ACO Participant Monthly Tasks

To achieve sustained ACO success, ACO participants must be engaged and provided the tools and information necessary to achieve clearly defined goals. Critical tasks are listed in the summary below to be completed monthly or a during patient encounter.

Monthly

HCC Diagnosis Recapture Rate: The goal is an HCC recapture rate of 85% by the end of the year. The recapture rate is the rate at which the provider or clinic has recaptured recurring chronic conditions for patients from the prior year. A diagnosis is removed (unless recoded) after 12 months. A monthly report should be downloaded by the clinic each month to review all HCC diagnoses not recoded and schedule appointments for patient's with no encounters or high volume of HCC not recoded.

Annual Wellness Visit (AWV) Completion Rate: The goal is an AWV completion rate of 85% by the end of year. The AWV completion rate is the rate at which the provider or clinic has completed an annual wellness visit for their assigned patients. A dashboard should be accessed by the provider clinic monthly to review each provider's AWV rate and to drill down to the incomplete patients. Incomplete patients should be scheduled for an encounter.

Acute Hospital Utilization (AHU) Rate: The goal is for the AHU rate to be below the provider's AHU benchmark or expected number of hospital discharges. A dashboard should be accessed by the provider clinic to review each provider's AHU rate and to drill down to the patients driving the rate above the benchmark or expected number of hospital discharges.

Potentially Costly Patients: The goal is for the clinic to engage potentially costly patients (those driving the most spend in the clinic) in a care management program such as CCM and/or RPM. A dashboard should be accessed by the provider clinic to review their potentially costly patient's health history and high spend areas.

Scorecard: Access expenditure and utilization scorecard that matches the Medicare quarterly aggregate expenditure and utilization areas to target spend reduction areas when the clinic or provider is above the national average. The scorecard should also include quality measure performance compared to the national average.

Patient Encounters

A point of care solution is vital to a successful ACO. Each clinic should access a value-based care summary of a patient at the point of care during each encounter. Specific tasks to complete at the patient level:

• Review HCC Diagnoses not recoded and recode current and removed diagnoses if applicable to the patient.
• Review medications list prescribed by all providers treating a patient. Often providers are not aware of medications prescribed by other providers treating their assigned patients and this may result in contradictions and other medical concerns. Another important area is to review prescriptions no longer being picked up.

• Review high spend areas such as imaging, admissions, re-admissions, or emergency encounters to determine if a care plan or medication change is required.
• Review quality measure completion status and address incomplete quality measures.
• Review out-of-network migration by a patient to redirect them to in-network care managed services.

• Review patient indicators such as potentially palliative care ready, avoidable emergency room use, COVID vaccine status, and percentage of spend used to assist in formulating a care plan.

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Kris Gates, [email protected], 480.912.1209