Steward Medicare Pioneer ACO 'Patient Trackers'
The ability to track patients across a continuum of care sites is a perennial challenge for healthcare organizations—even a top-performing Medicare Pioneer ACO.
"We can't prevent a readmission back to the hospital or redirect unnecessary emergency department visits if we don't know the patients were in the hospital to begin with," noted Kelly Clements, Pioneer program director at Steward Healthcare Network, during Medicare Pioneer ACO: Care Management, Quality Improvement and Data Integration Yields Substantial Performance Gains, a Healthcare Intelligence Network webinar now available for replay.
But Steward's Medicare Pioneer ACO meets this challenge head-on with two tools: a home-grown patient surveillance tracker, and the "Patient Ping" service that provides real-time patient admissions and discharge notifications to providers. Both tools help Steward to identify and coordinate care for Pioneer ACO beneficiaries who seek services from both Steward and non-Steward providers.
These innovations have helped Steward's Medicare Pioneer ACO, aptly named Promise ("For our promise to do the best we can to coordinate beneficiaries' care and increase quality of care," said Ms. Clements), to emerge as one of the top CMS Medicare Pioneer ACO performers in 2013, with gross savings of $19.2 million.
Three Medicare Pioneer ACO Challenges
Supporting care management, the internally developed patient surveillance tracker is Steward's in-network solution for real-time tracking of care received from Steward providers and facilities; the contracted Patient Ping service allows the Pioneer ACO to communicate with skilled nursing facilities (SNFs) outside their network that care for Steward Pioneer patients, providing the SNF is registered with Patient Ping.
"Through the Pioneer program, we've learned that a large portion of our opportunity to reduce cost and achieve savings as an ACO is in the post-acute care space, particularly in the SNFs," noted Ms. Clements.
To engage physicians in the delivery of accountable care, Steward has done everything from holding road shows for providers to creating performance improvement teams for each geographic "chapter" in the ACO to work with physician practices to improve efficiency and quality. Physician report cards measure stewardship (including attendance at chapter meetings) and other efficiency and quality indicators.
And finally, to drive performance improvement, Steward has worked aggressively on data integration, with a strong focus on the two most popular electronic health records (EHRs) its physician network, in order to feed its 'quality data warehouse.'
This focus, along with efforts by the physician practices, has generated results. Steward saw its Pioneer ACO raw quality scores rise significantly from performance year one to performance year two: a 39 percent jump in the preventive health domain, and a 42 percent improvement in the at-risk domain (care for chronic conditions such as diabetes and coronary artery disease (CAD).
There is one additional hurdle: Steward must decide which ACO program it will participate in next year: Pioneer ACO, Next Generation ACO or Medicare Shared Savings Program (MSSP), Track 3. "The more efficient we become, the harder it will be to achieve shared savings, because the benchmark will keep getting lower, so this is one of our big concerns," said Ms. Clements.
"Our leadership is fully committed to pursuing risk aggressively and it's been worthwhile being at the table with Medicare and advocating for programmatic changes that will benefit our providers and patients in a sustainable way."
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:
You can "attend" this program right in your office and also learn how Steward engages providers in its ACO model, improves performance among its providers and leverages technology.
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 how managing the Medicare population differs from managing commercial populations under risk-based contracts, the providers' response to measures and incentives, the frequency with which performance metrics are shared with PCPs, skilled nursing facility integration strategies and how Steward defines high-risk and rising risk patients.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Medicare Pioneer ACO: Care Management, Quality Improvement and Data Integration Yields Substantial Performance Gains, please visit:
You may also be interested in these accountable care resources: