High Risk, High Reward for ACOs: Identifying Patients Who Need Immediate Intervention to Improve Outcomes and Cost Savings

January 19, 2022 | Written by: Phyllis Wojtusik, RN, EVP of Health System Solutions

Accountable care organizations (ACOs) are already facing some tough challenges…and 2022 has just begun. Despite efforts by leading healthcare organizations to use pre-COVID data to set Medicare Shared Savings Program (MSSP) benchmarks, CMS based them on 2019-2021 spending targets. The Next Gen model has expired, paving the way for direct contracting, and participation in the Shared Savings programs has flattened without a full-risk option. Furthermore, ACOs are still recovering from fluctuating patient populations and negative impacts from the pandemic.

Meanwhile, patients – and your network – continue to depend on you. Despite the obstacles, there are opportunities to both improve care outcomes and realize savings now. You just need to look at the right place in your network.


Patient Demographics Tell the Story

There are high-risk patients all along the continuum of your ACO. But many of them reside in skilled nursing facilities (SNFs). It’s not surprising given the patient profile: predominantly older, higher acuity, and often suffering from multiple chronic illnesses. They’re also more likely to need post-acute care after a hospitalization, putting them at high risk for readmission. COVID-19 only exacerbated these scenarios.

As a result, your SNF network represents the largest post-acute expenditure segment of your ACO, both volume and cost combined. Despite their hard work, SNFs often don’t have sufficient equipment or resources to address patients’ changing conditions. And what happens in the SNF network affects patient transitions to other care segments.

How much do you really know at any given time about your SNF patients? You may glean information from monthly or quarterly reports or notice a trend in claims data or ADT feeds after the fact. But you need to know which patients are at greatest risk RIGHT NOW, before a decline occurs. A change in condition, especially an acute one, threatens more than that SNF patient’s outcome. It also increases the SNF’s costs, and potentially those of other parts of your ACO where the patient may be treated.

SNFs hold the key that enable you to work with them to identify and address high-risk patients before an adverse event occurs. It resides in their patient EHR data, offering information on every single patient’s conditions at any given moment as well as indicators of whose conditions are mostly likely to change for the worse.


Data Transparency Helps You Manage Risk Together

When SNFs open their “black box” of EHR data to you, it enhances your insight into the patients moving through your ACO. Together, you can see subtle changes that might lead to emergent events, like the CHF patient who has quickly gained weight or a blood pressure drop in a patient known to be a chronic fall risk. What you learn – and then apply – from the analysis of EHR information can make the difference among a poor outcome, a readmission, or a high-quality, cost-effective patient experience.

Using live clinical data, you should first work with your SNFs to stratify patient risk. By looking at pain scores, oxygen levels, and other vital signs, along with admission history, you can rate SNF patient risk as high, medium, or low. “Highest risk = greatest number of resources” is a tenet of case management, so using the EHR data up front enables you and your SNF to develop an effective plan for monitoring and deploying resources for your most vulnerable patients. It also helps your SNFs (and you) provide more proactive, prioritized care and avoid surprises.

Once the high-risk patients have been identified, be sure your SNF partners know your expectations for patient care. By communicating clinical standards and offering training and equipment as necessary to help them achieve your desired goals, SNFs can effectively move your patients through the care continuum. The investments you make to treat patients in place will be far less costly than avoidable rehospitalizations. Some of these might include:

  • Supporting testing and treatment interventions in the SNFs rather than returning patients to acute care
  • Providing specialists to help the SNFs identify and address key indicators in the most precarious patients
  • Educating post-acute clinicians on new clinical developments and technologies
  • Including a telehealth option for physicians covering post-acute facilities to reduce emergency room visits.

Besides contributing to the cost savings of reduced readmissions, live post-acute analytics can also help manage SNF length of stay along with the timing and destination of subsequent care transitions. It can reveal trends that indicate whether an individual is stable enough to return to independent living, requires home health services, or needs ongoing medical oversight.


Post-Acute Collaboration Can Lead to Shared Rewards

For several reasons, many ACOs haven’t focused on patient-level management in their SNF network. You may think the SNFs know what they’re doing, that as partners they don’t want or need your input, or that their patient care isn’t your business. In fact, as an ACO responsible for total cost of care, what happens to your patients during a SNF stay is very much your business.

The consistent and deliberate use of live data to proactively see and affect the trajectory of your high-risk SNF patients offers more than better outcomes for those patients. It also can lead to increases in shared savings. What ACO doesn’t need to boost savings, after the financial blow of the pandemic? When your savings increase, you can reward your SNF partners too, with financial incentives and ongoing referrals to top performers. It’s important to recognize the SNFs who are driving your clinical outcomes, and helping you achieve your goals as an ACO.

When it comes to high-risk patients, you and your SNF network must become trusted partners. Remember, you’re all there to improve care and respond to the patients – they come first!


About the Author

With over thirty-five years of health care experience in acute care, ambulatory care, and post-acute care, Phyllis has led the development of post-acute networks, participated in the Medicare Shared Savings Program and other value-based contract programs. Prior to joining Real Time Medical Systems, Phyllis led the development of a preferred provider SNF network for PENN Medicine Lancaster General Health. In this network she developed and implemented strategies that reduced total cost of care and readmissions while improving quality measures and patient outcomes. She utilized system approaches, clinical standards and care management tactics to improve coordination and transition of care while reducing post-acute length of stay in a network of non-owned SNFs.

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