Hospitals can use new CMS Condition of Participation regarding ADTs to enhance strategic alignment with independent physicians and post-acute providers

• New requirements regarding notifications of admissions, discharges and transfers present both a challenge and a strategic opportunity for hospitals.
• In general, hospitals should plan for a moderate to significant increase in their operating budgets if they plan to handle the new requirements internally.
• The requirements may pave the way for improvements in value-based care and referral relationships.

Effective May 1, 2021, hospitals must send real-time e-notifications of any admissions, discharges or transfers (ADTs) to a variety of community-based and post-acute care providers. The requirement stems from a new CMS Condition of Participation (CoP) created as part of the Interoperability and Patient Access final rule.

Although this new CoP may require some technical steps to push the data, it also presents an opportunity to align with physicians more strategically, said Jitin Asnaani, vice president of strategic partnerships at PatientPing. “How can they work more effectively with community physicians so they become a more attractive referral partner? There’s a clear line to revenue.”

It’s ultimately about improving patient care and also driving patient volume back to the hospital. That’s exactly what Nicholas R. Szymanski, vice president and chief information officer at Signature Healthcare in Brockton, Massachusetts, is hoping will happen.

Signature Healthcare owns a 150-provider medical group and is part of an accountable care organization (ACO). However, Szymanski says the organization is always on the lookout for ways to prevent network leakage and foster patient retention.

“The data will likely spark a lot of conversations,” he said, and provide insights as to who is requesting the information and how the health system can better align itself with those providers.

“You can have this great visibility into who is actually taking care of your patients or who wants the information so they can take care of your patients more effectively,” Asnaani said.

The data will also help financial leaders understand revenue leakage. For example, if a health system sees a large number of attributed patients going to specific community-based providers that aren’t part of its network, leaders might question whether the issue is a perceived lack of quality, lack of specific services or something else.

Specifics of the new requirements

The new CoP requires a hospital, psychiatric hospital or critical access hospital to send real-time e-notifications of ADT data to providers that have established care relationships with a patient of the hospital and that need the information for treatment, care coordination or quality improvement activities.

Recipients may include the following:

• Patient’s established primary care practitioner
• Patient’s established primary care practice group or entity
• Other practitioner, or other practice group or entity, identified by the patient as primarily responsible for his or her care

Examples of other practitioners or entities could include federally qualified health centers, ACOs, home health agencies, hospice and skilled nursing facilities.

“The rule is very clear,” Asnaani said. “You need to get the data into the hands of those who need that information to coordinate care for patients.”

What must e-notifications include? At a minimum, the names of the patient, the treating practitioner and the sending institution. Sending the patient’s diagnosis is strongly encouraged (if not prohibited by other applicable law).

Sending ADT data to a health information exchange (HIE) may not be sufficient, Asnaani said. “CMS has been very clear that the rule does not take into account regional boundaries,” he said. “If you get a request from a provider who is not in your region, you must still make a reasonable effort to fulfill it. State-based HIEs may not have the legal authority to share information beyond the boundaries of the state.”

Approaches to compliance

First, organizations must determine whether they have the technical capability to send ADT data, meaning they must ensure that their EHR vendor can capture the patient’s provider information and publish the ADT event data so a requesting provider or entity can access it, Asnaani said. EHRs certified based on Meaningful Use Stage 2 criteria already have the ability to push data through Direct Project messaging, he adds.

Next, organizations need an operational process to fulfill requests. In general, hospitals should plan for a moderate to significant increase in their operating budgets to handle the new requirements internally, Asnaani said. Tasks include:

• Managing patient rosters and matching patient care events to those rosters, which then trigger notifications
• Updating patient attribution information on the rosters, accounting for care relationships that can change daily, especially in the post-acute setting
• Installing data-sharing agreements between the hospital and notification recipient to ensure compliance with all federal and state laws and regulations

“Hospitals should consider the workflows, processes and human resource requirements for establishing this type of infrastructure in order to determine if they can adequately address them,” Asnaani said.

While there is not a one-size-fits-all approach, steps an organization can take to implement a manual process include:

• Create a way for community providers to submit a request for ADT data. For example, this can be accomplished through a web portal, phone number or hotline.
• Identify the provider organization. For example, organizations can collect information from requesting providers such as national provider identifier, address and contact information.
• Complete legal documents asking the requester to comply with HIPAA and federal/local regulations pertaining to information privacy and security.
• Provide the requester with a way to submit and update its roster of patients. For example, the requester can securely transfer an Excel-based list.
• Verify whether there is an established care relationship between the patient and requester by reviewing medical record documentation and information in the hospital’s registration system. On an ongoing basis, validate relationships for any new patients submitted on updated rosters.
• Turn on functionality within the EHR to send automatic event notifications to that requester. Turn event notifications on and off for individual patients in tandem with roster updates.

Strategic opportunities through compliance

With more frequent exchange of ADT data comes clear pathways to improvements in value-based care. “This can profoundly impact care coordination,” Asnaani said. “We need to increase this coordination between the silos to drive better outcomes and lower costs.”

Szymanski agrees. “This rule is about the patient. That’s where the positive impact will be,” he said.

Perhaps the most strategic opportunities come into play as hospitals and health systems better understand the types of entities taking care of patients in the outpatient and post-acute care settings, Asnaani said. This is particularly true as more patient care shifts to the community setting or even the patient’s home, he added.

“Traditionally, hospitals spend a lot of time, money and resources trying to determine their referral network,” he said. “It’s an internal process that doesn’t necessarily track where patients are actually going. There’s an opportunity to build a relationship with those community providers who you didn’t realize could be some of your strong referral partners.”