The ACO is Here. What’s the Primary Care Strategy?
Posted by Mark Angelo, MD, MHA, FACP on October 10, 2017
When it comes to ACO success, a well-considered strategy using population health sets the path for success.
At AllCare Health Alliance, we have taken a multifaceted approach to managing the care of our patients. This evidence-based approach uses population health strategies to understand our patient base as we set forth programs to improve quality and cost of care. Below, I share a snap shot of the strategy around data, care coordination, and the post-acute care network. Posts further discussing components of the strategy will be provided by colleagues.
We use “Big Data” including claims and EHR data about our population to understand patterns of utilization, quality performance, and cost of care. This data helps us to segment our population into high-risk/high utilizers, rising risk category, inappropriate utilization, healthy. In addition, proper documentation of disease severity is important. Risk score, known as Hierarchical Condition Category (HCCs), are assigned to each beneficiary by Medicare. You may also be aware that Medicare resets the risk scoring of patients on January 1st of year each, and requires that providers evaluate and report patients’ chronic conditions throughout the calendar year.
In addition to data analytics, care coordination is a big part of our strategy under the new primary care model. AllCare has introduced Population Care Coordinators (PCCs) to each office to help manage those patients with the greatest need. Care coordination is further advanced through the use of Health Coaches who assist the care team in managing the rising risk population and closing gaps in care for all patients.
In parallel to care coordination, continual management of the post-acute care network is important to our strategy at AllCare Health Alliance. When we look at the data surrounding utilization of inpatient rehabilitation facilities upon discharge among AllCare patients, we see excess use and prolonged lengths of stay compared to other ACOs and health systems across the country. To address this, AllCare has begun an intensive management of the post-acute care network through the implementation of transitional care APNs who work closely with our preferred providers, monitoring the management of our patients in the rehab setting, and setting up a system of accountability for readmissions.
