In today’s evolving health care landscape, many organizations have one foot in “fee-for-service” and one foot in “value-based care.” To effectively straddle the volume versus value business models requires strong referral partner relationships, especially as an organization accepts more risk for an episode of care. 

The more risk a company accepts, willingly or by Centers for Medicare & Medicaid Services (CMS) regulatory mandates, the more the playing field changes. 

Outperforming one’s peers becomes more and more important to retain the referrals required to sustain the census level needed for an organization’s operational and financial goals. 

As it seeks to employ technology to help solve some of the challenges associated with maintaining strong referral partner relationships, here are a few capabilities that should be at the top of the list:

• Having visibility into referral trends from referral sources to gain an understanding of the evolving relationship;
  
• Tracking relationship development and nurturing efforts to improve the number of appropriate referrals based on the organization’s care delivery services; and
  
• Streamlining the admissions process for screening referrals accepted under care.
  

Managing Relat​ionships 

As networks continue to narrow, the company’s current spreadsheet approach may not be adequate to the new tasks before it. But outperforming local peers requires technology that will allow it to not only track referrals to referral sources, but to also track collaboration with its health system, physician, and health plan partners to confirm that they are sending—and the company is accepting—the right patient profile for the organization’s capabilities.

Using paper folders and spreadsheets to manage referrals and referral source relationships and for basic task tracking is no longer enough. Solutions that provide visibility to and tracking of referrals from referral sources, including conversion rate tracking of referrals taken or not taken under care, become critical for monitoring and improving performance. When evaluating technology solutions for managing referral partner relationships, the following capabilities should be on the evaluation checklist:

• Ability to review health care provider referral partner profiles that include both historical referral trends and current referrals/admissions rates;
  
• Ability to assign responsibility for and track activities associated with developing and maintaining the referral partner relationships; and
  
• Ability to track referrals taken and not taken under care by a referral partner so that this information can be used in discussions to educate the referral partner on the organization’s capabilities.
  

Determining if a Referral is a G​ood fit

Whether the company currently participates in a CMS accountable care organization, bundled payment for care improvement advanced, or other bundled payment program or is just anticipating the impact of the CMS skilled nursing facility value-based payment program, the decision of who to take under care has an impact on current and future reimbursement rates. The program starts October 2018 and focuses on unplanned and potentially avoidable hospital readmissions 30 days after hospital discharge.

A short checklist may no longer be enough for decision making. The referral screening process needs to change to consider not only the last acute care visit, but also prior health care events. As management evaluates technology solutions for screening or assessing referrals, the following capabilities should be determined:

• Ability to eliminate paper forms used for note taking while nurse liaisons work with hospital discharge planners to review referrals. This enables staff to easily share the information gathered with other nursing staff if assistance is needed to make the decision to accept or deny a referral;
  
• Ability to review a referral’s longitudinal health record to gain insights into their prior health care journey to help anticipate readmission risk while assessing referrals from referral partners; and
  
• Ability to leverage information from hospital partners that require use of electronic referral solutions, so that duplicate data entry is reduced and information about referrals not taken under care can be analyzed.
  

Demonstrating Value to Par​tners

The capabilities discussed above regarding managing referral partner relationships and tracking referral status based on screening results are some of the inputs the company will need to demonstrate value to its referral partners. If the analysis of referrals taken or not taken under care reveals that the provider’s “good” referral partner is sending it more “bad” referrals than “good,” it may need to educate the referring partner on the provider’s current capabilities and the results obtained from care provided to similar patients from other referral partners.

The analysis could also point to a need for the company to change its capabilities to continue to meet census level and associated business financial objectives. Having the ability to track and review this type of information is becoming more and more critical.

Selecting the R​ight Solution

If after analysis management realizes its current technology system to support decision making and track data is coming up short, then it is time to find the right solutions to apply to the problem. 

A few questions to ask—from both the company’s and the technology provider’s perspective—when evaluating potential solutions include:

• What kind of business intelligence or analytics, both current and historical, does the organization need to better understand the current situation with referral partners? 
  
• What additional information does the organization need to know about a referral to make a better decision about accepting or not accepting that person under care to better meet the terms of the alternate payment model agreements guiding care delivery?
  
• How can the current process be adapted to streamline the workflow and reduce the effort to track performance and report results back to the referral partners?
  
• What does the organization need to evaluate the performance of the resources devoted to developing and maintaining relationships with referral partners that help drive the occupancy levels needed to meet financial objectives?
  

Selecting the right solution is not just about the product currently available from a technology vendor. As alternative payment models continue to narrow existing referral networks and push the need for stronger referral relationships to respond to quality and cost expectations, providers also should consider how vendors will partner with them to help them attain their goals. 

Becky Capps is senior product manager at MatrixCare. She can be reached at Becky.Capps@MatrixCare.com.

Sponsored by MatrixCare​