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Care Coordination Tips from a Pioneer ACO

By Henry Chung | Thursday, March 10, 2016

Care Coordination Tips from a Pioneer ACO

Like other CMS Pioneer Accountable Care Organizations (ACOs), Montefiore Medical Center in New York City is a health care organization with years of experience in coordinating care for patients across care settings. While some Pioneer ACOs have struggled, Montefiore has achieved financial and organizational sustainability even though more than 80 percent of their patient population is on Medicare and Medicaid.

Henry Chung, MD, answered IHI’s questions about what his organization has learned about improving quality while reducing costs. Dr. Chung, Montefiore Vice President and Chief Medical Officer, is faculty for the IHI Virtual Expedition: Facing the Care Coordination Challenge, one of the benefits included in the Passport to IHI Training membership.

Over half of the participants in the CMS Pioneer ACO program dropped out. Montefiore Medical Center, in contrast, has seen an impressive amount of cost savings while also maintaining high quality scores. What have been the keys to your success?

Montefiore has been in the care management business for more than two decades, since it signed its first value-based contract with a health plan, so we were prepared for the Pioneer ACO program. We had a well-developed and tested infrastructure, with specialized chronic disease management programs, expertise in intensive case management and, equally important, advanced data analysis capabilities. These are essential components of a successful accountable care organization.

What lessons has Montefiore learned from its care management program that can benefit other organizations?

Access to a robust primary care network is obviously an important aspect of any care management program. But effective care management involves more than attention to a beneficiary’s medical condition — a focus on the social determinants that can have a significant effect on a beneficiary’s health is essential to controlling cost and improving quality. The Montefiore program features a comprehensive assessment that covers psychosocial factors, identification of potential issues, development of a personalized care plan with specific interventions targeted to each issue, an interdisciplinary team to deal with them, and frequent follow-up.

How have you engaged your staff and physicians in the ACO transition?

Communication is key, and physician involvement in policy-making is a very important component of success. Many physicians are new to the imperatives of accountable care, so direct outreach is essential. We already had a strong provider relations department because of our experience with value-based contracting. But we expanded its purview to include face-to-face guidance on quality metrics for practitioners and their office staff. We developed a program to help small practices obtain EHR systems. And we formed a Physician Quality Initiative Committee to help guide our priorities and policies. 

What challenges do you see on the horizon for ACOs?

The challenges are essentially the same as they have always been for organizations dedicated to providing cost-effective quality care, but they have taken on greater importance as government health care programs and private insurers increase their emphasis on accountable care. The basic requirements for success include:

  • Sophisticated risk stratification for targeted interventions;
  • Care management activities tailored to the needs of the individual;
  • Robust operational and IT infrastructure platforms; and
  • A scalable, configurable delivery approach to align with unique customer competencies.

How have these changes made a difference for patients?

Two recent stories come to mind. They both show how our interdisciplinary approach improves care for patients. 

The first involves a woman in her mid-60s, who was covered by both Medicare and Medicaid, who came to the hospital because of an asthma attack. A licensed practical nurse on the ACO Care Transitions team called her at home several days after her discharge, and referred her to the ACO Pharmacy team because she was taking a lot of medications. The woman’s primary language is Spanish, so a Spanish-speaking member of the ACO’s Pharmacy team called the woman to talk about her medications. During the conversation, the ACO Pharmacy team member learned that the woman hadn’t gotten her prescribed nebulizer solution — her local drug store told her that they couldn’t fill the prescription because it required prior authorization. The ACO Pharmacist then called the community pharmacist to suggest that the prescription had been billed incorrectly. The community pharmacist made the correction, filled the prescription, and had it delivered to the beneficiary. The team’s interventions helped prevent a possible delay in this woman getting the medication she needed to help prevent future asthma attacks.

Another story involves a 39-year-old man with several chronic conditions, including end stage renal disease. He held a job earning $60,000 a year until his renal disease progressed to the point that he needed dialysis three times per week, he was no longer able to work, and he depleted his savings. An ACO patient educator arranged for rental assistance from a community-based housing organization and food stamps. At the same time, an ACO social worker coordinated with his dialysis center so he could qualify for Medicaid benefits, which made him eligible for transportation to his medical and dialysis appointments. All of this coordination, communication, and support helped him to stabilize his living circumstances and receive the care he needed.

 

You may also be interested in:

Share the Work, Share the Wealth - Lessons from Coastal Medical’s ACO Journey

Commonwealth Fund Case Study - Montefiore Medical Center: Integrated Care Delivery for Vulnerable Populations

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