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larger, multidisciplinary team if needed. An analysis six months after the interven- tion found two unplanned hospital admis- sions among the 25 patients who received complex care management compared to 31 unplanned hospital admissions among 91 patients who did not receive enhanced care management. The ACO plans to scale the intervention,


setting a goal to engage 1,800 patients by the end of 2023. An anticipated success rate of 80 percent would avoid 1,440 unplanned hospital admissions, which at an estimated average cost of $15,000 per admission would equate to $22 million in cost avoidance. “One of the things I'm excited about as a


clinician is really looking at disease-based interventions,” Fish added. “We're trying to predict who has rapid progression of diabetes who ultimately entered a hospital- ization, rapid progression of CKD and then rapid progression of unplanned dialysis. We can bring a lot of individual clinicians to the table and talk about what are the interventions for each of these based on the model, not just the wraparound mul- tidisciplinary team, but what do you need to do as a physician if you have a list of five of your patients who are actually at high risk for rapid progression that you probably weren't thinking about?”


Delaware Valley ACO Beth Souder, P.T., M.S.P.T., vice president of clinical operations for Delaware Valley ACO, explained how the ACO was able to show a roughly $9,000 per patient return on investment in the last 90 days of life through a comprehensive community- based palliative care strategy. A collaborative team of clinicians and


analysts built clinically relevant claims- based views of end-of-life care among the ACO’s Medicare patients and national benchmarks, finding, for example, that almost half of the ACO’s patients (47 per- cent) received hospice care for a week or less before death, much higher than the 28 percent nationally. Further analysis showed that longer hospice stays helped reduce the total cost of care. The ACO used the findings to build


the case with key stakeholders for earlier activation of palliative care, which centers on pain and other symptom manage- ment, care coordination and planning, and assessment and support of caregiver needs. Advance care planning toolkits were distributed to clinicians with tailored com- munity-based information and resources. Services included in-home provider visits


“We were focusing 100 percent of our energy on yesterday’s risk and not tomorrow’s. That made us say that maybe this isn’t the right approach to this. How could we incorporate yesterday’s risk, but really try to identify tomorrow’s risk and spend our energy there?” — Jason Fish, M.D., chief medical officer with UT Southwestern ACO


and access to social work and chaplain services, rehabilitation therapy, 24/7 on- call help with in-home visit capabilities, telehealth, telemonitoring, and advanced illness management services. The share of patients receiving hospice


for one week or less before death improved from 47 percent to 32 percent. Along with providing more positive end-of-life experi- ences for patients and families, an analysis found that patients receiving home-based palliative care resulted in savings of about $9,000 in the last 90 days of life compared to patients who didn’t receive palliative care. Moreover, providing home-based palliative care to patients before death reduced emergency department visits by 35 percent, inpatient admissions by 51 percent, and inpatient length of stay by 1.5 days. The program also increased the percentage of the ACO’s seriously ill population with an advance care plan from 25 percent to 46 percent. “We are definitely moving palliative care


and hospice upstream, which is our goal,” Souder said. “It feels good to say that we changed care delivery and oh, by the way, it was very helpful for value-based care. Patients who had home-based palliative care and did have admissions, their length of stay in the hospital was statistically sig- nificantly lower, so it's synergistic with the hospitals’ goals to reduce length of stay.”


UCSF ACO Shirley Wong, PharmD, a clinical pharmacist with University of California San Francisco ACO, described their efforts to address dis- parities in blood pressure control. After identifying a 10-point gap in 2020


between Black/African-American (67.6 percent) and White patients 77.8 percent) with controlled high blood pressure, UCSF Health set a health equity goal of reducing hypertension disparities. “After the dis- parity was recognized, it mobilized and incentivized groups to come together to brainstorm ways to work on this dispar- ity,” Wong said.


26 hcinnovationgroup.com | JULY/AUGUST 2023 Working with UCSF health disparities


researchers, the ACO conducted inter- views with Black/African-American patients to better understand their preferences, barriers, and competing priorities. Based on patient input, the ACO designed interventions, includ- ing culturally tailored hypertension educational materials. The ACO also developed a team-based coordinated intervention among primary care, pharmacy, and population health to help patients manage their hypertension. Patients with uncontrolled hyperten-


sion were offered a 2- to 3-month inten- sive program with telehealth pharmacist visits to review medication management and coaching from healthcare navigators to support smoking cessation and other healthy behaviorsassociated with con- trolling hypertension.The ACO launched a separate effort for patients with hyperten- sion and no recent blood pressure reading. Health navigators mailed home blood pres- sure monitors, taught patients to use them via the phone and video conferencing, and collected remote blood pressure readings. Patients with out-of-range readings were scheduled for primary care appointments. In-clinic distribution of blood pressure cuffs and nursing-based patient education were also used. A year after implementa- tion, disparities in blood pressure control narrowed significantly, with 73.1 percent of Black/African American patients attaining blood pressure control compared with 74.3 percent of the overall population. “The gains that we made in reducing


hypertension disparities have actually been sustained until 2023. We've now expanded to other additional disparity groups,” Wong said. “We're working with our Latinx population with dia- betes and on Medicaid patients with diabetes. We are going to continue working with other disparity popula- tions and other chronic conditions. We're looking to scale the program through remote monitoring.” HI


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