Progressing Toward the Next Era of Value-Based Care with ACO REACH

September 14, 2022 | Written by: Margie Latrella, VP of Clinical and Network Quality

With an acceptance of fewer than 50 percent of applicants, CMS has named the 110 Accountable Care Organization (ACO) participants provisionally accepted to participate in the new ACO REACH model.  With the existing CMS Global and Professional Direct Contracting (GPDC) model concluding this year and the impending launch of the redesigned ACO REACH in January 2023, now more than ever, increased emphasis is needed on accountable care models that improve patient care and outcomes while reducing costs.

CMS has implemented a distinctive model placing a strong importance on health equity, which coincides with their goal to eliminate health disparities and ensure the health system is inclusive to all. This new model departs from traditional fee for service and aligns more with value-based care (VBC). What can ACOs do in preparation for this 2023 rollout to better manage patient care and outcomes across their post-acute network, one of the costliest segments, and how will the priority of health equity impact quality of care and delivery?


Prioritizing Health Equity and Access to Care with ACO REACH

As the name implies, Reaching Equity, Access and Community Health, this new model was created to improve care coordination and quality of care, as well as to achieve equitable health outcomes for traditional Medicare beneficiaries, especially for those in underrepresented regions. As health equity is a priority for CMS, it also introduces the benefits of accountable care to a vulnerable population.

The ACO REACH model will focus on health equity by introducing new policies. These include a submission of a Health Equity Plan (HEP) by all participants, health equity data collection, reporting of social determinants of health (SDOH) and demographics, and health equity benchmark adjustments, which will increase the benchmark for ACOs caring for a larger population of underserved patients on a Per Beneficiary Per Month (PBPM) basis. The HEP is a strategic plan aimed to eliminate health disparities in defined populations. CMS has developed a Disparities Impact Statement template that can be used to guide the development of the HEP. The steps within the template include the following: identify health disparities and priority populations, define goals, establish the organization’s health equity strategy, determine what the organization needs to implement in its strategy and monitor/evaluate progress. Participating ACOs will have to develop a HEP and strategy to submit to CMS for identifying health disparities within their respective communities across the care continuum and then take the appropriate actions to address them. This will require ACOs to collect patients’ SDOH data, a requirement that currently does not exist in Medicare.


Adhering to CMS’ New ACO REACH Model – Easier Said then Done?

The ACO REACH model, which is replacing the GPDC model, shifts care delivery to prioritize health equity. ACOs will need to collect SDOH data across their patient’s care journey, a requirement that doesn’t currently exist within other CMS models and generally isn’t captured in indiscreet fields in many EHRs. Data can be collected and documented in the EHR by any care provider (CHWs, SWs, Care Coordinators, Nurse Navigators, etc.) using a SDOH screening tool which can then be mapped for collection and reporting across the post-acute network.

There is currently ICD-10 coding for SDOH (Z codes) and ideally the documented SDOH would be mapped to the Z-codes (i.e., Z55 – Problems related to education and literacy) to be captured in claims data. Routinely data pulled from the EHR and claims data can be analyzed to improve care coordination, access, and quality. The data can also be used to trigger alerts or referrals to community resources, as well as be ingested into reports. Once measurable goals are set, it will be crucial to implement or rely on the organizations’ existing capabilities of tracking outcomes. For example, blood pressure control in the African American population would require data to be extracted by race.

Undoubtedly, this new model ushers change which includes additional emphasis on greater health equity and high-quality of care with the focus on the underserved population.  The new ACO REACH model will have a big impact on the current participants in the GPDC model as they will have to agree to abide by all of the new rules in ACO REACH to continue to participate. Evaluation of the community served, the financial risks of the model, and the ability to create an infrastructure to support the model are critical for the program’s success. Understanding that within these health populations are impoverished areas with very low incomes, minimal to no transportation, little access to healthy foods and many barriers complicating health status. It is critical to comprehend the population’s SDOH and address them accordingly. To attain success, technologies will need to be implemented to track the SDOH and required information for reporting, plus the creation of a clinical infrastructure and programming to address the care coordination needs of the population within the post-acute setting.


How Do We Start to Change the Script with Addressing Population Health Inequities?

With the priority of health equity at the forefront of this model, it is imperative for healthcare providers to fully understand the gaps in care of their populations and to go outside the standard four walls in looking at care delivery across the patient’s entire continuum of care, specifically – the post-acute setting. It is important to look for trends within the community (is there a high percentage of diabetes or COPD), how do the trends correlate with ethnicity or sex, start asking different questions and don’t generalize health conditions across the board. After analyzing the collected data and trends, ACOs may then need to develop standardize care plans that fit the population across their care journey rather than referencing standard guidelines.

The ACO REACH model is the first of its kind to require an HEP and address health disparities among underserved populations. The program will bring benefits of accountable care to this population including improved quality of care, care coordination, access to care, patient satisfaction, and assistance with their social needs. Success in this program can lead to scalable changes in similar programs with other payers.

Participating ACOs should begin formulating their HEP and strategies for implementation. The infrastructure will need to be assessed, including staffing needs for data collection and care coordination for the program, plus the appropriate technology to be successful managing the underserved population in a downside risk agreement. Additionally, SDOH data collection tools should be evaluated and considered for the program prior to the rollout of the new model.


Improving Quality of Care and Patient Outcomes with Individualized Data

With ACO REACH replacing GPDC and health equity becoming a main driver in this model, there will be more stress on ACOs to track underserved populations and those who don’t have access to care and are suffering with multiple comorbidities. With Real Time Medical Systems (Real Time), ACOs can help improve care to impoverished communities with their post-acute partners, by helping to provide clinical line of sight into their patient’s PAC journey, with the aid of live data analytics by providing customized reports specific to health issues based upon various social determinants such as race, age, zip code, etc.

Real Time’s Interventional Analytics solution establishes an individualized 72-hour baseline, sending live alerts with suggested interventions to care teams when a change in condition occurs, a key differentiator in managing population health and inequities in the post-acute setting. Interventional analytics can easily identify high-risk patients and clinically prioritize their needs, so clinicians can act faster to prevent adverse events from occurring. With ACOs needing to formulate an HEP and ensure they have a method of tracking the data to monitor for improvement, an analytics data solution is crucial to patient success and improved outcomes.

For measures surrounding clinical indicators, Real Time has the capability of pulling data on patients in the post-acute, based upon race, ethnicity, zip code, age, etc. This will aid in the ease of monitoring outcomes and reporting the data. Real Time’s solution collects clinical data on all patients in post-acute facilities, not historic information as with claims data/MDS reports, so immediate interventions can be ordered to care for patients who may be declining. Providers can view alerts, which may indicate a change or decline in clinical status and notify the facility.  All of this leads to improved health outcomes for the population.

The post-acute arena is one of the biggest areas to control excess spend. The ACO REACH participants are assuming the greatest loss/gain risk potential and also includes Primary Care Capitation payments or Total Cost of Care capitation payments. The data analytics solution offered by Real Time has been proven to reduce readmissions and impact length of stay. Providers can intervene to prevent costly and often unnecessary readmissions, and the data transparency allows for appropriate care at the appropriate time and place, which can increase total cost of care savings. Lastly, the Real Time platform plus staff interventions, can positively impact an organization’s quality scores within the ACO REACH model.

Learn how Real Time can help ACOs access live clinical data across their post-acute networks, and specifically within underserved populations, to proactively manage care for chronically ill, high-needs patients, reduce readmissions, and impact total cost of care. Contact us today to get started.

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