Are you a provider, payor or population health organization looking for a quick tune-up to your existing strategy and planning? Then look no further. In this series of posts, we’ll be sharing 7 quick wins the ACG System offers its users.

Next up: Improving efficiency of existing health care programs

Care management, disease management, and transitional care are critical tools to support patients with chronic disease and to optimize outcomes. At the same time, these essential programs are often resource-intense and some of the most expensive to operate—making their efficiency and ROI a top priority for providers, payors, and population health organizations alike. The ACG System can help users confirm existing programs are running at optimal performance, and more finely target the right program for each patient, to make better use of resources.

How does it work? The ACG System’s various patient-level clinical markers support detailed analysis to refine program targeting. Once an organization has defined enrollment criteria and optimal outcomes for each program, the ACG System can automate program referrals and, where appropriate, program enrollment. For instance, one marker may flag patients with a specific chronic disease so they can receive automated information about a specific disease management program, while system users can leverage predictive markers and multimorbidity measures to refer patients to programs for more complex care. Additionally, specific markers can help identify patients to exclude from certain programs, such as pregnant patients, patients with cancer diagnoses, or specific age groups, such as pediatrics. Clinical resources such as physicians and nurse practitioners may focus on patients with multiple chronic diseases, more complex needs, or high risk of cost, hospitalization or readmission. The ACG System’s ability to stratify a patient group by level of health risk can help target specific groups that need services from specific programs.

To illustrate, let’s look at an example of a diabetes medication adherence program. In a single practice, 1134 patients were eligible based on initial criteria of suboptimal MPR (medication possession ratio) – clearly too many for the PCPs to manage as a bulk referral list. How can the panel be optimized to make the best use of the clinician’s time?

• 10% of the target patients had not seen a PCP in the past year. These patients can be outreached by office staff to schedule a routine PCP appointment, in alignment with best practices for patients with diabetes.
• Half the patients had suboptimal adherence and polypharmacy .These patients may see the clinical pharmacist for review of overall medication regimen and assistance with medication adherence.
• 81 patients had Emergency Department visits for non-emergent purposes, and can be referred to the practice’s nurse-led ED diversion program to ensure optimal preventive and urgent care.
• 10% of patients were at risk of having total cost in the top 5% range in the coming year. PCPs can focus their efforts on this subset of the overall cohort, narrowing the intervention population to a more manageable size.

The Win

No matter what the unique health care needs of your patient population, the ACG System can assist you in optimizing program performance with its ability to identify specific patient groups. The benefit? Patients receive the care that is best for them, staff workflows are optimized, and clinicians can focus attention on high- and rising-risk patients who need the most care. Sounds like a win-win to us.

Other posts in this series:

Quick Win #1: Optimize Enrollment in Existing Programs
Quick Win #2: Streamline Medication Needs
Quick Win #3: Effectively Manage Multimorbidity
Quick Win #4: Maximize Primary Care Provider (PCP) Usage
Quick Win #5: Reduce Avoidable Emergency Department Visits

While these techniques are focused on US customers, we have parallel suggestions for international ACG System users, developed by our team based in Europe with support from one of our UK users, Sollis. Please contact us for more information.