UT Southwestern ACO Home Health Narrow Network Reinforces Providers’ Home Care Accountability

Cathy BryanAfter UT Southwestern Accountable Care Network (UTSACN) discovered its home health spend was more than twice the national average, it applied data analytics to create a preferred home health network of 20 agencies (down from 1,200) that has saved more than $6 million in home health utilization in the first quarter of 2016 alone.

In this podcast, Cathy Bryan, director of care coordination at UTSACN, describes the provider reeducation process supporting the launch of this narrow network that has improved accountability, data sharing and communications related to home health utilization.

During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a September 2016 webinar now available for replay, Ms. Bryan shares how her organization’s care coordination model manages utilization while achieving its mission of bridging care gaps and enhancing health outcomes for approximately 250,000 covered lives.


Length: 3:21 minutes

HCSC’s Community Behavioral Health Links Essential to Duals Care Coordination

Relationships with community organizations that support mental health as well as recovery from addiction are essential to care coordination of Medicare-Medicaid beneficiaries, notes Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation (HCSC). These collaborations enable HCSC to address the needs of duals as “a whole sick person, and not just as a diagnosis,” she explains, noting that duals often suffer from depression along with some physical disability. HCSC also has its own integrated team with behavioral health expertise.

Julie Faulhaber shared her organization’s approach to designing a care coordination model for dual eligibles and initial findings from these new programs during a March 12, 2014 webinar Moving Beyond the Medical Care Coordination Model for Dual Eligibles, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 4:06 minutes

Assessing Readmission Risk to Prioritize Home Visits for Complex Patients

Modifying a popular hospital admissions risk assessment tool for its own use helps Stanford Coordinated Care to prioritize home visits for its roster of high-risk patients, all of whom have complex chronic conditions, explains Samantha Valcourt, MS, RN, CNS, Stanford’s clinical nurse specialist. Stanford’s HARMS-11, based on Iowa Healthcare Collaborative’s HARMS-8 hospital risk screening tool, looks at individuals’ utilization, social support and medication issues, among other factors, to measure a patient’s risk of readmission.

The resulting home visits, a critical component of Stanford’s care transitions management program, help to uncover health challenges the complex chronic patient may still face, including four common medication adherence barriers Ms. Valcourt describes in this interview.

Samantha Valcourt shared how Stanford’s Coordinated Care uses a home visit assessment to improve care transitions post-discharge during a December 19, 2013 webinar, Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions.


Length: 6:28 minutes

Medical Home Neighborhoods: Uplinking Specialists To Create Integrated Systems of Care

If payment inequities can be addressed, communication and technology tools in place in large physician multispecialty groups make them ideal candidates for a medical neighborhood, suggests Terry McGeeney, MD, MBA, director of BDC Advisors. Dr. McGeeney, who spent 13 years of his practice career in a large multispecialty group, has also seen some FQHCs and managed Medicaid programs that do a good job of linking community and social supports required in medical neighborhoods.

As for engaging patients in this emerging integrated care delivery system, try explaining the medical neighborhood’s value proposition for them, he suggests. Patients already get why the integrated approach is good for physicians and insurance companies but need to hear why they should buy in to team care, patient portals and other aspects of centralized care coordination.

Dr. McGeeney shared his expertise in developing medical home neighborhoods during a November 20, 2013 webinar, Medical Home Neighborhoods: Uplinking Specialists To Create Integrated Systems of Care.


Length: 6:16 minutes

Aligning Value-Based Reimbursement with Physician Practice Transformation

In its quest to transform 70 to 80 percent of its physician practices to a patient-centered medical home (PCMH) over the next three years, WellPoint has adopted a “meet the practices where they are” philosophy, reports Julie Schilz, director of care delivery transformation for WellPoint. Each practice is at a different place in the transformation effort and requires specialized supports, she adds.

Smoothing the transformation rollout is the simultaneous participation of 500 WellPoint practices in CMS’s Comprehensive Primary Care (CPC) program, whose goals dovetail with key PCMH principles — as though WellPoint had another partner in its transformation initiative, Schilz notes.

Just as important as practice support is transparency with health plan members, Schilz adds, especially when it comes to explaining the concept of the medical home neighborhood — where care coordination is a collaboration between primary care and the specialist.

Ms. Schilz shared the key features of WellPoint’s transformation initiative, including results from its pilot program that have led to a system-wide rollout, during an October 24, 2013 webinar, Aligning Value-Based Reimbursement with Physician Practice Transformation.


Length: 5:29 minutes

Dual Eligibles: Closing Care Gaps and Engaging Members in Self-Management

The philosophy that healthcare is local — and therefore, care needs to be local and community-based — forms the core of WellCare’s efforts to connect its dually eligible population to health services, explains Pamme Taylor, WellCare’s vice president of advocacy and community-based programs. The Tampa-based healthcare company takes a culturally competent approach to assessing duals’ unique personal circumstances, ensuring their “soft landing” into WellCare’s care coordination system.

Care managers at the heart of WellCare’s multidisciplinary team, conducting a comprehensive needs assessment with each Medicare-Medicaid beneficiary and driving the resulting care plan, ensuring duals’ complex care needs are met at the most appropriate time and level.

Ms. Taylor shared Wellcare’s strategies for meeting members’ needs with community-based partnerships and engaging duals in self-management of their care during an October 2, 2013 webinar, Dual Eligibles: Closing Care Gaps and Engaging Members in Self-Management.


Length: 7:16 minutes

Medicare Pioneer ACO Year One: Lessons from a Top-Performer

Lauded for its care coordination service, Monarch had to overcome a few challenges when retrofitting the Naylor Transition of Care (TOC) model for the ACO — among them insufficient patient access, patient skepticism and resource limitations. By focusing on readmissions reductions and four disease management conditions — ESRD, COPD, CHF and diabetes — and creating a care coordination team that included the newly created care navigator, case managers, and pharmacist, the organization has improved patient compliance, reduced negative drug interactions and hospital days and improved patients access to community services.

During Medicare Pioneer ACO Year One: Lessons from a Top-Performer, a September 18th webinar at 1:30 pm Eastern, Colin LeClair, executive director of ACO for Monarch HealthCare, shared first year lessons from its Medicare Pioneer ACO experience, how it evolved in year two and the impact on its organization’s participation in other accountable care organizations.


Length: 14:03 minutes