Meritage ACO Lowers Readmissions With Mobile Care Management Program

The Novato, Calif.-based Meritage Accountable Care Organization (ACO) has announced successful results of a two-year mobile care management program designed to help lower preventable hospital readmissions among its highest-risk patients.

The Bay Area-wide patient readmission rate dropped to 10.2 percent, placing it considerably below the 17.5 percent national average in 2013 for Medicare patients, according to Meritage officials. Meritage ACO is the first healthcare organization in the North Bay Area of California to be designated a Medical Shared Savings ACO by the Centers for Medicare & Medicaid Services (CMS), according to the organization. It encompasses 250 primary care physicians and specialists from its own network and 21,000 beneficiaries across Marin, Sonoma and Napa counties.

The care management program combines an internally developed, evidence-based hybrid model of care with a driven mobile care navigation network from the Los Angeles-based Zynx Health. The cloud network brings all participants onto a single electronic information-sharing platform, allowing them to collaborate on evidence-based transition plans and follow-up with patients post-discharge, officials say.

In developing the program, Meritage ACO targeted older adults who are at a high risk for readmission as identified through evidence-based tools. Most of these older adults have complex chronic conditions requiring close management, and some have complex psychosocial needs that impact their ability to manage their own healthcare. Meritage ACO nurse care managers visit patients at the bedside before discharge to provide care transitions coaching. The care managers explain the process, provide education, answer questions, assess the patient’s willingness to engage in their own care needs, and plan for their transition.

The program’s readmission process improvement placed Meritage ACO just below the coveted 90th percentile for chronic heart failure, asthma, chronic obstructive pulmonary disease and all-cause 30-day readmission avoidance. “As an ACO, we have extra incentive to lower readmissions by managing the quality of the care we deliver throughout the entire continuum,” said Andrea Kmetz, R.N., director of care management and quality assurance at Meritage ACO.