A study in The American Journal of Accountable Care analyzed the clinical and administrative workforces of 17 ACOs. An aspect of the analysis looked at the resources needed to reduce the overall cost of care by improving care for high-risk patients.

The study provides a window into how ACOs manage high-risk, moderate-risk and low-risk patients and the use of post-acute providers and care transitions. Different care management strategies are applied to patients at different levels of risk.

High-Risk Patients

The healthcare workers who were most commonly assigned to manage high-risk patients across ACOs were care coordinators or case managers, roles that were typically filled by registered nurses (RNs) or social workers at the sites participating in this study. All sites reported using someone in this coordination role, although the titles varied. Most ACOs embedded them in at least some of their primary care practices, 5 primarily used centralized care coordinators for either telephonic or face-to-face care, and a few used a hybrid approach because not all practices had the patient volume to support an on-site person. The primary duties of this role included communicating with other care team members and the patient to ensure that the provider’s recommended care plan was put into place, that any gaps in care were met, and that appropriate follow-up appointments and tests were scheduled as needed.

 “Six ACOs were working to coordinate more closely with staff at home health agencies and visiting nurse associations to ensure patient adherence at home to providers’ care plans, to alert the health system in cases of unsafe living arrangements, or to provide extra services due to changes in patients’ personal support networks.”

Although the number of patients assigned to each care coordinator varied by ACO, there was general agreement among different ACOs that 1 care coordinator or case manager could actively manage somewhere between 100 to 150 high-risk patients. Those assigned to a larger population of patients tended to have patients at different risk levels, not all of whom required the same level of care management (for example, some case managers were assigned 1000 to 1500 patients, but only 5% to 10% of them had health needs so significant as to require active case management). Some care coordinators expressed a preference for lower patient-to-provider ratios to improve efficacy in addressing individual patient needs; however, not all programs had sufficient funds to support this.

Four sites developed separate clinics devoted to intensive outpatient care management services—sometimes referred to as “ambulatory ICUs [intensive care units]” – that were specifically designed to intervene and break the cycle of repeated hospitalizations for high-risk patients or those with complex chronic diseases. These clinics were quite resource-intensive and had much lower patient-to-provider ratios than general primary care practices, allowing providers to devote more time and more frequent follow-up visits to these high-need patients. They also included additional team members, such as addiction and behavioral health specialists, geriatricians, dieticians, pharmacists, and patient navigators, to meet specific needs.

Recognizing that social determinants are a major contributor to costly but avoidable hospitalizations and emergency department (ED) visits, 11 ACOs targeted additional services to high-risk patients that go beyond the scope of traditional primary care services. Social workers, social service navigators, or, in some cases, community health workers link patients with community resources, such as housing, transportation, public health services, or in-home care, when needed. Seven of the ACOs were able to provide personnel—whether physicians, NPs, RNs, social workers, or emergency medical technicians—to conduct home visits for the frail elderly or patients with conditions that limited their ability to come to the clinic, often through pilot waiver programs or supported by other resources designated by the health system. Six ACOs were working to coordinate more closely with staff at home health agencies and visiting nurse associations to ensure patient adherence at home to providers’ care plans, to alert the health system in cases of unsafe living arrangements, or to provide extra services due to changes in patients’ personal support networks.

Many sites also discussed examples of primary care practices coordinating with hospitals in the region to receive daily updates about their patients who had been admitted or visited the ED. In some cases, this could trigger outreach from a social worker or community health worker affiliated with the practice to ensure continuity of care. Finally, some ACOs were working more closely with skilled nursing facilities. Agreements ranged from developing new protocols for sharing discharge information to placing a full-time NP or other clinician on site with the aim of preventing the need for ED visits and hospital readmissions.

Moderate-Risk Patients

ACOs, in general, reported fewer changes in roles for professionals caring for what are sometimes called “rising risk” or moderate-risk patients. These patients have conditions that are currently stable but, if exacerbated, could push them into the high-risk category.

Some ACOs reported devoting some modest care coordination (2 ACOs) or nurse-led wellness and education protocols to these patients (eg, smoking cessation or motivational interviewing around diet and exercise) (8 ACOs) to monitor them and prevent them from rising into the higher-risk tier. For example, 2 ACOs assigned certified diabetes educators, who are registered dieticians with additional training in diabetes medications and management, to meet with patients with diabetes across a number of primary care clinics who have been identified by the ACO as at risk for uncontrolled blood sugar. These professionals help to create a customized care plan for each patient, help the patient understand his or her condition and set goals for improvement, and monitor progress. Pharmacists are also being increasingly integrated into care teams for moderate- or high-risk patients (8 ACOs), to review medications and help resolve duplications and interactions, and identify strategies to improve patient adherence and health outcomes.

A common theme running through services provided for high-and moderate-risk patients was enhanced access to behavioral health services. Staff providing such services – which might consist of individual or group therapy sessions, psychiatric medication management, or alcohol or drug treatment – typically included licensed master’s-level behavioral health specialists, such as clinical social workers, therapists, and drug and alcohol counselors. In 8 ACOs, behavioral health specialists (either licensed professional counselors or licensed clinical social workers) were embedded in primary care clinics or co-located with primary care teams to provide real-time access for patients dealing with acute mental health issues, or to provide a warm handoff to ongoing care.

Moderate-risk patients who are hospitalized may also receive care transition services from nurse or social worker care coordinators to help smooth the transition from hospital to home or another facility. These services, which generally aim to ensure the patient continues receiving quality care outside the hospital and to prevent readmissions, may include comprehensive discharge planning, taking into account the patient’s physical and social needs, enrollment in a care management program led by a nurse or social worker, and the coordination and scheduling of follow-up appointments with primary care or specialist physicians within a short period after discharge.

Low-Risk Patients

All patients in an ACO, including low-risk patients, are generally tracked and flagged for preventive care such as vaccines and screenings, by a patient data analyst. The personnel in this role varied greatly by site, from medical assistants, licensed practical nurses, licensed vocational nurses, and/or RNs searching the electronic health record for risk factors and identifying groups of patients, to professionals with training in health informatics to perform complex risk-stratification analyses.

Some ACOs also reported other changes in care for all ACO patients, including low-risk patients, such as directing referrals to specialists who can demonstrate that they provide high-quality care at lower cost or to those who participate in agreements to send information about the patient back to the primary care office (3 ACOs). In general, few major workforce changes were found to have taken place for the low-risk patients who make up the vast majority of ACO patients, but additional wellness and patient engagement efforts were often cited in interviews as service areas that ACOs would like to expand in the future, once enough savings had been generated from better management of higher-risk patients to enable investing in other areas. Directing patients to smoking cessation and weight loss resources were mentioned as common starting points.

From a PAC provider perspective, this information is helpful to better understand the “inner” thinking of an ACO structure. PAC providers can analyze where their services can integrate with risk-stratification to reduce the cost of care, manage patients in the home, and provide resources for community-based, private pay, hospice and palliative care services.

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