Innovative Strategies Can Boost ACO Provider Engagement, Performance

At the National Association of ACOs (NAACOS) Fall 2018 conference, being held October 3-5 in Washington, DC, panelists shared successful innovative initiatives that have been developed by their accountable care organizations (ACOs). What worked and what did not was the focus of the conversation led by Debbie Welle-Powell, chief population health officer, Essentia Health.

Participants included Melissa Arana, MSN, RN, CMSRN, director of quality improvement, Baylor Scott and White Health; Amanda Gerlach, JD, MPA as executive director, Mission Health Partners (MHP); and Beth Souder, director of post-acute network, Delaware Valley ACO (DVACO). All 3 organizations are winners of NAACOS’ call for ACO innovations.

Baylor Scott and White

Baylor Scott and White Quality Alliance (BSWQA)’s ACO, which includes more than 6000 providers spread across 50 hospitals and 95 postacute care facilities, has also signed 13 to 14 value-based contracts with both commercial and Medicare payers, Arana said and added that provider performance on predefined quality measurements drives their compensation distribution model.

She shared a process map with the audience to show how BSWQA identifies care gaps in workflows and then develops interventions to cover these gaps.

“Interdepartmental groups came together to understand why providers weren’t meeting quality requirements and developed a fishbone diagram,” according to Arana. “The highest bucket of care to focus on was identified through a prioritization tool,” which included issues with such as lack of direction on goals and accountability, lack of organizational arrangement, and multiple measures, lag time in reports, and lack of standardized internal reports among many others.

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She then presented 4 of the innovative solutions that were a part of their wining submission:

1. Network utilization: Because providers were unable to identify BSWQA patients to keep them in-network, 3 interventions were proposed:

• Network utilization education was disseminated to providers who were below a particular threshold. “Thresholds are set when we develop goals; if you don’t meet them, you shouldn’t participate,” Arana said.
• Providers were educated around ACO-BSWQA patient identification
• A provider search tool was added to all provider dashboards to allow patient identification: a drop-down menu allowed them to look at provider network for ease of reference. This improve patient care coordination.

The impact of this intervention was increased network utilization from 54.6% to 56.8% between 2016 and 2017.

“We are sustaining this by our Network Teams following up with the providers who are below a particular threshold on a quarterly basis.”

2. Focus measures creation: Presence of multiple quality contract measures led to lack of focus in physician efforts, which ultimately affected provider performance. The 3-pronged intervention included:

• Identifying the most common measures across various payer contracts to develop focus measures. “We drilled down into [electronic health records] to understand workflows in provider offices,” she said.
• Focus measure goals and thresholds were developed and implemented in May 2017
• Finally, the focus measure action plan was implemented

A drastic reduction in quality measures was observed, from 63 down to 8, which in turn improved performance on the metrics.

3.Internal gap report creation: Duplication of efforts due to multiple reports being developed to identify gaps.

• The analytics team at BSWQA developed standardized care gap reports
• These reports were utilized for patient reach outs and the gap closure process was revised

4. ​​​​Provider dashboard enhancement: Limited patient-level performance information with providers and care gaps. To improve on this:

• Provider dashboards were updated to include focus measures, including provider’s performance, patient-level data for each care gap, and links to resources to improve performance
• Include provider and practice-level reviews in newsletters.

Provider logins saw a 4-fold increase, from 9284 in 2016 to 37,906 in 2017.

“Provider education on this front continues and the dashboard is being enhanced over time,” Arana said.

Coming full circle, provider performance showed definite improvement. “The overall provider quality performance was 58.1% between October 1, 2017, and March 30, 2018, exceeding the goal of 52%,” according to Arana.

Their value-based care model is patient-focused and includes preventive services, as well as management of chronic illness and more adolescent well-care visits, screening for patients with diabetes, preventive cancer screenings, and more.

“Our total gross performance-based savings were $46.4 million, employers saved $22.7 million, and total performance revenue was $25.7 million,” Arana concluded.

Mission Health Partners

MHP, which was established in North Carolina in 2014 and started operations as a Medicare Shared Savings Program ACO a year later, has an urban-rural reach. Gerlach told attendees that MHP is engaged in 6 value-based arrangements with Medicare Advantage and commercial payers and has also generated savings as a Medicare ACO. According to a press release from the organization, MHP’s quality score for its 2016 performance crossed 97% and saved Medicare $11 million.

“We were advised to form a strong primary care base to ensure we met the ACA requirements,” for their urban-rural patients. Geralch said that MHP maintains a know-your-provider culture. Understanding provide culture was vital, she said.

A majority of MHP’s providers are specialists, most of whom (n = 455) are employees and a smaller number (n = 363) are independent. Primary care physicians form a relatively small segment of MHP’s providers (n = 298) and a majority of them run independent practices (n = 223), Geralech said. They have 450 practice locations, including mini-satellite locations that may operate for a half day.

“Our care model is built on relations with patients in a non-threatening way, and we wanted to develop a similar approach for providers,” she added.

MHP conducted a communications survey and an important suggestion that came out of it was the creation of a useful app for care providers.

The organizations bottom line is consistent and constant communication with these providers via diverse platforms ranging from onsite visits to electronic portals to provider-dedicated podcasts. “The app continues to grow, with new features being added. Additionally, we share a quarterly newsletter that includes practice spotlights to share innovative programs/successes from within our network of providers.”

MHP’s practice managers interact with providers on a monthly basis via webinars and they also conduct networking events with these managers and with providers.

Delaware Valley ACO

The third winner, from the DVACO, Souder was tasked with effective collaboration with postacute leadership of ACO Member Institutions and postacute partners to promote the optimization of all quality improvement, utilization management, and care management activities for patients in postacute settings.

She directed the award to the postacute care (PAC) steering committee who she said play a vital role in guiding their ACO strategies.

This year, DVACO has about 2000 physicians, a mix of employed and independent; one-third are PCPs. Its early strategy in late 2016-2017 included:

• Assign PAC duties to current staff member that has 1 or more other assigned duties
• Focus on skilled nursing facility (SNF) spend
• Develop a preferred SNF network based on lengthy application process and primarily self-reported/difficult-to-measure responses
• Perform performance measure feedback report to partners based on limited, readily available claims data

“A major lesson learned from 2017 is that establishing preferred networks is really the easy part,” Souder said. “Leveraging them to improve outcomes is more difficult and critical to success in improving value.”

Addressing cost saving opportunities in home health, she said that while there is variability across quality and cost among home health agencies, there is definite value in home health care in decreasing the total cost of care.

In acute care, SNFs are overutilized and there’s a culture of immobility being fostered, which is not healthy and causes avoidable delays in discharge, which in turn raises costs. DVACO hospitals are all implementing a patient mobility program to address this.

The next steps in this process for DVACO is to work creatively to repurpose care coordinators, care liaisons, SNPs, and home health coordinators to provide care management for the PAC population.