Innovation Care Partners (ICP) is a physician-led Clinical Integration Network (CIN) and Accountable Care Organization (ACO).

The organisation was founded with a mission of transforming healthcare delivery in the greater Scottsdale, Arizona community.  Its focus is on achieving the “Triple Aim” of healthcare: improving the health of the patient population, improving the patient experience and reducing costs. Today,  ICP has contracts with ten major insurance companies and covers more than 170,000 patients. 

ICP have a set of key factors that contribute to the success of their organisation and lead to improved quality, reduced cost and improved patient satisfaction. As part of the Orion Health Speaker Series, Faron Thompson, Chief Operation Officer and Karen Vanaskie, Chief Clinical Officer of Innovation Care Partners, discuss one of their key success factors, the Care Coordination and Transitional Care Management model.

Supporting the patient through the continuum of care

The ICP Care Management model “hugs the patient through the continuum of care”, describes Karen.

Two key components of the model include Transitional Care Management and Comprehensive Care Coordination. The model is managed by a central Care Management Department who enable collaboration with Payors to understand their services and programmes.

The Transitional Care Management team is facilitated by a team of nurses and social workers who manage the patient experience from hospitals to post-acute care settings, assisting with the transitional needs of patients. The main focus of the Transitional Care Management team is to keep the primary physician notified of the patient’s care plan through clear communication between the health care team in the hospital and the primary care physician in the office, ensuring a smooth transition and preventing readmission.

The Comprehensive Care Coordination programme is an intensive outpatient care programme managed by well-trained care coordinators who are embedded directly into the primary care team. They use a predictive analytics tool to identify moderate to high-risk patients in the primary care setting so that they can work closely with these patients to deliver personalised care plans, increasing patient engagement and removing barriers.

The right technology

ICP’s Care Management model is supported by a core set of technologies. Innovation Exchange, a Health Information Exchange (HIE) provided by Orion Health, brings together patient data from multiple disparate sources providing a longitudinal patient record. It makes all of the patient’s information available to their care team such as ED visits, labs, home health information, Payor information and connects hospital data and state HIE data.

To support the continuity of care, ICP integrates other technology with Innovation Exchange including HIPAA compliant texting systems that allow care coordinators to set up notifications for their patients such as inpatient admissions and discharges, ED visits and lab results.

Karen describes “I think [Innovation Exchange] is what probably gives our clinical team it’s strength because they have a lot of information at their fingertips to make good decisions or to catch escalating issues quite quickly”.

Measuring success

The overall goal of the ICP Care Management model is to improve patient health. The Care Coordination team complete a series of assessments with the patient and repeat every six months to measure improvements. These results show that patients are highly engaged in their own care. ICP’s data from the programme also shows that Hospital readmission rates have successfully remained at low levels.

ICP’s journey so far has taught them many lessons including the necessity of having a clearly defined work model that is underpinned by supportive technology, the importance of continuously training and educating your care team and measuring your programme’s results.

Watch the full webinar below to hear more about the successes of ICP, their Care Management model and the lessons they have learnt.