To date, experience has shown that ACOs need tools to succeed, including comprehensive EHR systems, a method to identify patients who need specialized care, data to help providers manage patient care, networks that support the delivery of care and educational strategies for workforce development.
Accountable care organizations are just learning how to survive and thrive in the new healthcare marketplace today. Given that all of the approximately 500 ACOs in the United States today have formed since Congress passed the Patient Protection and Affordable Care Act in 2010, some ACOs are just getting started and some have a few years of operating experience.
One ACO that has three years of experience and can show some modest success today is Allina Health in Minnesota. In 2011, CMS named the nonprofit 11-hospital system as one of first 32 Pioneer ACOs. In its Pioneer ACO program, CMS rewards ACOs based on how well they improve the health of Medicare patients and lower costs. CMS defines an ACO as a group of physicians, hospitals, and other healthcare providers who join together voluntarily to deliver coordinated high-quality care.
The next year, 2012, Allina's ACO was recognized for its Patient Census Dashboard Team. This program was a semi-finalist for the Healthcare Informatics Innovator Awards Program. The editors of the publication said Allina convened an interdisciplinary team of experts from 10 hospitals to outline the barriers to coordinating care for patients with complex needs and to assist clinicians in the identification of patients at higher risk for readmission. "The 11-hospital, 90-plus-clinic, 24,000-employee, 5,000-physician Allina organization is already nationally known for its innovations in many areas of patient care delivery and operations," Healthcare Informatics reported.
Last summer, Becker's Hospital Review called Allina Health one of the 100 ACOs to watch, saying Allina's expense trend grew at less than 1 percent in 2012. Allina Health is part of the Northwest Metro Alliance, a collaboration between Allina and HealthPartners in Bloomington, Minn. The NMA is an ACO that covers more than 300,000 people. Allina itself has 60,000 Medicare members in its ACO.
Given its results to date, Allina has identified five keys to ACO success:
1. Install a comprehensive EHR system.The need for a comprehensive EHR system is obvious because ACOs are managing the health of the population, which requires patient care records on every patient in the system. In an ACO, Allina is at financial risk for managing all patients, regardless of whether they're healthy or very sick.
By forming an ACO, Allina is making a deliberate decision to focus its resources on providing all care for our 60,000 patients. To do that well, Allina has an EHR from Epic that allows the physicians to see the past history of each patient.
The EHR includes clinical, demographic and other data that Allina uses to give a full picture of each patient's needs. Eventually the information will be used to gather data on each patient's total cost of care.
2. Identify patients who need specialized care. The EHR can help all providers identify those patients who need specialized care, such as those who are the frail elderly, for example. These patients may need more care than other patients simply because they are old and frail, and any illness or injury from a fall could be serious and life threatening.
Allina Health has a number of preventive care resources to identify patients who may need some level of extra care or attention to prevent a healthcare crisis or sharp increase in utilization.
A more difficult challenge for ACOs is identifying those patients who need specialized care for chronic conditions before their need for care becomes acute. Allina has interviewed patients about their needs and worked closely with them to develop a care model that supports the delivery of preventive health services. In addition, the ACO uses patient registries to track each patient's needs and to allow providers to design care plans to improve each patient's overall health.
Once Allina identifies patients who have certain conditions, we can give them support and coaching for their conditions, such as if they smoke and want to quit.
3. Use data to help providers manage care. Data collected in each patient's EHR allows Allina to run predictive models on what costs providers can expect for the population. Allina has a readmission prediction model, for example, that it uses to calculate the likelihood of a patient requiring a multiple hospital stays. The ability to make such predictions allows providers to improve patient care and manage costs as well. All hospitals face penalties for readmissions from patients with certain conditions and CMS recently announced that it would increase those penalties in 2015 and add more conditions to the list for which it would issue penalties. One way we can reduce readmissions is by standardizing discharge planning throughout the system and providing that information to the patient when he or she leaves the hospital.
Other data we use to manage care includes information we collect on patient satisfaction. We conduct extensive surveys of our patients in the traditional manner with the Consumer Assessment of Healthcare Providers and Systems surveys from the federal Agency for Healthcare Research and Quality. Allina also is conducting point of care surveys to assess patients' needs in various settings.
4. Build a network that supports the delivery of care. Just as every other health care delivery model needs a widespread and diverse network of providers who can deliver care to each member, so too do ACOs. The basis for any delivery network is a core group of primary care physicians who supervise patient care using the data Allina has collected on what these patients need. Other members of the network include registered nurses, care coordinators, pharmacists, social workers and physicians in all the various specialties.
At the same time, Allina is enhancing its care delivery network to provide different ways of delivering care to seniors who have different needs. Some primary care physicians may coordinate care for some patients, and some geriatricians may see other patients. Some physicians who are specialists in dementia, mental health and psychiatry might see still other patients who need the specialized care these providers offer.
Allina also has a senior care transition team that provides services in transitional care units or skilled nursing facilities to patients who are moving from one site of care to another. For those patients needing long-term care, Allina has a geriatric service. We have teams located in clinics that are focused on delivering care to all applicable patients, including those who are members of our ACO and those who are not.
It's important to note that in care management we are seeing patients in their homes, the hospital and in skilled nursing facilities, but we also are doing some telehealth in which a physician or other provider conducts video visits with patients.
Allina also has what it calls care guides, who are laypersons trained to develop relationships with patients to help them improve their health by supporting them in making changes in their lives. In a study published in the Annals of Internal Medicine in August 2013, researchers showed that these laypersons may help improve the quality of care for patients with chronic diseases.
In all of these ways, Allina is has put together a comprehensive network for the Medicare population in its ACO.
5. Develop educational strategies for workforce development. In such a large healthcare system, it is important that all members of the care team recognize the value of delivering care in a standardized fashion. Following protocols is an important element in many healthcare settings today, and standardized online workforce development allows us to deliver standardized care to a large number of patients efficiently and consistently. To do so, we have an online training program to train our care coordinators and social workers to deliver care in the most effective and efficient ways, including in an ACO environment. Online training for our care coordinators and social workers allows us to assign courses to match our priorities for improving patient care, and the best online training sites also serve as clinical reference tools for providers who need guidance on particular patients or conditions.
Using online training coupled with continuing education credits, we can train care coordinators to achieve high ratings in patient quality measures. Also, we can use this form of workforce development to elevate the core competencies of care coordinators and social workers involved in all cases in the hospitals and in many of the cases concerning patients who are not hospitalized. In this way, we are improving patient outcomes and transitions of care, reducing readmission risks and improving claims management. We also are cutting the number of avoidable delays, which reduces length of stay and overall costs.
Directors can assign online courses as needed to help staff shore up their abilities. Also, staff can take the courses at any time, even nights and weekends if they prefer. Many of the best online training providers also offer continuing education certificates, which are necessary for case managers and other staff seeking to stay up-to-date with the CE work.
While these five strategies are important, there are many others that ACOs are implementing as they deliver care based on increased value to patients, meaning lower costs and better outcomes. Accountable care, after all, is a reflection of what patients, providers, and health care payers want from the system: better care at lower costs.
Karen Tomes is vice president, care management and coordination at Allina Health in Minneapolis.