Executive Summary

According to one accountable care organization, the key to success is to change the healthcare philosophy of intermittent and emergent care to an ongoing, coordinated care philosophy.

• A New Jersey ACO embedded trained case managers in provider practices so they could interact with high-risk patients on a regular basis.

• The ACO made it a goal to reduce the number of patients discharged from the hospital to a subacute facility, which in the state has been twice the national average.

• Giving patients a three-month supply of medications at discharge greatly improved medication adherence.

 

The accountable care organization model works well with ensuring patient adherence to treatment, as well as preventing unnecessary emergency department visits and hospitalizations, according to an ACO president.

“ACO is a hot topic, but it’s all about the way you practice medicine,” says Morey Menacker, DO, president of Hackensack Alliance ACO in New Jersey. The Hackensack Alliance ACO, with 575 care providers, was launched in 2011 and began commercial contracting in 2014.

“We look at the ACO as a clinical laboratory,” he adds. “We identify doctors who are motivated to change practice, and we try out new programs.”

The ACO decided to use the medical home model and had all primary care physicians become patient-centered medical home (PCMH) certified. Also, all medical practices switched to electronic health records so they could be better integrated with the hospital and more easily share data, he says.

The third piece to the ACO model was to change the healthcare philosophy of intermittent and emergent care to an ongoing, coordinated care philosophy. “We trained nurses in case management and embedded them in practices to interact on a regular basis with our high-risk patients,” Menacker says.

“Case managers basically make sure people are cared for on an ongoing basis,” he adds.

“One of the things that sets us apart from a lot of other programs is we also are looking at the post-acute period, and not just the hospitalization period,” he says. “We identified in New Jersey that the percentage of patients who are discharged from the hospital to a subacute facility is twice the national average.”

After analyzing data, they identified a group of patients who could benefit from going directly home or shortening their stay in a subacute facility. “This was beneficial from a cost and quality standpoint,” Menacker says.

Case managers from the hospital setting and from the payer/provider setting work together to identify the newly admitted patients who would be optimal candidates for being discharged directly to their homes, he explains.

Case managers also work with high-risk patients to improve their quality of care and outcomes, and when they find a strategy that is successful, it can be rolled out to the entire ACO network of 85,000 patients, Menacker says.

For example, one pilot program involved giving hospital patients a three-month supply of medications before they were discharged, he explains.

The program began at discharge planning and involved the discharge nurse, a pharmacist, and a case manager making rounds on the floors and reviewing the plan with patients, he adds.

They tell patients at discharge to throw out the medications they have at home because their new prescriptions will be the medications they are taking home with them, Menacker says.

“After three months, the patient can continue [the new prescriptions] by getting pills from the hospital pharmacy or transferring prescriptions to a pharmacy of choice,” he adds.

This program was enormously successful from a compliance standpoint, and so it has been expanded to all ACO patients, he adds.

“Imagine an 85-year-old being discharged and someone fills out a prescription for seven different medications,” Menacker says. “The patient will end up duplicating medications or waiting a week to fill the prescription and end up back in the hospital.”

By giving patients a three-month supply, the ACO absorbs that cost, but improves compliance immediately.

Another program involved congestive heart failure (CHF) patients who had significant readmissions. “We supplied them with electronic tablets that had a medication calendar, reminding patients to take their medication. The program told them which pill to take,” Menacker says. “Then patients had to tap the tablet when they took out the medication. If they didn’t tap the tablet, then a message was automatically sent to the case manager, who would call immediately to find out what the problem was.”

The tablets also recorded patients’ daily vital signs, and each person was weighed on scales that recorded his or her weight.

Case managers received the data so they could intervene if a CHF patient’s weight went up or if something else was out of the ordinary.

The program resulted in a 75% decrease in hospitalizations, Menacker says.

In one example of anecdotal success, one patient who received the tablet had been hospitalized six times the previous year, but then went 18 months without one hospitalization after participation in the program, Menacker says.

“This elucidates how case management can work in a proactive manner, as opposed to being reactive and only dealing with patients after they have been hospitalized,” he adds.

The ACO works through a partnership of provider and payer. Together, the two groups can collect the best analytics and create a system in which case managers work for both groups — no matter which signs their paycheck, Menacker says.

For instance, the Hackensack Alliance ACO recently expanded to provide coordinated care to 10,000 Aetna members. Aetna will supply the case managers, but the CMs will work for the ACO, following the ACO’s guidelines and reporting for the case management program, he explains.

“They’re going to be taking care of our Aetna patients, but utilizing the skills we’ve identified, maximizing quality, and minimizing costs,” he adds.

“This is a partnership between the hospital’s case management program and the ACO’s care coordination program, and it benefits everyone,” Menacker adds. “Our long-term plan is to eventually make case management population-based as opposed to hospital-based and location-based.”