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Proactive Care Management in a Top-Performing ACO: Closing Quality and Care Gaps in High-Risk, High-Utilization Populations
Proactive Care Management in a Top-Performing ACO: Closing Quality and Care Gaps in High-Risk, High-Utilization Populations
Proactive Care Management in a Top-Performing ACO: Closing Quality and Care Gaps in High-Risk, High-Utilization Populations
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As one of 2016's top 10 performing MSSP accountable care organizations, UT Southwestern Accountable Care Network (UTSACN) generated nearly $17.5 million in shared savings.

Proactive Care Management in a Top-Performing ACO: Closing Quality and Care Gaps in High-Risk, High-Utilization Populations divulges some of the secrets behind UTSACN's success in the Medicare Shared Savings Program (MSSP) for ACOs. Winning strategies of the UTSACN ACO include a commitment to data analytics to inform programming and improve utilization and quality as well as holding its healthcare providers accountable for clinical and fiscal decisions.

In this 25-page resource, Cathy Bryan, UTSACN's director of care coordination, describes the structure and focus of the UTSACN ACO, selected in January to participate in the Next Generation ACO model. By functioning as extensions of primary care teams, UTSACN's care teams reduce barriers to care plan adherence and help patients bridge gaps to self-management.

In addition, Ms. Bryan hones in on the rewards of leveraging data for quality improvement in the area of UTSACN's home health utilization and efficiency, where costs had been twice the national average. She walks through the analytics that reduced UTSACN's disparate network of more than 1,200 providers to a preferred network of the 20 most efficient home health agencies, generating $6 million in savings and reducing utilization by 8 percent.

Part of this process included the education and engagement of providers in more efficient use of home healthcare, as well as raising awareness of their clinical and fiscal responsibilities as providers within the ACO.

Ms. Bryan outlines the following concepts in this special report:

  • Eight secrets of UTSACN ACO success;
  • Three key types of data leveraged by UTSACN for care management of high-risk, high-utilization patients;
  • Care management team structure, focus and responsibilities;
  • Seven ways UTSACN multi-factorial care teams address barriers to medical care plans;
  • Five specialty sub-teams that support care management;
  • UTSACN 'pod' approach to population health management;
  • Detailed case study on how UTSACN leveraged data to risk-assess and improve home health utilization and efficiency;
  • Educating and engaging healthcare providers in effective use of home healthcare;
  • How UTSACN holds primary care providers accountable for their clinical and fiscal responsibilities within the ACO;
  • Seven key outcomes resulting from UTSACN data analytics;
and much more.

Table of Contents

  • Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO-Attributed Lives
    • 8 Secrets to ACO Success
    • A Look at UT Southwestern ACO
    • Leveraging Available Data
    • Care Management Team Focus
    • Addressing Barriers to Medical Plan of Care
    • Care Management Team Structure
    • Leveraging Data for Quality Improvement
    • Narrow or Preferred Network for Home Care
    • Educating Providers on Home Health Utilization
    • Engaging Providers in ACO Fiscal Responsibility
    • Outcomes and Ongoing Work
  • Q&A: Ask the Expert
    • Team Coordination Across the Continuum
    • Predicting ED Utilization
    • Most Critical Gaps in Care
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: January 2018
Number of Pages: 25
ISBN 10: 1-943542-76-7 (Print version); 1-943542-77-5 (PDF version)
ISBN 13: 978-1-943542-76-5 (Print version); 978-1-943542-77-2 (PDF version)
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