic view of the patient journey can ultimately improve outcomes and efficiency, and save time and money for the organization, he added.

“From our own experience in implementing a care coordination solution to increase transitional-care-management encounters, Allegheny Health Network has improved both the volume and quality of these encounters, better ensuring patients are receiving the appropriate care at the appropriate time and maintaining communication with disparate providers across the continuum – including primary care physicians – so that they are aware of the patient’s status and can take the appropriate necessary next steps in that patient’s care,” Johnjulio said.

When siloed systems become interoperable – and cross-continuum providers achieve improved transparency and communication – patient outcomes improve, he concluded. All providers should strive after improved interoperability across the care continuum to better serve their patients, he said.

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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