Measure: Follow-Up After ED Visits for Patients with Multiple Chronic Conditions (FMC)
What is the Population Health Model?
Health care providers are trained to deliver care to support their patients in achieving optimal health. Unfortunately, the way we pay for care in our healthcare system often conflicts with delivering the high-value care required for a positive patient experience and improved health outcomes. To transform the way health care is delivered, we must change the way we pay for it. OneCare’s payment reform strategies work in concert with quality and care coordination best practices that allow providers to practice the care they were trained to deliver.
As an Accountable Care Organization (ACO), OneCare has distinct goals to improve the quality of care for Vermonters. OneCare’s Population Health Model (PHM) is designed to focus our OneCare network of participating providers on a subset of quality measures that have known impacts on a population’s overall health outcomes and patient experience by offering financial incentive to meet or exceed the measures’ performance targets and care coordination accountabilities. The selected PHM quality measures work to drive improvements in preventive care through wellness visits and other means, chronic disease management, reducing unnecessary utilization such as potentially avoidable emergency department visits, and improving mental health and substance use outcomes.
What does FMC measure?
FMC measures the percentage of emergency department (ED) visits for members 18 years of age and older who:
- Have multiple high-risk chronic conditions (like hypertension, high cholesterol, diabetes, depression, etc)
AND
- Had a follow-up service (like an outpatient visit, virtual care visit, substance us disorder treatment, case management visit, etc) within 7 days of the ED visit (total of 8 days)
Why did we choose it?
Patients are at a higher risk of complications following emergency department visits because of their functional limitations and often multiple chronic conditions. Furthermore, studies have found that older adults have increased mortality rates and readmissions rates within the first three months after the emergency department visit.
This measure was selected to be a part of OneCare’s PHM program in 2024-2025 because it captures the importance of primary care providers having insights into emergency department use and managing higher risk encounters to prevent escalating issues. By offering a financial incentive through the PHM program, providers are encouraged to prioritize being actively involved after visits to the ED and ensuring the appropriate follow-up is received. This investment in prevention is not only good for the patient experience, but it saves on expensive emergency care. Investing upstream is more cost effective than paying for crisis care.
For comparison across regions: This measure is included as part of the Health Effectiveness Data and Information Set (HEDIS) Measures as identified by the National Committee for Quality Assurance (NCQA). The purpose of the standardized measure set is to allow for comparison of quality across health plans and across regions. This helps in measuring our success and impact relative to other health systems.
How OneCare supports our network in implementing this measure:
We support primary care in identifying best practices to implement in their practices in order to be successful in the FMC measure. We have one-on-one and group webinars for peer learning to encourage tips for success in FMC like:
- Have a trained care coordination team
- Obtain timely patient discharge reports and contact patient as soon as ED discharge notification is received and schedule follow-up visit:
- Discuss the discharge summary; verify understanding of instructions and that all new prescriptions were filled
- Complete a thorough medication reconciliation with the patient and/or caregiver
- Note the diagnosis for the follow-up visit does not need to match that of the ED visit. Also, it does not need to be associated with the chronic conditions that qualified the patient for the FMC measure
- Check in with patients following their emergency department visit either virtually or in-person, whichever is most suitable for each case (audio and/or video, e-visits, virtual check-ins, or in-person visits)
- Keep open appointments so patients with an ED visit can be seen within seven days of their discharge.
- Instruct patients to call their practitioner with any concerns or worsening of symptoms.
Example of success in this measure in the field:
Middlebury Family Health
In the 2023 performance year, Middlebury is the top health service area in the FMC measure meaning that the population of Middlebury has received improved follow-up care after ED visits. Middlebury Family Health in particular has demonstrated success in this measure coming in at 66%, exceeding the OneCare target of 58.7%.
Middlebury Family Health achieved this success by collaborating with the OneCare team to identify opportunities for improving their systems and practices to best support follow-up care for those admitted to the ED. These improvements included:
- Utilizing electronic health record access called “EpicLink” to obtain timely discharge patient reports
- Reviewing and finetuning protocols and policies around timely test result review; flagging medication changes and outstanding orders; monitoring referrals and patient status updates, and clear guidelines around appropriate follow-up
- Training their care coordination team that facilitates care among all the providers and the patient to ensure triaging and reporting to patient’s primary care provider, as well as panel management of high-risk patients using data from OneCare to identify high ED utilizers
OneCare’s success as an ACO has included the value it brings to the Vermont healthcare system by providing opportunities for learning and collaboration across our network. What works well in one area of our system should be shared and replicated in other areas of the system as we work to realized a value-based system of care. In the spirit of learning from what is working well, the Middlebury Family Health shared their written policies, procedures, and practices with OneCare and they have been incorporated into guidance for other practices across OneCare’s network.
For more information
Please contact Public Affairs at OneCare Vermont. public@onecarevt.org | 802-847-1346
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