Previously, we discussed how the ACG System collaborates with health care data analytics companies to deliver actionable insights to their customers – read that blog here. In this second installment, we will examine a critical challenge these companies help their clients tackle — closing quality measure care gaps.

This is no simple task, but by using data-driven insights, these organizations can help their clients streamline outreach efforts, prioritize patients who need care the most and ensure resources are used effectively.

Key Challenges in Closing Care Gaps

Addressing care gaps isn’t just about identifying where they exist — it’s about overcoming the barriers to closing them effectively. Here are some of the key challenges health care organizations face:

1. Prioritizing Outreach: With a large patient population, it can be difficult to determine where to begin. Stratification helps ensure the patients with the highest-need are prioritized.
2. Addressing Socio-Economic Barriers: Some patients face challenges like transportation issues, making it harder for them to access care.
3. Working with Limited Resources: Health care organizations have to be strategic in how they allocate their resources to make the biggest impact.
4. Navigating Continuous Improvement: Once an organization meets initial benchmarks, they must then focus on sustaining progress and adapting their approach to support the needs of more complex patients.

What is the ACG System and how can it help?

The Johns Hopkins ACG System is a globally recognized risk adjustment and predictive modeling software developed and maintained by the Center for Population Health IT at the Johns Hopkins Bloomberg School of Public Health. While many health care organizations use the ACG System directly, its impact is amplified through collaborations with data analytics companies that embed its functionality into their products.

The ACG System offers a data-driven approach to addressing these challenges by:

• Identifying At-Risk Patients: The System helps pinpoint patients most likely to have unmanaged chronic conditions.
• Targeting the Right Patients First: Data-driven insights allow providers to determine which patients should be targeted first for interventions.
• Optimizing Care for Chronic Conditions: By analyzing pharmacy claims and diagnoses, organizations can develop tailored care plans for individuals with multiple chronic conditions.

Real-World Examples

Effectively closing care gaps starts with putting data into action. By using analytics to identify at-risk patients and prioritize outreach, health care organizations can make a real impact on their population. Below are a few examples of how the ACG System helps tackle common care gap challenges:

• Child and Adolescent Well-Care Visits: The ACG System can identify children who are at the highest risk of missing annual primary care visits. Leveraging tools such as ACG GeoHealth, organizations can focus outreach on patients living in areas with limited transportation options.
• Depression Screening and Follow-Up: Using predictive analytics, the ACG System can identify patients at high risk for undiagnosed depression based on multiple chronic conditions and frequent emergency department visits. These individuals can be prioritized for targeted screenings and follow-up care to improve mental health outcomes.
• Follow-Up After Emergency Department Visit for High-Risk Patients: The ACG System can identify patients with multiple diagnoses who are at the highest risk for readmission after an emergency visit. By proactively scheduling follow-up visits and initiating targeted outreach, organizations can reduce hospital readmissions and improve long-term health outcomes.

Closing care gaps is no small task, but the right tools can make all the difference. The ACG System gives organizations the insights they need to prioritize patients effectively, make the best use of resources and continuously improve patient outcomes. By taking a strategic, data-driven approach, organizations can ensure they’re closing these care gaps — ultimately leading to healthier populations.

To learn more about the ACG System, visit hopkinsacg.org or contact us at acginfo@jh.edu. If you are a current ACG System customer, reach out to your Account Manager.