ACO/Value-Based Care Best Practices | January 2025 | News Flash

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January 14, 2025

 

ACO/Value-Based Care Best Practices

1....Primary Care Access

  • 24/7 access to PCP or clinical decision maker is required.
  • Annual Wellness Visits (AWV)
  • Great opportunity to do risk and safety assessment, close gaps in care, and code and document chronic conditions (HCC Coding)
  • Provide same-day access or direct provider communication with patients with acute conditions to reduce unnecessary utilization of urgent care and ED visits.
  • Provide direction to patient on how to seek care after hours.
  • Utilize MPP document on Where to go for care- urgent care vs ED.

 

2....Care Coordination

  • Chronic Care Management provided to targeted, high-risk populations (Diabetes, CHF, COPD, CRF)
  • Transitions of Care (TOC) visits
  •  Nurse Care Manager outreach to patient within 48 hours of discharge from hospital or SNF
  •  PCP expected to provide transition of care visit within 7-14 days to improve patient’s outcome and reduce readmission risk.
  • Perform medication reconciliation to ensure patient taking correct medications and dosages.

 

3....Coding and Documentation (Hierarchical Condition Category (HCC) Coding

  • Creates risk-adjustment factor (RAF) consists of demographics and illness burden for each beneficiary to better define the health of your population.
  • Proper coding and documentation of a beneficiary’s chronic conditions is required at least once per calendar year.
  • Impacts funding for each beneficiary which are totaled to achieve ACO spending target (financial benchmark).
  • The higher the benchmark target, the greater the chance of achieving shared savings.
  • Use the most specific diagnosis codes to improve risk adjustment (HCC Coding) used by payors to fund gainsharing agreements.
  • Do not use unspecified diagnosis codes.
  • MHPN provides two HCC Coding Assistance tools to our members:
  • Stanson HCC for Cerner One McLaren EMR
  • Persivia CareTrak HCC Module for integrated independent EMRs

 

4....Quality

  • Age-appropriate and disease specific gaps in care should be discussed at each visit, not just at preventive visits.
  • Every visit is an opportunity to close gaps in care.
  • Pre-visit planning is recommended.
  • MHPN provides regional quality team to support practices.
  • Gaps in care files are provided monthly to practice champion.
  •  Persivia CareView card is now embedded in Cerner One McLaren EMR
  •  Persivia CareTrak Gaps in Care for integrated independent EMRs
  • Use of standing orders where appropriate to allow team-based care delivery.
  • Discuss medication adherence to confirm patients are taking medications as prescribed.
  • Quality Improvement
  •  Better outcomes and improved patient satisfaction drive stronger patient engagement and increased patient acquisition.

 

5....Cost and Utilization

  • Eliminating unnecessary care and reducing total costs results in shared savings for patients, employers, health pans, and providers.
  • Utilize most cost-efficient specialists.
  • Avoid duplication of labs and ancillary testing, especially high-tech imaging.
  • Provide relevant patient records and testing results when referring patients.
  • Risk Optimization
  • Optimal reflection of population’s care needs facilitates improved care coordination and increased revenue.

 

6.      Upside and Downside Financial Risk-Sharing Success Factors

  • Patient access to provider 24/7
  • HCC Coding optimization
  • Cost-effective care (right care at right time and in right setting)

 

For more information, please contact Dr. Michael Ziccardi, CMO, at [email protected] or (248) 484-4923.