Health Plans | Utilization Management Post-Acute Care

Our patient-centric, comprehensive solution provides an individualized plan of care across the most appropriate continuum of post-acute care. We manage patient cases from day one of the inpatient stay to 30-, 60-, or 90-days after discharge from the acute setting.

Our Post-Acute Care solution relies on clinical protocols that utilize nationally recognized evidence-based guidelines. Our unmatched experience in care management and uUtilization Management UM ensures improved clinical outcomes, lower readmission rates, and enhanced care coordination.

eviCore’s Post-Acute Care solution works closely with the patient, their caregivers, and providers throughout the duration of the care continuum. This staying power enables us to better manage quality of care, cost, and readmission risk, while improving both patient and provider satisfaction.

Our current Skilled Nursing Facility (SNF) payment model is consistent with the new SNF payment model that CMS is mandating beginning October 2019.

eviCore provides utilization and length-of-stay management services as well as care coordination and discharge planning support for members requiring care in Long-Term Acute Care Hospitals (LTAC), Inpatient Rehabilitation Facilities (IRF), or Skilled Nursing Facilities (SNF). eviCore also employs in-market social workers to identify and help mitigate potential barriers to discharge. Our care coordinators identify members who may have behavioral health needs and ensure they are referred back to the health plan for inclusion into their case management programs. eviCore requires that the Post-Acute Care requests be initiated by the facility/interdisciplinary team currently providing care for the member. This ensures that the most up-to-date pertinent information is provided in support of a sound medical necessity decision and that care is delivered in the right setting at the right time.

eviCore’s Home Health program is a patient-centric program that assesses not only the clinical appropriateness of home health services, but also each patient’s unique home environment and psychosocial factors to determine whether the patient’s home is the most appropriate setting for recovery. Requests can be initiated by the acute hospital or Post-Acute Care facility, or can be community-based. Our clinicians ensure that services are initiated in a timely manner, and that the patient receives the right number of visits, with the right disciplines, from the provider best equipped to deliver the needed services.

The management of DME services is part of the eviCore comprehensive Post-Acute Care solution.We not only review the clinical appropriateness of the requested DME based on specific patient needs and recovery goals, but we also, per CMS guidelines, ensure patient understanding and satisfaction with the product and/or services that are being provided. eviCore will also address any complaints or concerns the patient may have regarding their equipment or service. The eviCore program partners with high-quality DME providers to promote the safe use of equipment and items to minimize any safety risks, infections, or other patient hazards.

eviCore has integrated its care solutions to provide the patient a seamless and efficient end-to-end pathway through the care continuum. The management path begins with imaging studies and conservative interventions and continues through the elective procedure and subsequent post-acute services. Early identification and management enable eviCore to positively influence the patient’s journey through use of:

• Predictive analytics with risk stratification to identify the members likely to need additional services post-procedure and follow-up to prevent avoidable readmissions
• Patient-centric care plans created prior to admission; these encompass a 360-degree view to identify and resolve barriers to successful outcomes
• Transitions between interventions and care settings that begin upstream, to avoid unnecessary delays to care delivery.

No other benefits-management company in the nation can offer this level of systematic coordination and integration among its solutions.

The connected care journey uses predictive modeling and a proactive approach to improve patient outcomes. This journey offers:

• Predictive analytics with risk stratification
• Individualized patient care plans proactively created prior to admission
• eviCore engagement triggered by notification of elective surgery or imaging
• Identification and resolution of potential barriers to successful surgical outcomes.

eviCore’s Radiology solution delivers cost savings and improved patient outcomes by ensuring that the health plan member receives the imaging test or treatment most appropriate for their individual case presentation or condition. This eviCore solution reduces inappropriate utilization, unnecessary radiation exposure, and premature scheduling of invasive procedures. eviCore’s approach is not to deny care that is needed but rather to redirect providers and patients to more appropriate testing and treatment options, to better preserve safety and maximize value.

The eviCore Musculoskeletal solution addresses the full spectrum of potential care and treatment, from holistic and elemental approaches, to the more advanced and invasive procedures. We apply extensive evidence-based clinical guidelines, and advanced technologies to ensure that the right evidence-based care is delivered.

eviCore offers the most comprehensive Post-Acute Care solution in the market:

• LTAC / IRF / SNF, HH, Network Models, DME, Home Infusion, Transitional Care, Palliative/Chronically Co-Morbid, Transportation, and Onsite Resources.

We ensure transitional care management and readmission avoidance:

• Available on a capitated risk basis.

We provide the capability to coordinate the journey among solutions:

• Musculoskeletal, Radiology, and Post-Acute Care.

We approach Post-Acute Care management as a partnership, and with a collaborative mindset:

• Highly engaged in day-to-day management with clients
• Direct access to eviCore leadership―open lines of communication
• Program collaboration that can be customized to our client's specific needs
• Services available 24/7, 365 days a year

Offer collaborative and flexible appeals management delegation:

• Based on specific health plan needs addressed during implementation process.

Focusing on each individual patient’s needs to develop customized care plans, we manage the best possible care:

• Embedding community resources in hospitals and post-acute care facilities
• Integrating proprietary analytics, advanced UM, in-depth site-of-service evaluations, and individualized care plans
• Providing discharge planning and active site-of-care shifts.

eviCore offers a dedicated in-market Provider Engagement team and program:

• Establishing the industry’s most sophisticated clinical training programs for post-acute care facilities
• Conducting hundreds of provider meetings per year
• Sharing provider reporting from an MDC/DRG (top-down) perspective
• Integrating with provider workflow technology partners (e.g., Allscripts).

By offering capitated risk contracts for all program offerings, we furnish our clients the extra measure of security as we assume the financial risk for managing their members.

We provide the unique capability to leverage both pharmacy and medical data:

• Driving additional value through enhanced predictive analytics capabilities by working with the health plan’s PBM vendor
• Enriching predictive capabilities to provide more accurate clinical guidance and decision support.

One of the key components of eviCore’s Post-Acute Care solution is preventing avoidable readmissions. This program provides the patient with the appropriate level of case-management, transitional, and care-coordination services―in the post-acute facility setting and once discharged to home.

The level of care, as well as the types and number of interventions, are tailored to the individual patient’s needs, which are identified through a comprehensive patient-readmission risk assessment. A patient-centric care plan is then created to include both short- and long-term goals, as well as risk factors for readmissions. As part of the Post-Acute Care team, the social workers coordinate with members and caregivers to facilitate care coordination, identify barriers to discharge, and identify community resources for additional support. This program also provides assessment and support for regimen adherence and medication reconciliation and management. The program can be offered at 30-, 60-, and 90-day intervals from day of discharge, based on the health plan’s protocols and the patient’s specific readmission-prevention needs.

Included in Transitional Care, eviCore offers Telehealth and Remote Patient Monitoring services. The Telehealth and Remote Patient Monitoring program offers enhanced care and education to eviCore members to help manage their conditions and maintain their independence. For clinicians and healthcare providers, Telehealth and Remote Patient Monitoring provides detailed information on an individual’s recovery, including vital signs, medication adherence, symptom surveys, and virtual visits.