The Centers for Medicare & Medicaid Services announced earlier this year that ACOs saved $380 million during their first year, with 29 out of 114 Medicare Shared Saving Program (MSSP) participants saving enough to generate bonus payments and nine of 23 Pioneer ACOs achieving savings.

Factors such as the implementation of robust quality measures, data analytics, clinical and IT integration, and leadership all contribute to ACO success. Some successful organizations say that embedded care coordinators, or care managers, are the glue in the care continuum that have allowed organizations to push forward effective population health management—helping them move the dial on the triple aim.

‘Trump Cards’

“Our care managers are our trump cards that help us take care of the sickest of the sick to make sure we are effectively implementing treatment plans for them,” says Jonathan Nasser, MD, co-chief clinical transformation officer at Crystal Run Healthcare, a Middletown, N.Y.-based multispecialty group practice that became a MSSP in 2012. Crystal Run also has achieved ACO accreditation from the National Committee on Quality Assurance (NCQA) and patient-centered medical home level III recognition for its six medical home sites.

The practice group includes 300 providers, which represent more than 40 specialties, and annually serves about 200,000 patients, of which about half are Medicare patients.

Since the embedded care manager program began, the 30-day all-cause readmission rate for Crystal Run patients cared for at Orange Regional Medical Center, an unaffiliated hospital, has declined from around 20 percent to 12 percent. Also, the program has helped the ACO reduce the cost of care for its diabetic patients by 15 percent; improve patient satisfaction scores and improve clinical quality metrics for other at-risk patient populations.

The care manager program is all about facilitating transitions, which begins on hospital admission. Transition coordinators embedded in the hospital, with access to the hospital’s EHR, review all admissions by the hospitalists and identify high-risk patients as well as reconcile hospital medications with outpatient medications.

“We’ve developed competencies to effectively advance the triple aim, and being involved in Medicare MSSP helped us move forward. Care managers are an integral part of many of these efforts,” says Nasser.

The Nuts & Bolts

“Population health is all about taking care of patients when they are not in front of us. Case managers help bridge that gap,” says Betty Jessup, director of quality and patient safety at Crystal Run.

The organization’s embedded care manager links physicians, community resources and patients. Currently, the health organization employs two transitional coordinators who work out of the local unaffiliated hospital and 10 care managers, who each handle a Medicare patient load of 150 (250 including commercially insured patients) and are primarily located at medical home sites.

“We’re one of the only departments that has grown since inception and still continues to grow,” says Jessup.

Each day, the coordinator sends a list of patient discharge information to office-based care managers and alerts the patient’s primary care physician as well as any relevant specialists.

A case manager will dispatch a nurse practitioner for a home visit within 24 hours if that patient is deemed at high risk for readmission through predictive modeling. The care managers ensure that anyone with heart failure, co-morbidities, frequent trips to the emergency room or noncompliance with prescribed treatments gets a home visit within 24 hours for evaluate medication compliance.

The coordinator also schedules visits with the primary care physician or specialist within three to five days post discharge.

It wasn’t until two years ago that the care managers received access to the hospital EHR. Jessup says that has been the key to their success. “It’s transformational having access to that.”

Accountable Care at Dartmouth-Hitchcock

New Hampshire-based Dartmouth-Hitchcock—with 18 locations that encompass 1,800 staff, including 400 providers—was one of the first Pioneer ACOs to report savings. It received more than $1 million from the Centers for Medicare & Medicaid Services and met all of the program’s quality benchmarks, including monitoring of patients with chronic conditions, and lower hospital admission and readmission rates.

“I would say the care coordinator role is one of the key clinical process transformations that supports this success as well as that of the patient-centered medical home,” says Barbara Walters, DO, senior medical director.

The organization also works with Cigna, one of its private payers, through a collaborative care arrangement that helps support the deployment of care coordinators.

“They are having great success, and offer wrap-around services they can include in their arrangements. Results have been released, and everybody is giving credit to the care coordinators,” says John Bailey, manager of customer segment data for Decision Resources Group, on the Dartmouth-Hitchcock-Cigna relationship. 

Dartmouth-Hitchcock embeds 38 care coordinators within its primary care practices and teams. These care teams, which vary in size, include physicians, nurse practitioners and social workers.

Dartmouth-Hitchcock operates patient-focused registries that cull information from claims, EMRs, EDT feeds and patient-entered data, says Walters. The registries allow care coordinators to identify patients who have gaps in evidence-based medicine.

The managers follow up on patients recently admitted to the ER and at risk of return, but they also engage in general population health management. For example, if clinicians want to run a prevention campaign to encourage mammograms, they can tap into the registry to report out a list of patients who have not had a mammogram for two years. Or, it can produce a list of patients with recent diagnoses, like diabetes, to direct appropriate care, Walters says.

Also, the registries allow care coordinators to monitor patient progress. Quality measures are loaded in the registries so the care coordinator working with the patient can monitor his or her progression or regression.

Remote Monitoring

Care managers also can play an effective role in facilitating remote monitoring device programs.

At Crystal Run, a recent biometric remote monitoring device pilot showed a “dramatic” ROI of 15 to 1, says Nasser. This initiative’s goals specifically were to reduce avoidable admissions for chronic heart failure and COPD; reduce 30-day readmissions and ER visits; and reduce utilization.

In the pilot—which took place between January and September 2013—the organization followed 30 patients equipped with various telemonitoring devices, including pulse oximeters and blood pressure cuffs.

“Care managers were pleasantly surprised on its impact on keeping people out of the hospital,” says Nasser. Among the results: For the cohort group, no hospital admissions or ER visits occurred in six months and no chronic heart failure or COPD exacerbation took place during six months.

“It was a surprise,” Jessup says of the pilot’s success. Some of the benefits derived from the program include better care for homebound patients, lower utilization and increased patient satisfaction. Managers had to learn to effectively handle wireless equipment and customize biometrics and equipment.

The inside advice

Looking to the future, how will ACOs succeed?

“My personal opinion is that they need to have some type of medical home-type model. It doesn’t have to be NCQA, which is established with an organizational structure and builds the groundwork up. It helps when standards are there to guide it,” says Jessup.

ACOs ultimately usher in stronger care coordination, and care managers are cornerstone to that progression. “It’s a natural step, a natural progression,” she adds.
For organizations just beginning to form their population health management strategy, Walters of Dartmouth-Hitchcock advises them to “just start somewhere, even if it is just one or two care coordinators calling patients after discharge, or calling patients with three or more comorbidities.”

Recognizing the importance of care managers, payers are getting into the game to find ways to get the role into the reimbursement structure, adds Laura Beerman, Decision Resource Group.

“Historically, reimbursement for care coordination has not been there but providers and payers now are working closely together and want the care manager to be a part of the risk model,” she says.