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ACO Snapshot: Helping Patients, One by One

BY CAMMIE FLORES, R.N. – Last year, a 20–year-old man with a history of alcohol abuse walked into a hospital’s emergency room. It was his third time in the ER in two months. In another instance, a 25-year old woman had made three ER visits in three months with abdominal problems, which revealed other medical issues beyond her gastric issue.

These are real-life examples of what many providers such as Facey Medical Group encounter on a daily basis: patients who may not know the breadth of health care options available to them, and consequently make repeated and often unnecessary trips to the ER. In both of these cases, what the patients needed – and ultimately received – was help from a nurse case-manager, who coordinated their care by helping to get appointments with primary care physicians, referrals to specialists and prescriptions for their symptoms.

This is the type of challenge that we tackle through our ACO collaboration with Blue Shield of California. In the past year, I’ve seen the positive impact our ACO collaboration has made in improving patient-care coordination, helping them navigate the healthcare system and reducing ER visits all of which help to improve patient health outcomes.

One example of that effort is our Central Clinical Outreach (CCO) team, created last year within our ACO Clinical Support framework.  Its purpose is to address immediate short-term patient needs that can be resolved within a specific time period. We work closely with the Blue Shield ACO team to flag and address specific patient behaviors and care issues using Blue Shield’s monthly claims-data reports.

We look for patterns such as high utilization of the ER and hospital, preventive measures or interventions required (e.g. colonoscopy, mammogram), patient behavior trends, gaps in care and possible health risks, or whether the solution is as simple as setting up an appointment with a patient’s primary-care physician. If needed, we also call patients to determine if they understand all of their healthcare options, follow up with letters describing the recommendations we’ve discussed, and start coordinating with their care team.  We share the patient needs we have identified with our physicians and the Blue Shield team.

If patients need longer-term support services such as medication management and ongoing education about their diseases, we refer them to our Complex Care Management (CCM) team.  This team works with patients who have illnesses such as diabetes, chronic obstructive pulmonary disorder, congestive heart failure and cancer.

Each of these patients are assigned to a nurse who follows up on key aspects of their coordinated care and communicates periodically with their primary care physicians and specialists about the patient’s condition. We check to see if patients are meeting their short-term goals such as medication management, lab tests and diet. If they aren’t, we work with their medical team to readjust those goals.

As for the two young people mentioned at the beginning, we were able to find them in the claims data because of their concentrated ER visits. The good news is that both are now using their primary care physicians and the Facey network for more appropriate and effective care. Both called to thank us for our help, and the 20-year-old man said the new coordinated care has saved his life.

Together with Blue Shield, we are helping patients receive the right care in the right setting for positive health care outcomes.

Cammie Flores, R.N., is senior director of Complex Care Management and ACO Clinical Support at Facey Medical Group


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