The ACO used EMR and claims data to identify the patients with the most hospitalizations, ER visits, and diagnoses of multiple chronic conditions. "These were our highest-cost and most fragile patients that we could help by intervening and very quickly getting them stabilized," Myers says.
The care team also talked to physicians to find out who they thought would benefit from care coordination. "Claims-based data is old data. By getting out into the offices, we could work with the staff to identify patients who needed extra assistance and get to them early," she says.
Myers hired an all-RN staff that could operate independently and with authority.
Care coordinators must have a broad base of experience across care settings and a breadth of life experience as well to help connect with patients, she says. "While it would be great if they had experience in care management, you just don't find that. We choose RNs who can manage complex medical conditions, understanding that sometimes a social issue is the linchpin. We don't want to be focused on prescribing insulin when what they really need are groceries."
NewHealth Collaborative's care coordinators are embedded in the primary care practices to act as both members of the care team and patient advocates to help develop and carry out a patient's care plan according to his or her life goals.
"The care coordinators marry what the doctor is going to do with what the patient can commit to," Myers says.
The care coordinator stays close to the patient, checking in by phone and in person, until the point where the patient's goals and the medical goals are achieved.
Each of the 13 care coordinators at NewHealth Collaborative has between 100 and 120 open cases. They are funded in part by payer contracts such as the Medicare Shared Savings Program.
"The care coordinators marry what the doctor is going to do with what the patient can commit to."
"We have achieved enough savings to get a portion of payer savings," she says.
The care coordinator program also gets a portion of the stipend that nearly 200 providers pay to be part of the ACO and receive these types of services.