As a top performer in Year 1 of the CMS Pioneer ACO program, the 2500-physician Monarch HealthCare is paving the way to accountable care with a foundation of patient- and provider-centered strategies that support Triple Aim goals.
Those goals – to improve quality, improve health outcomes and reduce cost, are detailed in Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care.
Colin LeClair, executive director of ACO for Monarch HealthCare, recounts how Monarch recast its Medicare Advantage (MA) care management program to target about 1,200 high-risk patients who have a similar constellation of issues.
“Monarch repurposed our Medicare Advantage (MA) care management program for the ACO,” LeClair said.
Monarch’s ACO care management team was designed to anticipate and prevent acute events and then to facilitate transitions of care for patients post-discharge, he said.
This interdisciplinary team is “comprised of a primary care physician who quarterbacks the team, and a care navigator, also known as a care coordinator, who performs most of the patient onboarding into the care management program and performs an initial triage of the patient’s needs,” LeClair explained.
The care manager is often a non-complex patient’s primary point of contact. The complex care manager is responsible for most of the complex cases, he said.
Then as needed, “we also deploy a behavioral health clinician, a community services coordinator, a clinic dietician and a palliative care nurse. The other resources may include a pharmacist or Pharm D to perform post-discharge medication reconciliation.”
Then, LeClair continued, “we have a team of medical directors, employed and contracted hospitalists, and employed and contracted skilled nursing facilitators (SNFs) to support us as well.”
The idea is that the team is tailored for the patient’s need at enrollment, and it can then be augmented as the patient’s health status changes, he observed.
This model scales best when you can target large patient populations with a fairly common list of conditions, which allows you to hire and assign clinicians with the appropriate expertise to each patient.
“For example, we can afford to hire and assign a registered nurse (RN) or a nurse practitioner (NP) who has experience in a dialysis clinic or a nephrologist office if we have enough renal disease patients to fill their case load,” LeClair said.
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