One is Mercy Clinic ACO, in Des Moines, Iowa, which in 2012 became a Medicare Shared Savings Program (MSSP) participant. The ACO has provider participants throughout Iowa and focuses on primary care, community resources, patient advisers and health coaches, who are registered nurses.
Mercy also uses patient advisers to find out what it can do to offer better service to patients and the broader community, as the imperative of improving population health becomes more pressing.
The Triad Healthcare Network, in Greensboro, N.C., is is also an MSSP ACO participant. Its initial patient-engagement efforts focused on care management for high healthcare users.But that only represented 5 percent to 10 percent of its patient population.
So it reached out via telephone to “under-utilizers” — patients with chronic illness who haven’t had an appointment in months. The idea, of course, is to more closely monitor their condition and care to prevent their illnesses from becoming more dangerously (and expensively) serious.
