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Our ACO Story: Creating an Integrated Care Delivery System without Walls

BY MARCUS THYGESON, M.D, M.P.H. — At Blue Shield of California, our Accountable Care Organization (ACO) arrangements have a successful track record of delivering more efficient, better coordinated care by working closely with our network providers.

We are building upon our success and the trust that we have with our providers in order to create a comprehensive and integrated care delivery system without walls.

Developing ways to help our providers address the challenges inherent in the current healthcare system has been an exciting process, and out of it our ACO strategy has evolved to focus on a few key areas. This new way of looking at the healthcare processes can help provide patients the right care at the right time in the right setting, at sustainably affordable prices.

The goal is to help healthcare professionals – physicians, nurse practitioners, pharmacists, care managers and others -- evolve into specialized care teams that treat patients with the most challenging medical needs. These teams will focus on these key areas, developed from industry best practices, so that care meets the needs of patients and their families:

  • Advanced Facility Care – We’re working with our providers to try to eliminate or reduce the duration of hospitals stays when care could be better provided in other settings – using comprehensive complex care centers and home care options as alternatives to emergency rooms and hospitals when possible. Teams of hospitalists, SNFists (primary care physicians who practice within a nursing home/Skilled Nursing Facility) and care transition nurses work together to ensure the best quality outcomes for patients, employing comprehensive care strategies and medication reconciliation, and checking in with patients after a transition of care to an outpatient setting. The team’s process is focused on improving patient outcomes and patient experience, and this is supported by technology to make sophisticated information available to all clinicians to assist them in providing best in class care.

  • Home Care – The ACOs will provide care to our most complex or chronically ill patients either in their own home or at their “medical home,” when possible, taking into account their chronic conditions, medical needs and social needs. Care will include home care, palliative care, medication management and care transitions management. Offering this right care in the right place offers convenience and comfort for patients while reducing hospital admissions, total hospital days and in-hospital patient deaths.

  • High Risk Clinics – These clinics will have a team of providers led by internists along with nurse practitioners, nurse care managers and social workers that offer patient care. This new setting will meet the complexity of patient needs such as advanced geriatric care, post hospital care, wellness visits, care for the chronically mentally ill, chronic condition group visits, cardiovascular and chronic pain programs as well as wound care and an infusion center.

  • Care Management/Coordination – Through team-based care management of complex cases and disease and care transitions, this integrated approach will improve patient experience and satisfaction while reducing hospital admissions and emergency room visits. This is the glue that helps tie together the other high-risk patient care programs and ensures that patients are not alone as they wade through a complex healthcare management system.

We have much to do in the coming years, and we recognize that implementing a new healthcare model will require us to effectively leverage our ACO provider agreements, be disciplined in our execution and, where appropriate, invest in our providers so they have the tools they need to improve care for our members while making healthcare more sustainably affordable.

Marcus Thygeson, M.D., M.P.H., is senior vice president and chief health officer at Blue Shield of California.