Since its first performance year in 2014, one Texas accountable care network (ACN) has maintained a 95% or better quality score and saved CMS more than $73 million.

The Southwestern Health Resources ACN manages care for about 87,500 Medicare beneficiaries in North Texas. The network focuses on reducing costs through care coordination and improving quality and efficiency. The network started with University of Texas Southwestern Medical School faculty and about 60-70 primary care physicians (PCPs) in private practice within the community, says Mack Mitchell, MD, vice president of medical affairs and interim executive vice president for health system affairs, as well as a professor at the University of Texas Southwestern Medical Center in Dallas.

“We created infrastructure for community physicians and faculty to measure quality scores and to link to care coordination and support services, including analytics,” Mitchell says.

“The physicians in the community were geographically aggregated into a pod structure where they met monthly with the care coordination team and the analysts,” he says. “Essentially, a pod representative brings in the quality team to analyze data.”

The original group of PCPs has grown to more than 300, and more PCPs, specialists, and advanced practice providers are being added to the network. The ACN also includes Texas Health Physicians Group members and independent community physicians.

“Along the way, we began a discussion about creating a clinical-oriented network that would include all physician groups and approximately 30 hospitals from the Texas health resources and our two universities,” Mitchell explains.

A support team of care coordinators and analysts helps the network identify patients who are at high risk for medical issues. They also follow up with those patients to manage their care in a way that improves quality and reduces costs, he says.

The people who are considered high risk often have multiple medical problems, multiple medications, and/or chronic conditions such as diabetes, hypertension, coronary heart disease, chronic liver disease, or arthritis.

“Essentially, you’ve got data feeding from two directions: claims data given on a monthly basis and data from electronic health records,” Mitchell says. “All of it goes into risk stratification software that tells us this person has this risk and it’s rising or stable or declining, and that allows us to say, ‘These are the folks that are in need of follow-up.’”

High-cost imaging and readmission data also are collected, but ED visit data is less of a chief issue for the Medicare population than it is for other populations, he notes.

“We look at high-cost imaging, like using MRIs when an ultrasound is sufficient, and we look at areas around some medication usage,” Mitchell says. “Some primary care physicians overutilize specialists, who overutilize diagnostic services.”

The care coordination team reaches out to physicians, telling them of patients they’re concerned about. It has bidirectional care coordination and communication. The care coordination plan is adjusted to meet individuals’ needs, and most outreach to patients is via phone, not the internet.

“We’re looking at this from the standpoint of patients who are older, and the telephone is their preferred method of communication,” Mitchell says. “We go out to visit them when necessary, and we coordinate with other caregivers who go into the home.”

The network is responsible for all of its patient population’s medical issues. Hotspots include diabetes and cardiovascular problems. Chronic kidney disease was moved out of the Medicare accountable care organization (ACO) population, so those in that group are not included in the network’s services.

While the network has commercial ACOs, its largest experience is with the Medicare population.

“With the Medicare population, one of our biggest areas for potential savings without compromising quality of care is in the post-acute care area,” Mitchell says. “How many days someone spends in a long-term care [LTC] facility or a skilled nursing facility [SNF] can make a huge difference in overall cost of care, and the same is true for home health.”

“We have a huge program around minimizing use of SNFs and LTCs,” Mitchell adds. “But more importantly, we’re cutting length of stay in those by making transitions more quickly and backfilling with care coordination and other services.”

These LTC, SNF, and home health services, used appropriately, are great resources. But when used repeatedly for circumstances they were never intended to cover, they are a liability, he adds.

“We use care coordinators to help patients manage their care without sending the home health company into the home for things that don’t provide a lot of value,” Mitchell explains. “We’re also looking for innovative ways of managing care, including direct patient engagement around the administration of IV antibiotics.”