Putting People at the Front of Accountable Care: Insight From CHI's Dr. Barry Hoover

In the fall of 2010, Englewood, Colo.-based Catholic Health Initiatives implemented accountable care readiness pilots in three cities — Lexington, Ky., Denver, Colo., and Lincoln, Neb. — taking a population health-based approach to caring for Medicare patients with chronic illnesses. Preliminary evidence indicates that outcomes have improved and readmissions have decreased for the 300 patients cared for in the pilot programs, according to CHI.

The pilot programs support Medicare patients, but none of the three have applied for demonstration status from CMS, nor do they intend to anytime soon, according to CHI.

Barry Hoover, MD, an executive sponsor of the accountable care readiness program at St. Elizabeth's Medical Center in Lincoln and CMO of the hospital's physician network, discusses CHI's accountable care model and shares three tips to make accountable care programs more effective.

Core of CHI's accountable care program

"When we started this pilot about 2 years ago, we didn't feel we had enough information to form a legal entity ACO, but we did feel ready to learn as much as we could about accountable care," Dr. Hoover says.

CHI's accountable care pilot was designed to systematically support Medicare patients with coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure and pneumonia. Patient participants have one of those four chronic illnesses, live within 30 miles of a test site and speak English.

There are three elements at the core of CHI's accountable care program. As Dr. Hoover points out, "they are not technology — they are people."
  • Transition coaches meet with patients before discharge and follow up with home visits and phone call for a month after hospitalization. The transition coaches are usually nurses with a caseload of up to  25 patients. They educate patients about medication use and treatments, as well as help with scheduling appointments with primary care physicians.
  • Health coaches are nurses stationed in the offices of primary care physicians and help Medicare patients manage chronic conditions, stay on track with health goals and change their behaviors if need be. There's also a nurse facilitator placed in physician offices on a temporary basis to help the practice make structural changes that improve patient outcomes. Facilitators are in charge of putting in place system-wide disease registry software to provide actionable information regarding certain diagnoses.
  • Social workers specializing in geriatric case management help patients and their home caregivers access community agencies and programs to avoid nursing home placement and hospital readmission. This social worker case manager works with the transition, health coach and PCP, and may receive referrals from any of those three care providers.
Dr. Hoover says the coaches and case managers alter the way care is provided.

"It's not so much traditional nursing as coaching the patient to help manage some part of their own illness," he says.

Patient transition


It took some time for patients to understand the role of the multiple players on the care team. "Patients were a little confused at first," Dr. Hoover says. They asked: 'who are all these people?'"

After awhile though, many of the elderly patients warmed up to the accountable care program. They liked the attention they received from the added care providers, as well as their accessibility. Coaches also did a notable job of explaining to the patients their role in working with the primary care provider, Dr. Hoover notes.

"Once we got over a little learning curve with patients, they accepted [the program]," he says.

Physician transition

Like patients, physicians needed to get used to the care delivery changes called for in CHI's accountable care pilot.
"There was some reluctance and skepticism around this idea," Dr. Hoover says. "I think [physicians] were at first hesitant to hand over elements of care to someone else. When we first started this pilot, I would say our nurse quality coordinator had to do a bit of a sales job."

But over time, participating physicians got to know case managers and nurses and realized the benefit of utilizing the added team members.

It paid off at St. Elizabeth's. Dr. Hoover says the hospital embraced the accountable care pilot and the culture change that came with it. Now, St. Elizabeth's and the other CHI pilot participants are tasked with taking what they've learned in the pilot and turning it into a sustainable care delivery model. Dr. Hoover continues to work on that with his staff and CHI and hospital administrators.

3 keys to making accountable care work

Dr. Hoover has seen firsthand what it takes to implement accountable care initiatives. Here he offers three crucial components that could help make ACOs and other accountable care models effective for years to come.

1. Strong physician leadership. "Accountable care organizations require strong physician leadership to meet the challenges of quality, communication and coordination of care in new delivery models," Dr. Hoover says. "Such leadership is also required to guide the organizations in developing equitable  distribution of revenue among various primary care and specialty arrangements in ways not necessary in a traditional fee-for-service model."

Physician leadership is also necessary to advocate for patients and to "protect the most vulnerable members of our society from being excluded from quality healthcare," Dr. Hoover says. In an effort to drive down costs, there could be "perverse incentives to cherry pick the healthiest patients and to avoid the neediest," he warns.

2. Robust information systems. ACOs in which partnering providers cannot share the right information will not be successful. For ACOs to have longevity, Dr. Hoover says providers will "need to be able to match up financial as well as clinical quality information for populations and episodes of care in ways not previously required."

3. Embracing a cultural change in the way care is delivered. Dr. Hoover says ACOs represent a fundamental paradigm shift in the way care is delivered. "Instead of having isolated touch points of care, the culture change is about tying all those components together," he says.

It's not enough to create a legal structure around existing care delivery processes and expect to succeed in the new model — that won't support accountable care in the long run. For accountable care programs to work, care delivery changes need to be system-wide and sweeping. "Organizations that create a healthy culture of care coordination, cooperation and a willingness to rapidly evolve and change will be more likely to succeed," he says.

More Articles Related to Accountable Care:

Report: ACOs Don't Hinge on Supreme Court's Healthcare Law Ruling
An Oncology ACO from the Hospital's Perspective: Q&A With Baptist Health CFO Ralph Lawson
6 Steps to Building an ACO's Health IT Capability


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