How are accountable care organizations innovating as they move into value-based payment arrangements? Here’s one example: To stop the revolving door between jails and emergency departments, the Central Minnesota ACO has worked to address behavioral health in St. Cloud, Minn., by bringing together police, jails and public health to create community action teams. For that work, the ACO was one of three organizations recognized as ACO Innovation Award winners celebrated at the National Association of ACOs (NAACOS) Fall meeting in Washington, D.C., last week.
Kathy Parsons, executive director for the Central Minnesota Health Network, a 13-partner clinically integrated network, and executive director of the Central Minnesota ACO, described the effort to address behavioral health issues. “It started with our healthcare organization talking with police, jails and public health, and we discovered we had 14 different silos,” she said. Their goal is to stop the revolving door of police calls and ER visits. Approximately 60 percent of police calls and 60 percent of jail inmates have mental health issues, she said, adding that like health systems, jails think the average length of stay is too long. Homeless people get picked up for loitering and end up spending eight days in jail. When the police, jails and emergency departments looked at who were their most frequent contacts in the community, there was amazing overlap.
The ACO took the unusual step of getting contracts with two county jails to provide healthcare services in the jails, replacing other outsourced vendors. They also created a Coordinated Care Clinic that cares for patients who have a combination of physical health, mental health and social determinant issues, she said. Some of these patients have been kicked out of other clinics. The clinic includes an addiction medicine physician, RNs, LPNs, pharmacists, mental health providers and a community liaison. Then jail patients can transition to the Coordinated Care Clinic. “We took the people we care for in jail and put them in the Coordinated Care Clinic,” Parsons said. They also created a Community Action Team to work on how to take care of high utilizers in the community.
“We have 43,000 people in Medicaid ACO and have been successful at shared savings,” Parson said. Although there was a gap in funding of about $100,000 for the jail clinic project, she added, “we have more than made up for that in shared savings. We know that this is a part of it.”
The community is taking several more steps, she said. For instance, the county hired two probation officers to go into jails and assess who needs mental health help. They also are adding advance release planning for all inmates to determine what services they need when they get out.
"We are looking at more partnerships,” she said. “We want to make the tent large, so we are looking at who else can we bring in.”
High Utilizer Care Plans
In a similar vein, Christina Lewis, M.P.H., R.N., executive director of Pennsyvlania-based St Luke’s Health Care Network, accepted an award for creating “high-utilizer” care plans. St. Luke’s Health Care Network is a clinically integrated network over 10 counties and two states with 1,900 physicians.
“In late 2017 we decided we wanted to do something to try to address the issue of high utilizers,” she said. First, they came up with a definition of who they wanted to help:
• Frequent ED visits and admissions
• Multiple campuses seeing the same patient
• Low primary care use
• Problems with ED throughput
“These are largely provider-centric reasons,” Lewis said. A larger reason is the failure of the health system to meet their needs.
Lewis said care plans are created for these patients and integrated with Epic. The care plan features a concise summary of key issues for the patient. ED physicians, nurses and hospitalists can initiate a care plan. Then when that patient is seen next, the patient’s chart has a clinical decision support flag telling the provider that there is a care plan for this patient.
They now have 88 patients with care plans, and have seen a 25 percent reduction in metrics they follow about them.
She said one learning was that “patients are dissatisfied when a care plan is written about them, but grateful when clinicians collaborate with them on how we can invest the right care teams to support their health and social welfare.” Now the conversation with the patient is that they are part of the creation of the care plan.
Lewis also said it is important to engage primary care. “We have not done a good job of this so far. These patients are often not seen by primary care. We are moving in that direction.”
Clinical Research in ACOs
Chastity Chace, director of finance at Wilmington Health Associates in North Carolina, accepted an award for her organization’s effort to create a collaborative of ACOs working together to advance clinical research.
Wilmington Health is a physician-led multispecialty group practice with one of the highest performing Medicare ACO’s in the country, Chace noted. It has 23 locations in four counties.
When a few of its clinicians were involved in clinical research studies, the group noted that patients had higher levels of engagement and satisfaction and some improved outcomes. Wilmington began doing more clinical research in its ACO and assessing the impact. A few years ago it decided to create a new group, Innovo Research, as a provider-sponsored, provider-led integrated network of ACOs using research as part of their population health strategy.
Working with a platform from vendor Optum, she said, the collaborative brings comprehensive site management services, centralized contracting and data management, increased study sponsors and pharma connectivity, and research site integration tools and capabilities.
