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How ACOs Manage Beneficiaries with Complex Needs

In the United States, one percent of patients account for more than one-fifth of healthcare spending. And just five percent of patients account for nearly half of all healthcare spending.

Under value-based care models, accountable care organizations (ACOs), which are financially incentivized to improve quality of care and reduce costs, devote significant attention to this population of patients who consume a disproportionate share of healthcare resources. Proactively identifying vulnerable patients and providing comprehensive care management is a cornerstone of ACO population health strategies, particularly now during the COVID-19 pandemic.

Defining Patients with Complex Needs

While an industry standard definition of “complex needs” does not exist, studies center around a few common themes. A BMC Family Practice research study described complex patients as those with multidimensional needs, including medical, social, and mental health. Similarly, a National Academy of Medicine study identified three primary criteria to look for when identifying high-needs patients: “total accrued healthcare costs, intensity of care utilized for a given period of time, and “functional limitations” in activities of daily living or those that support an independent lifestyle.

A study by The Commonwealth Fund defined high-needs patients as individuals with three or more chronic diseases and a functional limitation in their ability to care for themselves. The study found that high-needs patients require an average of $21,000 per person per year for healthcare services and prescriptions. That is nearly three times more than the average spending on adults with multiple chronic illnesses and more than four times the average spend for all US adults.

5 Strategies ACOs Can Use to Improve Care for Complex Patients

Many evidence-based strategies exist for providers caring for patients with complex needs. A six-foundation collaborative report identified the following strategies, surveying ACOs to gauge the use of these approaches:

  • Risk stratification, or identifying at-risk individuals
  • Segmentation, grouping patients with similar needs into subgroups
  • Improving transitions of care
  • Involving patients, families, and other caregivers in care decisions
  • Chronic condition management programs

While there are many evidence-based strategies available, there is significant variation among ACOs in their care management approaches—less than half of surveyed ACOs have adopted “advanced” approaches such as predictive risk stratification, transitions of care systems, and processes in place for clinicians to encourage patient involvement in care decisions.

However, 63 percent have comprehensive care management programs in place and those with comprehensive programs were more likely to have adopted at least one advanced care approach.

A Success Story of Proactive Care Management

By adopting comprehensive care collaboration technology, ACOs can tick the boxes for several strategies including proactively identifying vulnerable patients and effectively managing their care regardless of where they go—helping to cut down on unnecessary ED visits, admissions, and other care costs.

Nearly 60 percent of all ED visits in 2017 involved patients with one or more chronic illnesses. For one ACO participating in the MSSP, dealing with a high ED volume of patients with chronic illnesses, identifying patients was key. The ACO piloted using an ADT-based care collaboration platform in one of its Idaho hospitals to help identify patients with chronic conditions the moment they registered at the ED.

The ED and inpatient staff, local primary care providers, and the neighboring psychiatric hospital created a committee and met monthly to determine the best treatment for these patients with patterns of high utilization—recording care plans within the platform. Any patient that presented at the ED with a care plan would automatically trigger an alert to all parties involved in that patient’s care, allowing the patient to experience consistent care wherever they went.

With a real-time view of patient movement throughout the care continuum, ED physicians were able to redirect patients to more appropriate care settings—saving the ACO nearly $1 million in care costs at this hospital within the eight month pilot. Patients were able to have their chronic condition needs met in care settings best suited to meet their needs while also cutting down on unnecessary utilization and spend.

Brittany Eastman
Content Marketing Specialist