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As UT Southwestern Accountable Care Network (UTSACN) enters the last quarter of its three-year Medicare Shared Savings Program and reflects on its growth in attributed lives and provider participation, along with its success in achieving shared savings in both 2014 and 2015, it credits its continued success in managing utilization to its advanced care coordination program.
UTSACN, which has applied for both of CMS' upcoming value-based programs, Next Generation ACO and MSSP Track 3, has seen its attributed lives grow from 19,000 in 2014 to 250,000 this year and substantial growth in the number of participating PCPs, and has entered into three risk-based contracts with commercial plans as it moves toward more at risk-models.
During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a September 27, 2016 webinar, now available for replay, Cathy Bryan, director, care coordination at UT Southwestern, shares how her organization’s care coordination model manages utilization while achieving its mission of bridging the gap from where patients are to where they need to be to adhere to their care plan. Ms. Bryan also shares the key details behind its Home Health Evaluation Program, which saved the health system $6 million in just its first quarter.
You will learn how UTSACN's care coordination model:
- Uses a combined strategy to identify patients in need of care coordination, including a predictive model, PCP referral, hospital and ED utilization data and leveraging its own data warehouse;
- Takes a whole-patient approach to care coordination, addressing the socio-economic, education and psycho/social issues that can impact patients through a team-based approach of nurse care coordinators and community health workers;
- Develops relationships with PCPs and becomes an extension of the provider at the patient level through its care coordinators embedded in the primary care practice, as well as telephonic and home visits; and
- Delved into its data warehouse and identified home health as a key area in need of care coordination…and saved the health system $6 million in just one quarter by managing home health over-utilization while providing patients with the services they needed at the most appropriate level of care.
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WHO WILL BENEFIT FROM THIS CONFERENCE?
Presidents/CEOs, chief financial officers, chief operating officers, vice presidents, medical directors, population health executives, care and case management executives, physician practice leaders, strategic planning executives and reimbursement executives.
ABOUT OUR PANELIST:
As Direction of Care Coordination services for one of the largest Accountable Care Organizations in the country with currently over 230,000 attributed lives under various shared savings contracts, Ms. Bryan has a front-row seat to the impact of data in informing the stratification, identification and management of ACO attributed lives. With a blend of both Medicare, Medicaid, and commercial contracts, Ms. Bryan has a proven track record of leading a care coordination team through the challenges and nuances of this work.
Prior to joining UT Southwestern Accountable Care Network, now Southwestern Health Resources, Ms. Bryan has over 20 years of experience as Co-Founder and Chief Clinical Officer for CINA, a leading edge software development firm providing solutions for data extraction and standardization from clinical EMRs across a wide range of practice sizes, settings and EMRs.
As a researcher, Ms. Bryan was a founding collaborator to DARTNet Institute, one of the premier, federated network models for practice-based effectiveness research in the country. Ms. Bryan has served as a research collaborator and site investigator on many federally funded research studies, all based in primary care.
Ms. Bryan received a Bachelor of Science in Nursing from Baylor University and a Master's in Healthcare Administration from the University of Missouri-Columbia, where she also holds a position as adjunct faculty. Ms. Bryan has been published in peer-reviewed journals, serves as a sub-investigator for several federally funded research studies, and speaks frequently at national conferences.