At Spring Conference, NAACOS Quality Award Winners Share Keys to Innovation

May 4, 2023
Leaders from Delaware Valley ACO, University of California San Francisco, and Southwestern Health Resources present on patient care improvement efforts

At the National Association of Accountable Care Organizations (NAACOS) spring conference this week, three ACOs were recognized with Quality Excellence Awards for moving the needle on improving patient care: Delaware Valley ACO, University of California San Francisco, and Texas-based Southwestern Health Resources.

Jason Fish, M.D., chief medical officer with UT Southwestern ACO in the Dallas-Fort Worth area, spoke about working with a machine learning company called ClosedLoop. They are working to reduce unplanned hospital admissions among patients who receive complex care management by using a machine learning platform the ACO developed to help predict patients likely to incur a preventable event such as unplanned hospital admissions, emergency department high utilization, or death.

“When you traditionally look at how people take care management strategies toward population health, you usually do something called hot spots, right? You use historical data, claims-based data, and you say that's the population I want to focus on,” Fish explained. “The payers bring us lists of high utilizers, but these are yesterday's high utilizers. The question is, what percentage of them will be tomorrow's high utilizers. When we actually ran this, we found it was only 30 percent. And yet here we were focusing 100 percent of our energy on yesterday's risk and not tomorrow's. That made us say that maybe this isn't the right approach to this. How could we incorporate yesterday's risk, but really try to identify tomorrow's risk and spend our energy there?”

Working with ClosedLoop, UT Southwestern ACO, also known as Southwestern Health Resources, developed a risk stratification algorithm using machine learning techniques to match high-risk patients with complex care management services to prevent potentially avoidable hospitalizations and ED visits. Leveraging data from claims and EHRs, the ACO built predictive models and integrated and trained the models with data from publicly available social determinants of health data sets, such as the Social Vulnerability Index and the Area Deprivation Index, to identify socioeconomic barriers to care at the individual level.

The ACO then encouraged patients to enroll in a longitudinal complex care management program. Using personalized care management plans, patients received tailored support and care coordination for clinical, social, pharmaceutical, and behavioral health needs. The high-intensity multidisciplinary care management program spans three to four months and then community health workers follow patients for an additional two months, checking in with patients at least every two weeks and escalating issues to the larger, multidisciplinary team if needed. An analysis six months after the intervention found two unplanned hospital admissions among the 25 patients who received complex care management compared to 31 unplanned hospital admissions among 91 patients who did not receive enhanced care management.

The ACO plans to scale the intervention, setting a goal to engage 1,800 patients by the end of 2023. An anticipated success rate of 80 percent would avoid 1,440 unplanned hospital admissions, which at an estimated average cost of $15,000 per admission would equate to $22 million in cost avoidance.

“One of the things I'm excited about as a clinician is really looking at disease-based interventions,” Fish added. “We're trying to predict who has rapid progression of diabetes who ultimately entered a hospitalization, rapid progression of CKD and then rapid progression of unplanned dialysis. We can bring a lot of individual clinicians to the table and talk about what are the interventions for each of these based on the model, not just the wraparound multidisciplinary team, but what do you need to do as a physician if you have a list of five of your patients who are actually at high risk for rapid progression that you probably weren't thinking about?”

Delaware Valley ACO

Beth Souder, P.T., M.S.P.T., vice president of clinical operations for Delaware Valley ACO, explained how the ACO was able to show a roughly $9,000 per patient return on investment in the last 90 days of life through a comprehensive community-based palliative care strategy.

A collaborative team of clinicians and analysts built clinically relevant claims-based views of end-of-life care among the ACO’s Medicare patients and national benchmarks, finding, for example, that almost half of the ACO’s patients (47 percent) received hospice care for a week or less before death, much higher than the 28 percent nationally. Further analysis showed that longer hospice stays helped reduce the total cost of care.

The ACO used the findings to build the case with key stakeholders for earlier activation of palliative care, which centers on pain and other symptom management, care coordination and planning, and assessment and support of caregiver needs. Advance care planning toolkits were distributed to clinicians with tailored community-based information and resources. Services included in-home provider visits and access to social work and chaplain services, rehabilitation therapy, 24/7 on-call help with in-home visit capabilities, telehealth, telemonitoring, and advanced illness management services.

The share of patients receiving hospice for one week or less before death improved from 47 percent to 32 percent. Along with providing more positive end-of-life experiences for patients and families, an analysis found that patients receiving home-based palliative care resulted in savings of about $9,000 in the last 90 days of life compared to patients who didn’t receive palliative care. Moreover, providing home-based palliative care to patients before death reduced emergency department visits by 35 percent, inpatient admissions by 51 percent, and inpatient length of stay by 1.5 days. The program also increased the percentage of the ACO’s seriously ill population with an advance care plan from 25 percent to 46 percent.

“We are definitely moving palliative care and hospice upstream, which is our goal,” Souder said. “It feels good to say that we changed care delivery and oh, by the way, it was very helpful for value-based care. Patients who had home-based palliative care and did have admissions, their length of stay in the hospital was statistically significantly lower, so it's synergistic with the hospitals’ goals to reduce length of stay.”


Shirley Wong, PharmD, a clinical pharmacist with University of California San Francisco ACO, described their efforts to address disparities in blood pressure control.

After identifying a 10-point gap in 2020 between Black/African-American (67.6 percent) and White patients (77.8 percent) with controlled high blood pressure, UCSF Health set a health equity goal of reducing hypertension disparities. “After the disparity was recognized, it mobilized and incentivized groups to come together to brainstorm ways to work on this disparity,” Wong said.

Working with UCSF health disparities researchers, the ACO conducted interviews with Black/African-American patients to better understand their preferences, barriers, and competing priorities. Based on patient input, the ACO designed interventions, including culturally tailored hypertension educational materials. The ACO also developed a team-based coordinated intervention among primary care, pharmacy, and population health to help patients manage their hypertension.

Patients with uncontrolled hypertension were offered a 2- to 3-month intensive program with telehealth pharmacist visits to review medication management and coaching from healthcare navigators to support smoking cessation and other healthy behaviors associated with controlling hypertension. The ACO launched a separate effort for patients with hypertension and no recent blood pressure reading. Health navigators mailed home blood pressure monitors, taught patients to use them via the phone and video conferencing, and collected remote blood pressure readings. Patients with out-of-range readings were scheduled for primary care appointments. In-clinic distribution of blood pressure cuffs and nursing-based patient education were also used. A year after implementation, disparities in blood pressure control narrowed significantly, with 73.1 percent of Black/African American patients attaining blood pressure control compared with 74.3 percent of the overall population.

“The gains that we made in reducing hypertension disparities have actually been sustained until 2023. We've now expanded to other additional disparity groups,” Wong said. “We're working with our Latinx population with diabetes and on Medicaid patients with diabetes. We are going to continue working with other disparity populations and other chronic conditions. We're looking to scale the program through remote monitoring.”

Sponsored Recommendations

Patient Engagement and ML/AI – Modern Interoperability as an enabler for value based care

Discover how modern interoperability empowers patient engagement and leverages ML/AI for better outcomes in value-based care. Join us on June 18th to learn how seamless data integration...

The Crushing Weight of Healthcare Cloud Compliance & Security Debt: Perspectives & Strategies

Discover how to navigate the pressing challenges of healthcare cloud compliance and security. Join industry experts as they unveil key insights and actionable strategies to break...

Telehealth: Moving Forward Into the Future

Register now to explore two insightful sessions that delve into the transformative potential of telehealth and virtual care management solutions.

Telehealth: Moving Forward Into the Future

Register now to explore two insightful sessions that delve into the transformative potential of telehealth and virtual care management solutions.