For North Carolina ACO, Tech-Enabled Patient Outreach Drives Continued Success

May 23, 2018
At Triad Healthcare Network, technology has been a critical factor in the ACO’s success, specifically technology tools that help to identify gaps in care and scale patient engagement efforts, ultimately driving significant improvements in clinical outcomes.

Triad HealthCare Network, a subsidiary of Greensboro, North Carolina-based health system Cone Health, is a physician-led accountable care organization (ACO) with a network of more than 1,200 physicians and providers and six hospitals covering patients across five North Carolina counties in what’s known as the Piedmont Triad area, or the north-central region of the state.

In those five counties, Triad HealthCare Network (THN) participates in a number of risk-based contracts with multiple payers, and the contracts vary in ranges of risk from shared savings programs to full-risk contracts. THN covers 84,000 patients through several Medicare Advantage plans (Humana, United Healthcare, Health Team Advantage) and an employer-based plan.

In July 2012, THN was selected to participate in the Centers for Medicare and Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP) ACO program. According to THN leaders, the organization was ranked fifth in the country for quality in the MSSP ACO program in 2015 and scored 99.8 percent on the required quality metrics for that year. And, as of January 1, 2016, THN was selected to participate in the Next Generation ACO.

As Healthcare Informatics Managing Editor Rajiv Leventhal noted in an article published earlier this month, when CMS announced the Next Gen program early in 2016, the idea was to “build up on experience from the Pioneer ACO model and Medicare Shared Savings Program (Shared Savings Program),” the federal agency said at the time. Indeed, Next Gen model participants have the opportunity to take on higher levels of financial risk—up to 100 percent risk—compared with ACOs in other current initiatives.

CMS released the results of the first year of its Next Gen ACO model in October, which indicated 11 of 18 Next Gen ACO participants were able to earn shared savings in 2016. What’s more, all 18 ACOs in this model scored 100 percent on quality across 33 measures they were graded on. CMS announced that 28 ACOs joined the model for 2017, bringing the total number of Next Gen ACOs to 45.

Based on CMS data, Triad HealthCare Network generated $10.7 million in shared savings in the first year of the Next Gen ACO program, ranking second out of the 18 ACOs that participated in the program in 2016. THN covers 27,780 beneficiaries in its NextGen ACO program.

THN executive leaders contend that technology has been a critical factor in the ACO’s success, specifically patient engagement and care coordination technology tools that help to identify gaps in care and scale patient engagement efforts.

“The other key is having strong physician leadership. Our physicians are truly partnered with us. We feel we are physician-led and physician-managed; our physicians are driving what’s going on and really trying to affect appropriate change in the health care system. So, I think those areas—technology tools and physician leadership—are what’s making a difference for us,” Elissa Langley, director of accountable care operations for THN, says. And, the technology tools and care coordination together have helped to drive significant improvements in clinical outcomes.

Leveraging Technology to Advance Population Health

An interesting detail about Triad HealthCare Network is that while the ACO is a subsidiary of Cone Health, more than 60 percent of the practices and providers participating in the network are independent community physicians and are not directly affiliated with Cone Health, about 40 percent are employed by the Cone Health system.

“Our physicians are on over 30 different electronic medical record (EMR) platforms, so it’s been a challenge over the years to try to aggregate data for so many different disparate systems, but we’ve done a really good job of doing that. And, we’ve been able to report on 34 ACO measures that have been part of the Medicare CMS program,” Langley notes.

However, early in the organization’s MSSP ACO journey, THN executive leaders recognized the organization wasn’t reaching all the patients in most need, disabling the organization from meeting quality metrics necessary to receive payment. In the 2014 and 2015 performance years of the MSSP ACO program, THN did not achieve shared savings as the minimum savings requirement was not met. In order to better engage with its patients and ensure measures are met and dollars are not left on the table, THN worked with Emmi Solutions, a patient engagement software vendor now part of Wolters Kluwer, to implement several technology tools to address gaps in care and improve patient education and engagement.

The organization wanted to scale its outreach for preventive care and implemented the vendor’s EmmiPrevent tool, which provides customized, interactive call campaigns designed to inform patients about screenings, visits and procedures. “That tool enables outreach calls to our patients to remind them to have some sort of preventive service, such as to get their flu shot or get their mammogram. We’ve had incredible work in that area. We’ve been able to move the needle and actually increased our numbers, as when we first started out we had about 2,500 calls and now we’re up to over 100,000 calls a year. It’s been an invaluable tool in terms of helping us to close some of those gaps for our metrics,” Langley says.

As a result of this outreach work, THN has improved on a number of quality measures, particularly mammography screening rates, fall risk assessments and flu vaccinations. THN has increased mammography screenings from about 60 percent to 86 percent. THN also worked with Emmi on a new campaign to identify patients at high risk of a fall in order to provide early intervention.

“Fall risk assessment is pretty critical to our Medicare population, and we saw there was a lot of discrepancy about whether providers were doing it, how frequently they were doing it, and were they even charting it,” Tonda Gosnell, population health project manager for Triad HealthCare Network, says. “We launched that initiative late last year, we called over 7,000 patients and got a really good response rate, about 51 percent engagement. By collecting the information based on responses from patients and returning that information to primary care providers so they can act upon it, we were actually able to move the needle from the 80th percentile of that CMS metric to the 90th percentile.”

Gosnell continues, “We are really aiming towards hitting high marks on all 34 metrics. The EmmiPrevent tool, across all those various providers and various EMRs, helps us to really burrow down and get to the metrics that we’d like to achieve, all while driving patients back to appropriate care.”

ACO leaders also implemented a technology platform to improve transitions of care for patients upon discharge from an inpatient admission with the goal of preventing avoidable readmissions. The EmmiTransitions platform employs multimedia programs and interactive voice response calls to advance patient outreach, while also providing care teams with information about the patient’s status. Care teams receive flagged reports with the data collected from the patients, enabling clinicians to optimize their time to focus on those who may need extra help.

“It’s really an extension of our care management team. When a patient is flagged, the care management team will reach out and call those patients,” Langley says. “Some of the things that they commonly find for action is that patients didn’t fill their prescriptions, they didn’t take their medication, they did not weigh themselves for heart failure monitoring, or they are feeling worse, and that would flag one of our care managers to intervene, reach out to the patient and help to knock down those barriers.”

Through these efforts, THN has reduced 30-day readmission rates as well as 60-day readmission rates for certain patient populations. Langley says, “Particularly the areas that we were most effective were heart failure, pneumonia, COPD (chronic obstructive pulmonary disease) and stroke. We’ve been effective at reducing cost and improving outcomes for our patients.”

Citing data from THN’s work with one of its health plans, Langley notes the following results for 30-day readmission rates: heart failure readmission rate is now down to 7.55 percent, pneumonia readmit rate has dropped to 9.09 percent, COPD dropped to 4.55 percent and stroke patients dropped down to 2.50 percent. For those same patients, the 60-day readmission rate for heart failure patients has dropped to zero, as well as for COPD and stroke patients. The 60-day readmission rate for pneumonia patients dropped to 4.55 percent, Langley says.

Gosnell also notes that leveraging the transitions of care tool helped Cone Health’s Moses H. Cone Memorial Hospital to earn status as a Joint Commission Certified Advanced Primary Stroke Center.

“The transitions of care model is particularly interesting, because it’s not the technology alone. This model is pairing the technology, which is helping to scale these calls and ensuring consistency in what information we’re collecting, and then looping our care managers back into play when a patient is activated, or when patients are telling us that they have a need," Gosnell says.

THN leaders also focused on improving patient education and procedure preparation leveraging multimedia programs designed to simply medical information, manage patient expectations and increase patient understanding. “We wanted to have a standardized education platform for our patents. The tool is a library of educational videos that are interactive with the patients, and we really liked that approach,” Langley says.

The organization first deployed the platform in the GI department for colonoscopy patients. “We got a lot of great feedback that it helped to reduce anxiety for patients going for a colonoscopy for the first time. To me, that’s a big win because you’re helping the patient understand what they are about to go through,” Langley says.

All three platforms put together provides THN physicians and providers with point-of-care tools that improve care coordination and patient outreach, and reduces waste in the system, such as duplication of testing, Langley notes.

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