Notifications on “Frequent Flyers” Improves Care Coordination

Notifications on “Frequent Flyers” Improves Care Coordination

Clinical data is a vital tool for taking care of patients for the entire clinical team – physicians, nurses, social workers, care managers and other care providers. It is also vital for those caregivers to be alerted when one of their patients utilizes the emergency department or hospital on a regular basis so that they can offer alternative treatment options and perhaps more appropriate care plans. RelayHealth is helping JHC members to identify these “frequent flyers” of the healthcare system by offering the infrastructure features to detect such events of interest and notify the relevant providers.

“We have integrated use of the RelayClinical Notify tool into our daily workflow,” says Sheilah McCoy, Director of Care Coordination for the JFK Medical Center ACO.  “The system flags our ACO beneficiaries that visit hospitals out of our network and we are able to identify ‘frequent flyers’ of emergency and hospital services as a part of our ACO care coordination model. Because fee-for-service payments still underpin the shared savings model, care coordination savings come from reductions in admissions, ED visits, and other services. Knowing the facilities our beneficiaries visit helps us to reducing leakage, thus increasing the share of services provided by our ACO, which can offset some of the revenue loss from utilization declines.  RelayClinical Notify helps us to make an early identification of such patients, and in turn offer a tangible solution to benefit both the patient and the ACO.”

The RelayClinical Notify feature allows providers and/or care team members to receive electronic notifications of their patients’ hospital and emergency department admission and discharge events. To enable these notifications, the RelayClinical service accepts inbound HL7 ADT messages (A03 – Discharge/End Visit and A04 – Register a Patient). In response to the ADT, RelayHealth delivers notification of the admit/discharge event to the provider/care team member RelayHealth inbox as a standard message type.


The Benefits of RelayClinical Notify

  • Care team members with active connections to a patient are notified upon significant care transitions
  • Care team members or Practice Administrators can route notifications to specified inboxes in accordance with workflow preferences
  • Care team members who prefer not to receive notifications can disable notifications or Practice Administrators can disable notifications on behalf of the care team member
  • Data Administrators have visibility into Notify transaction processing with ADT transaction status and details available in the RelayHealth InterOp Portal

“Navigating through the fragmented healthcare system can be challenging even when you are healthy and is certainly compounded by illness,” says Maureen Sweeney-McDonough MSN, ANP-BC (, manager of care coordination at Robert Wood Johnson Partners Accountable Care Organization. “Our goal is to achieve the ‘triple aim’ through care coordination, ensuring that you receive the right care, at the right time, in the right setting. We use the real-time RelayClinical Notify feature to identify patients that are being either admitted to or discharged from emergency departments or hospitals in 9 hospital systems in New Jersey. This helps our providers coordinate care as patients transition between settings enhancing their care delivery and empowering them to better manage their own health.”

RelayClinical Notify Models

RelayClinical Notify supports the notification models below – all of which leverage RelayHealth’s enhanced processing architecture.

All Providers

This model allows the service to notify all RelayHealth providers who have an existing relationship with the patient when that patient has an admission and/or discharge event from an emergency department or hospital. In this model, RelayHealth discovers the list of “connected” providers from the patient’s record rather than provider or practice information sent in the ADT message. This model provides the highest level of visibility into the patient’s care events as it allows all members of the patient’s care team to receive notification.

Primary Care Provider Only

This model continues the previously available functionality of Primary Care Provider notification upon a patient’s admission and/or discharge from the emergency department or hospital. This configuration supports facilities that have the ability to send the PCP’s Provider ID and Practice ID in the ADT A03 / A04 transactions sent inbound to RelayHealth, when those facilities do not also require notification to other care team members.

Primary Care Provider + All Providers

In this combined model, the service sends the admission and/or discharge notification to the PCP and all other RelayHealth providers with whom the patient has an existing relationship. This configuration supports facilities that have the ability to send the PCP’s Provider ID and Practice ID in the ADT A03 / A04 transactions sent inbound to RelayHealth. When the service finds a matching PCP, that provider receives the admit/discharge notification, and the service uses the patient information in the inbound ADT to discover the list of any additional associated providers who should receive the notification.

For more information about the RelayClinical Notify feature, please visit this link: (