Accountable Care Organizations (ACOs) Leverage High-Tech, High-Touch Population Health Tools to Support Patients at High Risk for COVID-19

Faced with the greatest public health threat in a century, ACOs across America are identifying patients at high risk for COVID-19, educating them about minimizing exposure, making sure they have enough food and medication to stay home, and remotely monitoring their underlying conditions.

As of January 2020, about 550 Medicare Shared Savings Program (MSSP) and Next Generation ACOs cared for more than 12.3 million beneficiaries. The MSSP is a voluntary program that maintains beneficiary choice of providers while encouraging local physicians, hospitals and others to work together and take responsibility for improving quality, enhancing patient experience, and reducing waste to keep care affordable. Hundreds more commercial and Medicaid ACOs serve millions of additional patients.

In response to the COVID-19 pandemic, ACOs are using high-tech, high-touch population health strategies that leverage in-depth information with trusted relationships to support high-risk patients.

The ACO Difference

Too often, health care delivery is fragmented and siloed. Health plans and other payers, for example, might have information about emergency department visits and hospitalizations but lack trusted relationships with patients, limiting opportunities to improve care. On the flip side, providers often have strong patient relationships but lack information about care in other settings, missing opportunities to improve outcomes. The ACO model helps bridge this gap by getting providers data they can use to leverage strong patient relationships and improve care.

Identifying and Reaching Out to High-Risk Patients
At the epicenter of the nation’s worst COVID-19 outbreak, New York-based Mount Sinai At the epicenter of the nation’s worst COVID-19 outbreak, New York-based Mount Sinai Health System’s ACO lost no time in developing a tool to identify and reach out to high-risk patients—both for COVID-19 and with chronic conditions, such as COPD, heart failure and diabetes, that can spiral out of control if left unmanaged. "High risk can be subjective, and these patients are not just high risk for COVID but high risk generally, so the tool will be helpful in the future as well," said Robert Fields, M.D., Mount Sinai senior vice president and chief medical officer for population health. Trained staff call each patient, checking for food insecurity; verifying they have needed medications; screening for COVID-19 symptoms, underlying physical conditions, and mental health and wellbeing; and making sure patients know how to reach their provider, either in person or via telehealth.

ACOs connect population health and public health strategies to solve COVID-19 challenges.

Similarly, Advocate Aurora Health (AAH), which operates three ACOs across Illinois and Wisconsin, quickly established a surveillance system and COVID-19 patient

registry linked to patients’ electronic health records. Care management teams then monitor patients and provide virtual visits, as well as patient education and information on social resources. “Advocate Aurora Health rapidly came together to prepare our hospitals and physician groups for the fight against COVID-19, utilizing innovative technology solutions,” said Megan Reyna, AAH vice president of government and value-based programs. New Jersey-based Summit Medical Group, which participates in both Medicare and commercial ACOs, established a nurse hotline to respond to patients with concerns about COVID-19, triaging patients to affiliated urgent care centers for moderate to severe symptoms or arranging telemedicine visits for patients with mild symptoms. In North Carolina, where Coastal Carolina Quality Care ACO has seen less than a dozen COVID-19 cases and few hospitalizations to date, care managers also are reaching out to patients, especially those with mental health conditions, to answer questions, check on medications, make sure patients have food, or arrange to get groceries delivered. The ACO also informed the local hospital that it can monitor patients in their homes, multiple times a day, so that patients can leave the hospital more quickly and bypass nursing homes where they may be a risk to other patients or at higher risk themselves for coronavirus.

Telehealth and Remote Monitoring
Already leaders in deploying telehealth, many ACOs are accelerating the move to virtual visits in the face of the COVID-19 pandemic. For example, Adelade, which partners with independent provided its national network of physician-led ACOs with a comprehensive telehealth solution in a matter of days in late March, allowing primary care practices to maintain access for elderly and high-risk patients while staying safe in their homes and minimizing the spread of the virus. Similarly, New Jersey-based Atlantic Health System’s ACO is 

using predictive modeling to identify high-risk patients and, along with telehealth visits, providing remote patient monitoring, for example, for oxygen levels, to avoid hospitalizations or enable a discharge to home rather than a nursing home. In the same vein, Mount Sinai, along with conducting 2,500 video visits daily, has arranged for patients with high-blood pressure and/or heart failure to obtain blood pressure monitors and scales at no out-of-pocket cost to patients.

In South Jersey, AllCare Health Alliance, a Medicare MSSP ACO affiliated with Cooper University Health Care, is conducting annual wellness visits via telehealth to identify screenings and "tee up" other care needed once stay-at-home restrictions are lifted, according to CEO Daniel Hyman, D.O. "This approach will keep the health and wellbeing of the most vulnerable in the forefront," he said. Given the isolation and stress that many people face, especially older patients, Summit Medical Group, also in New Jersey, has expanded telemedicine access "to help our patients with chronic behavioral health issues or acute anxiety or depression due to the current crisis," said Ashish Parikh, M.D.