Breaking Down UTSACN Advanced Care Coordination:
"Data Analyst Is Your Best Friend"
Although the care coordination director for UT Southwestern's Accountable Care Network (UTSACN) insists there's no secret sauce that ensures ACO success, Cathy O'Brien readily proposes eight ingredients to season care management initiatives.
It's a recipe heavy on data analytics, and one destined to fail unless extracted data is transformed into actionable information, emphasized Ms. Bryan during a recent webinar, Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a September 2016 webinar now available for replay.
In case you missed this webinar, you still have a chance to watch this highly-rated program.
Register to view the conference today or order your training DVD or CD:
For that transformation, the Year Three Medicare Shared Savings Program (MSSP) ACO relies heavily on its data analyst. "Your analyst is your best friend. You need someone who is skilled and knows how to analyze large, complex data sources like you get with ACO claims data and other sources," Ms. Bryan said.
To better manage its nearly 250,000 ACO-attributed lives (up from 19,000 in 2014), UTSACN leverages data from a number of sources, including paid claims data from CMS and commercial payors; more than 100 disparate electronic medical record (EMR) systems; and ADT feeds. This data mining has helped UTSACN to identify and bridge care and quality gaps, manage transitions in care, and risk-stratify its population for care management, including 'risking risk' patients exhibiting signs of struggle with adherence to care plans.
It's also provided a starker picture of utilization, especially on the home health front. When data indicated UTSACN home health use had risen to levels more than twice the national average, UTSACN's analyst created an internal efficiency index to categorize the more than 1,200 home health agencies in use. The use of this claims-based, risk-adjusted score ultimately pared the home health network to a manageable twenty agencies and saved approximately $6 million in home health utilization costs in the first quarter of 2016 alone.
To engage physicians, UTSACN supported the rollout of this narrow network with a large-scale reeducation effort. Presented with the rationale for this change, providers now better understand Medicare's home health utilization rules and their accountability to the ACO for their share of costs, utilization and outcomes, notes Bryan.
"You've got to create buy-in. You don't just take providers a list and say, here's your problem. You've got to take a solution to them."
Another solution designed to support providers is UTSACN's primary-care-centric model, in which care coordination teams are paired geographically with eight to 15 physician practices. Composed of embedded care coordinators (as well as field staff that do in-home work), the care coordination teams reach out to the practices' patients on their behalf.
"We really see our team as an extension of the primary care practice, and we function as such. As we introduce ourselves to patients, we say we're with the UT Southwestern Accountable Care Network calling on behalf of Dr. Smith, your primary care physician."
As that extension, embedded care coordinators help physician practices to address barriers to patients' medical plans of care, from lack of transportation to medication costs to the presence of falls risks in the home.
You can "attend" this program right in your office and learn about UTSACN's advanced care coordination program. It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.
You'll get to listen to the question and answer session to hear details about how UTSACN's care coordination team works with patients as they transition from an inpatient admission to a post-acute provider to home; factors that indicate likelihood of ED utilization versus likelihood of hospitalization or readmission; and the most important gaps in care metrics to monitor and address.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, please visit:
P.S. -- You may also be interested in these care coordination resources: