NAACOS Recognizes Three ACOs for Care Improvement Efforts

At its Spring 2021 Conference, the National Association of Accountable Care Organizations (NAACOS) recognized three ACOs for their outstanding work to improve patient care in their communities.

NAACOS said the three inaugural winners exemplify how ACOs across the country are improving care by addressing food insecurity, making house calls to reduce preventable emergency department visits, and engaging patients in preventive services.

Essentia Health, which serves people across rural Minnesota, Wisconsin, and North Dakota, was recognized for its efforts to address food insecurity. Essentia piloted a screening program at three clinics to identify social needs, including food insecurity, transportation issues, and financial strain. Before every visit, patients are asked to complete a questionnaire available through the ACO’s EHR patient portal.

Essentia also developed an interactive dashboard to map social needs across the ACO’s service area and track performance metrics. When the COVID-19 pandemic hit the region in April 2020, Essentia rapidly scaled the initiative to more than 70 clinics. Since then, more than 420,000 patients have completed the screening questionnaire. Patients who report a social need are then asked if they would like to be contacted by a community health worker to help connect them to community-based resources. About 13.5 percent of patients reported at least one social need.

“We're very excited that we started a partnership with Aunt Bertha in February of this year to really align the stakeholders that are working together in the social care realm,” said Emily Anderson, Essentia’s director of community health, in accepting the award. “We're developing a resource referral network and integrated workflows between Essentia Health and community-based organizations. Our goal is really to create a more connected community with improved communication and coordination between and among healthcare and social service providers.”

Anderson said Essentia is working to integrate the community resource directory into the electronic medical record. “Our research institute in our organization has received funding for a three-year research study to evaluate the impact of the program on outcomes and total cost of care, as well as drivers and barriers around positive outcomes. We're also continuing discussions with payers on strategies to enable financial sustainability of care models that are remedying social needs, exploring ways to assess the return on investment patient experience.”

Ochsner Accountable Care Network

Ochsner Accountable Care Network in New Orleans partnered with telehealth firm Ready to develop a program that dispatches health workers to patients’ homes on-demand to reduce preventable ED visits.

By working with Ready, Ochsner was able to reduce preventable ED visits by almost 50 percent for more than 500 high-risk Medicaid and Medicare patients. The initiative takes a three-prong approach. The Ready at Discharge program, designed to bridge care until newly discharged patients can follow up with their primary care clinician, dispatches an EMT, paramedic or registered nurse to the patient’s home to review symptoms and provide minor treatments and services such as COVID tests. During the visit, the Ready responder and patient consult with the prescribing clinician to review and address any patient concerns. Ready Community Care takes a similar approach but with a different group of patients—those who frequently visit the ED and/or have multiple non-acute inpatient stays. The Ready responder makes three to five home visits a month for up to three months to take a deep dive into identifying what matters most to the patient and addressing underlying social needs that can contribute to high ED and hospital utilization. Along with establishing a strong link to primary care, the Ready responder connects patients to community resources and provides coaching to help improve health choices. For a select group of high-risk patients, the House Call program essentially provides mobile urgent care on demand.

“The partnership with Ready was critical to us in our response to COVID-19,” said Harry Reese, the ACO’s vice president for post-acute and home care. Among other things, Ready helped Ochsner in monitoring COVID-19 patients post-discharge. “We instituted a program where they would follow that patient for two weeks making visits on a daily basis at first and then spacing out every day to check on that patient to ensure they weren't decompensating,” Reese said. “We actually just launched last week doing in-home COVID vaccinations with Ready and we're excited to get that program flying.”

Primaria Health

Primaria Health launched a quality team that proactively reaches out to patients to educate them on the importance of regular visits with their primary care clinician, preventive screenings and chronic disease management.

In 2017, less than a third of the Indiana-based ACO’s patients were receiving recommended colorectal cancer screenings and less than half were getting screened for breast cancer. Designed to close these gaps in care, the ACO launched a quality team to educate patients about the importance of regular visits with their primary care clinician and completing indicated health screenings. They call patients to let them know they are overdue for a visit or screening and help them schedule appointments. The ACO also identifies higher risk patients who could benefit from more individualized care by using “Best Practice Alerts” to make sure clinicians are aware of specific concerns or patient issues.

For example, patients with diabetes who have an A1c score over 9 are flagged, and the Quality Team engages the patients and helps them schedule an appointment with a pharmacist as needed. Between 2017 and 2019, the ACO’s percentage of diabetic patients with poor A1c control dropped from 14 percent to 7.6 percent.

Andrea Osborne, senior vice president for ACO operations, said it was important that not only the primary care physicians bear this responsibility, but for everyone on the team to understand the quality expectations. “We made a point of educating all of our staff from case managers in the hospital to specialists,” she said. “We wanted to make sure everyone along the continuum knew how to identify open care gaps for the patient, and knew how to make a referral.”