Road Shows, Report Cards Engage Providers in Top-Performing Medicare Pioneer ACO

Kelly ClementsPhysician engagement is one of three top challenges of the Medicare Pioneer ACO model, along with performance improvement and care management, explains Kelly Clements, Pioneer program director for Steward Health Care Network, which operates Promise, a top-performer in CMS’s Medicare Pioneer ACO program.

To drive engagement in its accountable care organization at the provider level, Steward offers a range of physician tools and supports, including road shows and report cards, which Ms. Clements describes in this audio interview.

During a June 2015 webinar, Medicare Pioneer ACO: Care Management, Quality Improvement and Data Integration Yields Substantial Performance Gains, now available for replay, Kelly Clements shares her organization’s Pioneer ACO Program experience over the first three Pioneer performance years and how Steward leverages this experience with other risk-based contracts, including the newly announced CMS Next Generation ACO Model.


Length: 4:09 minutes

Yale-New Haven Embedded High-Risk Care Coordinators Monitor Geriatric Homebound

Dr. Vivian ArgentoFollowing weekly huddles with nurse practitioners, Yale New Haven Health System (YNHHS) geriatric care coordinators use a red-yellow-green system to prioritize care for its Medicare homebound patients, explains Dr. Vivian Argento, the executive director of geriatric and palliative services at Bridgeport Hospital, in this audio interview.

While the bulk of care provided by YNHHS’s geriatric care coordination model is delivered during house calls to seniors deemed homebound by Medicare criteria, the program also provides care to patients in assisted living facilities.

The YNHHS geriatric care coordination model was one of three embedded models of care presented during a June 2015 webinar, Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, now available for replay. During the program, Dr. Argento was joined by Amanda Skinner, YNHHS executive director for clinical integration and population health, who described livingwellCARES, embedded on-site care coordination for YNHHS employees; and its patient-centered medical home’s hybrid model of centralized and embedded care coordination resources.


Length: 3:11 minutes