patients with complex chronic diseases. While our goal was
low-cost care, we learned firsthand that if we didn’t have an
encounter with a patient, then we didn’t have attribution—a
necessity in the MSSP program. Using our analytics platform,
we discovered the amount our ACO spent on these patients
and how much, based on industry benchmarks, we could
save if care managers were allocated wisely. After researching our patient population—where people resided and were
empaneled—we determined that we needed six care managers. Knowing how much of those savings would be reflected
in MSSP bonuses, the ACO’s leaders demonstrated to Maury’s
management how the care managers could create a return on
investment via care coordination and reduced readmissions.
Our care coordinators manage the top 15% to 20% of
the population, including high-risk and rising-risk patients.
Medical assistants and LPNs,
whom Maury calls “community
health workers,” function as
health coaches, interacting with
low-risk patients and proactively
scheduling appointments with
patients who have open care gaps.
Care managers in the hospital
also identify and follow high-risk
patients post-discharge. These
nurses focus on preventing readmissions and improving transition
to the next level of care. Furthermore, they follow patients who
are part of a bundled payment
program for the duration of each
episode of care.
Gleaning Data’s Meanings
Our Enterprise Data Warehouse
(EDW), which is integrated with our
EHR, provides the data infrastructure that supports our system’s
population health management
process. Claims data are integrated
with EHR data (and eventually will
include information on social determinants of health) in the EDW (see
“Our Enterprise Data Warehouse”).
The analytics platform identifies
Building on Results
high-risk patients and care gaps so
that providers and care managers
can deliver the right care to the right
patients. The ACO staff also uses
this data to contact patients who
are overdue for preventive visits and
chronic care management. Registries
of chronic-disease patients are created and assigned to care
managers. In addition, care coordinators use the registries
to obtain information they need to care for patients without
having to dig through their charts. Maury uses the data in the
EDW to generate action within its MSSP population as well as
with its Medicare Advantage (MA) plan members.
Since Maury began its journey in early 2017, the costs of its
ACO’s MSSP (and MA) patients have started to decline. In the
first year of operation, Maury’s ACO saved Medicare more than
$560,000. Readmission rates also are beginning to decrease.
For high-risk patients identified by our ambulatory care
coordinators, we’ve seen a 45% reduction in hospital-based
utilization since the ambulatory care coordinators started
actively managing our target high-
risk cohorts and high utilizers.
Furthermore, Maury’s ACO joined
Medicare’s new Advanced Bun-
dled Payments for Care Initiative
(BPCI-A) after successful partici-
pation in both the Comprehensive
Care for Joint Replacement (CJR)
program and MSSP.
This year, Maury plans to obtain
National Committee for Quality
Assurance (NCQA) certification for
its patient-centered medical homes
and expand care coordination for
patients with diabetes and high utilizers of its emergency department.
It also is exploring telehealth visits
for urgent care and remote patient
monitoring, facilitated by a U.S.
Department of Agriculture (USDA)
rural telemedicine grant.
The workflow for care managers would not be possible without
the IT infrastructure Maury built
and the patient data its EDW
provides. The infrastructure gives
the health system and its ACO
actionable, real-time insights into
patient care needed to succeed in
population health management,
bundled shared savings, and payment programs.
Mark Kirschbaum, RN, Ph.D., is vice
president of population health, and
Jill Gaddes, M.S.N., RN, CNML, is
director of population health and care
coordination at Maury Regional Health.
The cloud-based Lightbeam enterprise data
warehouse (EDW) is populated by importing
MSSP Medicare claims files from the Centers
for Medicare & Medicaid Services (CMS), and
through integration of electronic health record
(EHR) clinical and demographic data. The
front-end query tool on this platform uses an
industry-standard, visual presentation layer that
anticipates the majority of ACO management
decisions—financial performance with drill-downs to understand where claims dollars are
spent (including leakage), population description
and panel management tools, and quality performance and rankings. Each dimension allows
drill-down to the location, provider, and patient
level. This platform provides a risk score as well
as a summary score for ability to impact, which
supports chronic disease care management.