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What are the best ways to turn your accountable care organization (ACO) into a high performer? Physician engagement and co-located care coordinators are among the keys, Bob Rauner, MD, MPH, chief medical officer at OneHealth Nebraska ACO, said Thursday at the annual conference of the National Association of ACOs.

Rauner, whose ACO includes 23 clinics in four Lincoln-area communities, summarized findings from a recent of primary care practices in Michigan that participated in Medicare's Comprehensive Primary Care Plus demonstration project and had their results input into a performance dashboard. Milbank researchers also spoke with leading health provider groups such as Ochsner, Geisinger, Stanford, ChenMed, and VillageMD.

The investigators found six factors that were common to these organizations:

Physician engagement drives patient and practice team engagement. "You've got to get the docs on board with this," said Rauner. "They've got to believe it; they've got to want to do it. They've got to know this is good for their patients and for them."

Co-located (rather than centrally housed) care management greatly improves practices' ability to share information and coordinate team-based care. Rauner noted that at the clinic in which he practices, "the care coordinators don't work for me. We have ... at the home office a nurse [who] helps train them, but all the care coordinators work for that clinic. And that's huge. You can do it centrally, but I think the fact that Lupe [our clinic's coordinator] can call and say, 'I'm calling for Dr. Fornander; here's what you need to do ... They know Lupe; that is so much more helpful than a phone-bank person."

Off-loading routine tasks (e.g., medication refills, gap closures) from the primary care physician work stream frees them to focus on patient needs and champion team-based care. "We had to convince docs to let some stuff go," he said. "It doesn't take a medical degree to know somebody needs a flu shot. Let someone else make that decision; it's an easy protocol."

Availability and responsiveness to patient needs as well as patient awareness of the availability mattered more than extended hours. "You've got to be available and responsive," said Rauner. "And I think that's one thing we have -- really good access to care."

Integrating performance reporting into regular team huddles or communication drives accountability for performance. Sharing provider-level performance regularly also motivates improvement among individual providers. "We have very, very little churn in our system," he said. "You've got to integrate the quality performance -- even though the data is not perfect, that doesn't mean it's useless."

High-performing practices have a method for identifying patients who will benefit from interventions. "You have to have a way to do risk stratification," Rauner said, adding that in his ACO, "every clinic decides how to do that, and it has worked well for us."

He added that there were several things high-performing ACOs didn't need, such as a common electronic health record (EHR). "We've got 23 clinics, all with their own EHRs," said Rauner.

Remote monitoring and predictive analytics also aren't necessary, he added. "I think most of the time our care coordinators have a better idea of who's sick and who's not, and who needs help. And they know as of yesterday on a phone call; they don't have to wait 3 to 6 months to see what the claims data shows."

A large central administrative infrastructure is not needed either. "We're basically at the equivalent of three FTEs [full-time employees]" in the ACO, Rauner said, adding that he himself only works for the clinic halftime.

Rauner listed what he called the "Big 5" quality measures for his ACO, along with the percentage of his ACO's patients that reached each measure in 2021: annual wellness visits (83%), well-controlled blood pressure (82.2%), breast cancer screening (84.2%), colon cancer screening (85.2%), and poor control of HbA1c in diabetes (6.6%). "You want to be at more than 80% on [the first four] and at less than 10% on diabetes," he said. "That's kind of what my goal for our group has been, and we've done it for a couple of years now. So I'm really happy with that."

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