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Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life
Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life
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When acknowledging its position as a top-ranking Medicare Shared Savings Program (MSSP), Memorial Hermann is quick to credit its own physicians—who in 2007 lobbied for a clinically integrated network that formed the foundation of the current Memorial Hermann accountable care organization (ACO).

Now, collaboration and integration continue to be the engines driving the ACO's cost savings, reduced utilization and healthy patient engagement rates associated with Memorial Hermann ACO's highest-risk population.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life details Memorial Hermann's carefully executed journey to quality and the culmination of the ACO's community-based care management program.

In this 25-page resource, Mary Folladori, RN, MSN, FACM, CMAC, system director of care management at the Memorial Hermann Physician Network and ACO, explains the four key pillars supporting her organization's care coordination approach as well as the significant impacts of these pillars, particularly in the area of complex care management.

Ms. Folladori presents the following Memorial Hermann ACO program elements in this report:

  • History of the clinically integrated physician network and the network's evolution as the backbone of Memorial Hermann ACO's care management initiatives;
  • Development and support of a cross-discipline team of healthcare professionals;
  • Immersion of care coordinators into the cultures of physician practices;
  • How close relationships with payors have informed Memorial Hermann's care management process and enhanced data collection;
  • Strategies behind a 74 percent engagement rate for patients enrolled in Complex Care, an initiative for patients with complex medical conditions;
  • Pilot programs testing virtual care for heart failure patients newly discharged from the hospital;
  • Memorial Hermann's Pathways to Life training that equips providers with tools to detect when members may desire different levels of care;
  • Targeted data dives to identify high-risk members proactively and connect them with critical health services;
  • A holistic member intake process resulting in comprehensive health risk scores for patients in Memorial Hermann's Complex Care Program;
  • Design of member-centric longitudinal care plans that follow Complex Care patients for up to 18 months with the goal of transitioning patients back to their baseline level of functioning;
  • 2014 quality results and cost savings achieved by the Memorial Hermann MSSP ACO;
and much more.

Table of Contents

  • Care Coordination in an ACO: Managing the Population Health Continuum from Wellness to End-of-Life
    • Memorial Hermann Health System Overview
    • Building the MSSP on Clinically Integrated Network
    • Construction of Cross-Professional Care Team
    • Impact on Patient Engagement
    • Payor Relationships Enable Data Collection
    • Patient Touchpoints and Engagement Tactics
    • Impacts of Complex Care Program
    • Holistic and Evidence-Based Patient Intake
    • Member-Centric Longitudinal Care Plans
    • ACO Support and Success
  • Q&A: Ask the Expert
    • Care Coordination Versus Case Management
    • Measuring Patient Engagement
    • IT Systems to Support Care Coordination
    • Administration of Member Intake
    • Risk Score Examples and Outreach
    • Capturing the Care Plan
    • Care Coordination Case Loads
    • Cultural Embedding of Care Coordinators
    • Barriers to Patient Engagement
    • Chronic Disease Targets
    • Social Workers’ Role in Care Coordination
    • Care Coordination for Injured Workers
    • Discharge Criteria and Patient Handoffs
    • Telehealth and E-Visits in Care Coordination
    • Elements of Longitudinal Care Plans
    • RN Responsibilities in Care Coordination
    • Health Coach Duties and Ratios
    • Identifying Physician Leaders
    • Drivers of MSSP Success
    • Working with Non-Engaged Patients
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: December 2015
Number of Pages: 25
ISBN 10: 1-941329-98-5 (Print version); 1-941329-99-3 (PDF version)
ISBN 13: 978-1-941329-98-6 (Print version); 978-1-941329-99-3 (PDF version)
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