This Week's Challenge: By applying an "ACO magnifying glass" to high-risk patients and high-cost events, and using an organizational background in rapid cycle improvement, Atrius Health's focused interventions hit Triple Aim goals within its Medicare's Pioneer ACO model. We wanted to share Atrius Health's roster review of high-risk patients.
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What We Learned: "In our redesign of our geriatric care model to meet care gaps, we have developed a ‘high-risk roster review’, a multi-disciplinary team review of the highest risk patients. We used a new risk stratification tool to identify our high-risk patients. Those patients go on a roster that in the primary care practice is reviewed by a multidisciplinary team to achieve outcomes. A roster helps the team see metrics: for example, have we documented patients’ advance directives? Do we know what patients want for care at the end of life? What are the gaps? It helps the team address those gaps."
Emily Brower, executive director of accountable care programs at Atrius Health.
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Excerpted from Medicare Pioneer ACO: Case Study on Atrius Health's Focus on the Triple Aim, a 45-minute webinar, during which Emily Brower shared the first year lessons from Atrius Health's experience as a Medicare Pioneer ACO and how the program is evolving in year two.
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