Originating before President Obama signed the Patient Protection and Affordable Care Act into law, the integrated care model in northern California is a pioneer in the commercial ACO arena.
After one year in business, the ACO witnessed a 22 percent reduction in hospital readmissions. Here are five specific initiatives that have helped leaders of the Sacramento model advance a coordinated care agenda, according to the report:
1. Implementing a coordination of care document. This enabled sharing of clinical data between Hill physicians and Dignity Health hospitals through an expanded health information exchange.
2. Defining enhanced evidence-based guidelines for surgery. “We used hospitals and cross-hospital standardization to establish consistent processes to manage inpatient stays,” said John Wray, the senior vice president of managed care at Dignity Health. The hospitals followed evidence-based protocols.
3. Creating Post-Discharge Needs Assessment. The organization analyzed the clinical course and major events of a patient’s stay to make discharge as smooth as possible. Discharge planning began within 48 hours of a patient’s admission. The planning process included a scheduled follow-up visit within 8 to 10 days of check out. Caregivers shared a written discharge plan in lay terminology with the patient and forwarded that plan to the appropriate primary care physicians and care managers.
4. Repatriating patients admitted to other hospitals. This process allowed the ACO model to maintain coordinated care and also helped Dignity Health maintain market chare.
5. Developing new case management programs. The focus of the new management programs was on chronic pain and reducing both emergency visits and pharmacy costs.
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