Success as an ACO likely won’t come from any one strategy, but from many. Christopher Kim, MD, MBA, SFHM, a hospitalist and associate professor of internal medicine at the University of Michigan, says the Michigan Pioneer ACO serving roughly 20,000 beneficiaries in the state’s southeastern region has benefited greatly from a variety of pre-existing relationships and initiatives. The university’s medical center, one of 10 participants in a Medicare ACO precursor called the Physician Group Practice demonstration project, was among the few sites to successfully meet the requirements and gain the full cost savings benefits in all five years.
The newer ACO, which officially launched in January 2012, pairs the university’s Faculty Group Practice with Integrated Health Associates Inc. (IHA), a large multispecialty private-practice group. Many IHA providers already had access to the university’s electronic health records so they could track admitted patients. One preliminary collaborative effort between the two entities hinted at a trend toward lower readmission rates among a small group of patients who were seen by a primary-care provider within seven days of a hospital discharge, underscoring the importance of a smooth transition.
Providers also have been able to tap into statewide initiatives aimed at improving quality and care coordination in key areas, such as cardiovascular disease, cancer, and hospital care transitions (sponsored by Blue Cross Blue Shield of Michigan).
—Christopher Kim, MD, MBA, SFHM, associate professor of internal medicine, University of Michigan Health System, Ann Arbor
“These programs helped physician organizations and hospitals throughout the state become familiar with best practices related to these kinds of conditions,” Dr. Kim says, “and I think partly because of that, we were very prepared to work on a quality-improvement initiative such as this while also improving efficiency.”
Listen to Dr. Kim discuss the added responsibility hospitalists in ACOs like the one formed between the university faculty and a large multi-specialty practice called Integrated Health Associates, Inc.
For stratifying beneficiaries by risk, the ACO has benefited from a separate initiative called the Michigan Primary Care Transformation Project, which uses the concept of a pyramid to classify increasingly complicated patients. A complex-case manager, typically an advanced practice nurse, acts as the point person for guiding patients in the upper half of the pyramid toward the best resources while preventing unnecessary duplication of tasks or consultation referrals. Optimal coordination means that hospitalists need to communicate effectively with these managers as well as with other providers.
From Medicare claims supplied by CMS, Beth Israel Deaconess Physician Organization (BIDPO) in the Boston metropolitan region has used software to identify its highest-risk patients, or those most likely to be admitted to the hospital within the next 12 months. As part of the process, BIDPO officials asked doctors to validate the results based on their own patient records and observations.
The ACO has hired nurse practitioners through a company called INSPIRIS Massachusetts to visit its sickest and frailest Medicare beneficiaries at home to prevent hospital admissions and to avoid post-discharge readmissions among the highest-risk patients. BIDPO also uses nurse care managers to do telephone-based care management for less acute patients, and is asking emergency department staff to recognize patients who could be sent home safely with appropriate care rather than be admitted. Patients with cellulitis, for example, could be treated via IV antibiotic therapy at home, a service made possible through a collaboration with a home infusion company.
Dr. Parker, BIDPO’s medical director, says hospitalists will be key to understanding the need for excellent inpatient care and thoughtful, comprehensive discharge planning that helps avoid adverse events post-discharge.