How Accountable Care Organizations Use Chronic Care Management

Accountable Care Organizations (ACOs) can scale their patient cohort through care management, particularly through the Medicare Chronic Care Management program. But what are the most effective, research-based strategies ACOs use to maximize the value of Chronic Care Management?

Here, we highlight strategies reported and documented through surveys, interviews, and research. We’ll also look at specific characteristics of ACOs that meet quality, cost, and ROI benchmarks.

Accountable Care Organization goals

Accountable Care Organizations (ACOs) are focused on delivering high-quality, coordinated healthcare services, improving health outcomes, and managing costs. 

They represent an alternative payment model that supports both value-based and fee-for-service payments. ACOs may cover a specific geographic area or concentrate on specific patient populations, such as Medicare beneficiaries, those with multiple chronic conditions, or certain conditions like chronic kidney disease.

To achieve these goals, ACOs must increase patient attribution and scale, meet performance targets, and achieve positive ROI. 

High-performing ACOs meet the novel needs of their patient population, as well as intra- and inter-organizational partnerships with hospitals, health systems, health plans, and physicians.

High-performance ACOs share common characteristics and strategies

A study of 283 Medicare ACOs discovered that 25% reported having comprehensive care management strategies. These high-performing ACOs featured specific characteristics associated with their success, including better utilization, cost, and ROI outcomes.

The table below highlights common features of comprehensive care management programs in high-performance ACOs.

In general, these programs are larger, cover more beneficiaries, and offer more primary care physicians. 

They are physician-led and engage in activities associated with services such as CCM, Transitional Care Management, Behavioral Health Integration, Annual Wellness Visits, and Advance Care Planning.

Care management strategies common among high-performing ACOs

An ROI comparison study uncovered four characteristics of ACOs that achieved better cost outcomes and return on investment. These include:

• Offering nurse-led Chronic Care Management
• Optimizing CCM patient panel size
• Patient contact strategies and frequency
• Focusing on a patient subpopulation at risk of disease exacerbation and deterioration

Nurse-led chronic care management 

Successful CCM programs typically utilize a nurse-led case management approach. This allows nurses to collaborate closely with the primary care team. Additionally, they generally assign all patients of a single provider to the same case manager.

CCM patient panel size 

A case manager’s panel may include as many as 500 patients or as few as 25, depending on the cohort’s complexity and the interventions required. The ROI study found that 31.1% of case managers had a caseload of 17 to 49 clients per month, and 42.2% had a caseload of 50 to 99 patients. The most successful CCM programs had a panel of around 40-70 patients. 

Patient contact strategies

This should include regular and consistent patient engagement and communication, with a minimum of one face-to-face visit per month. Face-to-face contacts should also occur as regular visits before or after appointments with the primary provider.

Both CCM with telephone contact only and CCM with telephone  and face-to-face contact trended toward lower hospitalizations after just four weeks. A reduction in hospitalizations reached statistical significance at 12 weeks for both types of patient communication strategies. 

Targeting patient subpopulations

Most high-performing programs concentrate on a subpopulation of patients with multiple chronic conditions who are at risk of disease exacerbation and deterioration.

One example is the Kaiser Model, which incorporates different levels of coordination based on patient risk. 

• Low-risk patients receive supportive care
• Moderate-risk patients receive education on self-management of their disease
• High-risk patients receive all care management services

Additionally, some programs identified eligible patients based on criteria, such as Medicare requirements, but also utilization and other factors, including:

• Three or more emergency department visits or hospitalizations in the past 12 months
• Two or more medical office visits in the past three months
• One or more deficiencies in activities of daily living
• Diagnosed with cognitive impairment

Another method for identifying subpopulations is associating criteria with poorer health outcomes and increased costs. Care Oregon focused on high-utilizers. They found those with two or more inpatient admissions and six or more emergency visits made up 32% of healthcare costs - while being only 3% of the entire population.

Interviews indicate high-performing Accountable Care Organizations utilize strategies, such as: 

• Providing Annual Wellness Visits
• Implementing a system-wide approach to close preventive care gaps

CCM helps Accountable Care Organizations decrease hospital utilization

According to the Advisory Board’s research, beneficiaries enrolled in an ACO utilizing CCM experienced fewer hospitalizations, post-acute admissions, and in-person appointments. 

Numerous research studies demonstrate CCM services reduce hospitalizations. This includes a review of a Northwestern ACO that achieved a six percent decrease in hospitalizations for those in a CCM program. This was compared to an 18.9% increase in hospitalizations in the non-CCM group.

The reduction in admissions was more pronounced among high-risk patients. The study also indicated CCM significantly lowered total hospitalizations and decreased the chances of being hospitalized multiple times by 34%.

CCM helps ACOs reduce costs

According to the National Rural Accountable Care Consortium, CCM has been shown to decrease costs by 20-60%.

Cost analyses showed that CCM could significantly reduce Medicare costs. For example, CCM services demonstrated a $106 per member per month reduction in hospitalizations and fewer hospital days. Another example from a three-year demonstration saved Medicare $2.60 for every dollar spent.  

Chronic Care Management helps ACOs improve ROI

A return-on-investment comparison, specific to three different CCM payment models for a northwest physician hospital organization, demonstrated significant savings for Medicare and a positive ROI for the ACO. 

 The three payment models included:

• The practice as a member of the comprehensive primary care plus (CPC+) initiative but not a member of an ACO
• The practice as CPC+ and a member of an ACO
• Using Medicare CPT codes for Chronic Care Management fee-for-service billing only 

The largest ROI for CCM services was found for CPC+ members in an ACO that met the minimum savings rate to participate in shared savings incentives. The ROI results for all three payment types included:

• CPC+ ACO that met the MSR: ROI of $1.55 for every dollar the practice invested in CCM
• CPC+ ACO that did not meet the MSR: ROI of $1.34 for every dollar the practice invested in CCM
• CPC+ not in ACO: ROI of $1.39 for every dollar the practice invested in CCM
• CCM CPT billing alone: ROI of $0.44 for every dollar the practice invested in CCM

CCM helps improve Accountable Care Organization patient satisfaction

The ROI analysis indicated Chronic Care Management influenced ACO performance in patients’ self-reported quality of life, confidence in nursing roles, and satisfaction with care. 

ACO-assigned patients receiving CCM services reported statistically significant higher care quality scores. 

They were two times more likely to rate care as highly satisfactory, which was true for low- and high-utilizers. CCM participants had significantly greater odds of giving a high rating for care coordination.

ThoroughCare helps Accountable Care Organizations coordinate care

ThoroughCare helps Accountable Care Organizations coordinate care efficiently for improved outcomes and greater ROI. We offer a comprehensive software and analytics platform, clinical advisory expertise, and tailored assistance to achieve your organization’s goals.

Our platform streamlines care coordination, giving the care team greater tools to engage patients. ThoroughCare supports: 

• Comprehensive care planning tools
• Evidence-based assessments (lifestyle, health risks, behavioral conditions, SDOH) 
• Automated billing code assignment with audit trail
• Data integration across EHRs, HIEs, remote devices, and advance care plans
• Analytics to report on care performance and operations