Florida ACO achieves value-based care goals with real-time patient data platform

Florida ACO achieves value-based care goals with real-time patient data platform

Photo: Ricardo Matos

Achieving value-based care goals remains a difficult challenge for many providers who also are trying hard to provide equitable care. Pathways Health Partners, an accountable care organization that works with more than 280 providers across multiple clinical specialties, works with organizations to address these issues.


“Ensuring access to patient records in real time, regardless of where patient care is delivered, was an ongoing hurdle for our organization,” said Ricardo Matos, CIO at Pathways. “It was a significant limitation with regard to our providers making timely, informed care decisions.

“And we knew from our experience working with partners over the years that trying to locate discharge documents is any practice manager’s least favorite task,” he continued.

However, without real-time access to patient data, providers in the network were limited in understanding more fully the interventions that could make the greatest impact.

“We also needed more immediate healthcare data to improve quality measures reporting and achieve the Centers for Medicare & Medicaid Services mandate that all Medicare beneficiaries be covered by value-based care models by 2030,” he explained.


The Pathways ACO turned to health IT vendor Audacious Inquiry, a PointClickCare Company, for help.

“For value-based care goals to be fully realized, Pathways needed a system that provided prompt access to patient data regardless of where care was delivered,” Matos said. “PointClickCare’s healthcare technology platform could solve our challenge of having limited access to patient records in real time.

“The system provides patients’ individual clinicians with notifications of hospital admissions and other real-time patient data,” he added. “This was information that never existed in the fee-for-service environment.”

With this technology, Pathways Health Partners could provide patients’ individual clinicians with notifications of hospital readmissions to coordinate with primary care providers more quickly and seamlessly.


With the new platform, Pathways more easily realizes its mission to provide care for patients and work with doctors who have been community physicians for decades to follow ACO guidelines.

“Knowing a patient is in the hospital is the first indication to act,” Matos noted. “Pathways Health Partners layers this data with transition care management and does not require patient discharge documentation.

“PointClickCare’s healthcare technology platform also provides lab results, which then are fully integrated into the organization’s population health data dashboard,” he continued. “As a result, healthcare providers have been able to reduce readmission rates significantly.”


Since Pathways became an ACO in 2013, there have been substantial changes in the types of data available to members. Previous data aggregation efforts included relationships with data clearinghouses to gather granular detail on registration and payer activity. Notifications of hospital admissions and other real-time patient data is the latest addition in the data journey.

“We’ve achieved a near 100% response rate to inquiries on payer activity, an impressive success,” Matos reported. “And as an ACO, we continually gain broader insights into the populations we serve. These more timely and broader insights are shared with primary care providers to support informed care decisions for their patients and mitigate readmission risks.

“With a growing volume of accessible, real-time data, we’ve also introduced new methods to connect and inform care,” he added. “The result is reduced costs for hospital readmissions, by making those outside services available to the patient, including at skilled nursing or long-term care facilities.”


First and foremost, providers should ensure they have the right infrastructure and resources to realize value-based care for their patients, Matos advised.

“For organizations working to optimize strategies to improve cost-effectiveness in operations, real-time patient notifications are an imperative,” he continued. “Providers should prioritize adopting clinical data exchange.

“Ultimately, these types of notifications get patients into treatment faster,” he said. “No matter the condition a patient has, regardless of their socioeconomic status, real-time notifications allow providers to connect with patients and deliver critical care faster.”

Additionally, notifications allow for closer monitoring between short- and long-term care, he noted.

“Beyond analysis, these notifications trigger faster access to care, from skilled nursing facilities, hospice, and home care, making all of those resources available to people, equitably,” he concluded.

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