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Adopting Accountable Care: An Implementation Guide for Physician Practices3. Combine your raw analytics with clinicalintuition. Providers have insights about theirpatients that cannot be ascertained by mostanalytic models. This includes gauging whichpatients do not show up for appointments, livealone, are unsteady on their feet, or have otherpsychosocial comorbidities. We recommendgiving providers a list of patients generatedelectronically, and have them review the listbased on their own knowledge of the patients.CHAPTER 1Identifying and Managing High-RiskPatientsA cornerstone of successful accountable care is toidentify patients who are not receiving optimalcare, are overutilizing health resources, and as aresult are contributing to excessive spending. Byidentifying those patients who are not currentlywell served by the health system and providingadditional targeted resources (i.e., carecoordination,socialservices,orcaremanagement), there is an opportunity to improvepopulation health and achieve significantreductions in total spending.This chapterprovides an overview of approaches to identifyhigh-risk patients and strategies for implementingeffective care management.4. Take advantage of patient-reported data. Byasking patients to share personal information withtheir providers about their health care goals anddisease-management challenges, a wealth ofuseful information can be obtained. ACOs can useestablished metrics such as the Patient ActivationMeasure (PAM), or they can create their ownpatient measures to track.A. Identifying High-Risk PatientsB. Care Management1. Define an intervention. A key step isdetermining how you will intervene in the care ofpatients identified through a risk stratificationprocess. If your goal is to perform intensive caremanagement on the patients most likely to beadmitted to the hospital for poorly managedchronic conditions, then analytics should betailored to identify this population. If you hope tion process should be set up to flagthese patients. This process can help determinethe most promising care management tools foryour ACO, and select the patients most likely tobenefit.1. Invest in coordinated care transitions.Creating a standardized workflow for smooth caretransitions is essential to reducing hospitalreadmissions and can significantly reduce costs.Success of such a program will rely on the abilityto receive notifications of patient discharges fromhospitals and post-acute care facilities. Providersalso benefit from a daily workflow that ensurespatients are contacted within 1-2 days ofdischarge, medications are reconciled, referralsare tracked and patient education is completed.2. Use intensive care management thoughtfully.Think carefully about how to select patients forintensive care management. Data show that suchprograms can have dramatic success, but they arealso costly. Care managers are precious resourcesand must be deployed in such a way as tomaximize their impact on the patients theymanage. Choosing patients who already havestrong support networks and dedicated caregiversmay prevent you from realizing significantbenefits from your intervention and from reachingthe patients who need care management themost.2. Use analytics tools that are most accessible.If your population health vendor has set up anintegrated predictive modeling platform thatintegrates all of your claims and EHR data, thenuse that tool. Look elsewhere if you don’t havesuch a tool at your disposal or your vendor hasover-promised and the integration is runningbehind schedule. Start with the data you haveavailable and use a free risk-stratification methodsuch as Hierarchical Condition Categories (HCC),Charlson, or the Chronic Condition Count. You cansimplify efforts by creating a list of patients withmultiple hospital admissions over the past sixmonths.3. Set up your care management to promotemeaningful relationships. Position your caremanagers such that they are able to developrelationships with the patients they are managing.6

Adopting Accountable Care: An Implementation Guide for Physician PracticesIf their offices are embedded within a primarycare practice, they can meet with patients duringan already scheduled visit, and they can buildstrong relationships with primary care providers.If embedded care managers are not practical foryour organization, consider having care managersconduct home visits, hospital visits or even postacute facility visits. The stronger the bondbetween care manager and patient, the morelikely the patient will be to contact the caremanager when medical needs arise.which providers outside of the ACO are caring foryour ACO’s patients? These data can be obtainedthrough chart reviews, clinician surveys, claimsanalysis, or public use datasets. Once established,this information can inform more activemanagement of referrals and improve carecoordination.2. Reduce unnecessary referrals. There is widevariation among primary care physicians regardinghow often patients are referred to specialists. In afee-for-service model there is no financialincentive to think twice before sending a patientto see a specialist for even minor medical issues.Sharing individual referral variation data withprimary care physicians and establishing careprotocols for common conditions can help reducereferrals for conditions that can be managedequally well by a primary care practice. Primarycare physicians can also obtain the training tomanage certain conditions that are often referredto specialists, including simple skin biopsies,diabetes or heart disease.4. Use information technology to promote caremanagement success. Very few electronic healthrecord (EHR) systems are equipped to integratecare management. However, without ITintegration, the hard work of a care manager maynever result in meaningful impact. Consult with ITstaff to develop a communication system thatallows care managers to coordinate with otherhealth providers including primary care,hospitalists, ED physicians, home health nurses,and others. If a patient is part of a caremanagement program, this should be prominentlydisplayed in the record to flag as a high-riskpatient.3. Improve care coordination between primarycare and specialists. Inefficiencies in the healthcare system, such as lack of EHR interoperability,mean that a primary care physician often cannotreceive information about a specialist referralunless the document is faxed. Similarly, specialistsmay not be aware of prior tests or diagnoses priorto the visit. As a result, many patients receiveduplicate tests and other unnecessary services.Implementing the medical home neighbor modelcan help provide a framework for improvedcoordination of care and increased efficiency.Elements of this model include greements, and shared expectations regardingcommunication between providers.CHAPTER 2Developing a High-Value ReferralNetworkPrimary care services represent only 6 to 7percent of total health care spending for any givenpatient, yet primary care physicians indirectlycontrol or influence a much larger percentage ofhealth care spending through decisions regardingreferrals, diagnostic testing, home health care,and other ancillary health services. Physician-ledACOs will need to work beyond their own ACO toimpact care throughout the care continuum,including specialty, inpatient, and post-acute care.This chapter describes strategies to improverelationships with clinical providers outside ofyour ACO.4. Avoid unnecessary facility fees. Medicarereimbursement rates for a screening colonoscopyor lumbar spine MRI are significantly higher in ahospital setting. Identifying imaging centers andendoscopy centers that are not affiliated withhospitals and do not charge a facility fee couldfacilitate significant cost savings.1. Understand existing referral patterns. The firststep in crafting a high-value referral network is tounderstand the current referral patterns of yourACO providers and how your ACO patients areutilizing resources. For example, do you know5. Identify and partner with cost-effectivespecialists and other providers.While7

Adopting Accountable Care: An Implementation Guide for Physician Practiceschallenging, identifying cost-effective providerscan be achieved with the help of a robust analyticsteam who can gauge utilization and adherence toclinical guidelines by looking at claims data. If suchanalysis is beyond the capability of your practice,another option is to consult with primary carephysicians. Finally, if your ACO has the potential todrive a significant amount of volume to preferredspecialists, a preferred partnership may providean incentive for the specialist to coordinate care,and to practice more cost-effectively withoutcompromising quality of care.strategies and highlights examples of ACOs thatare using technology to improve carecoordination.1. Get your data house in order. An advantagefor many physician-led ACOs is having readyaccess to clinical data. Ensuring that you aremaking meaningful use of existing EHRs willprovide the necessary foundation from which youcan pull key elements of population health.Fundamental information about patient problems,medications, tests, demographics and vital signsare the building blocks from which all other datafeeds can expand. Creating master patient indexeswith care team relationships defined is alsonecessary.6. Bring specialists into your ACO. A furtherstrategy to control costs is to integrate specialistswithin your ACO and enable them to beaccountable with you for the cost and quality ofcare. They will be able to participate in sharedsavings and may undertake stronger collaborationwith primary care physicians. For high-demandspecialists such as cardiology, psychiatry,dermatology and endocrinology, the specialistcould be embedded within the primary carepractice itself.2. Leverageexistingrelationships.Takeadvantage of state-wide or regional healthinformation exchange (HIE) capabilities wherethey exist. However, if sufficient HIE infrastructuredoes n

Exchange on physician-led ACOs. This toolkit would not have been completed without their perspectives, . LLC, Privia Quality Network, Renal Physicians o