Community partnerships, health navigators crucial to engage patients

Leaders of two accountable care organizations (ACOs) shared the strategies they use to actively engage patients and improve healthcare delivery and outcomes while reducing costs during Wednesday's preconference session of the sixth annual National ACO Summit in the District of Columbia.

A three-pronged approach has worked well for Mercy Clinic ACO in Des Moines, Iowa, which in 2012 became a Medicare Shared Savings Program (MSSP) participant, according to Kelly Taylor, R.N., who serves as the ACO's director of care management and quality. The ACO has provider participants throughout the state and focuses on primary care.  In order to boost patient engagement, Taylor said the ACOs focus on community resources, patient advisers and health coaches, another word for care managers or patient navigators.

Mercy's health coaches are RNs who work with patients to educate them about their conditions, coordinate care and also listen to their concerns. By establishing these personal connections, Taylor said, the health coaches learn what is important to patients so they can better offer support. In addition, health coaches connect patients to community resources that offer the most value, she said.

"Our health coaches have a list of the best resources. . . the folks that answer the phone, deliver what they promise and the ones we hear high praise about. It's not the volume of community resources but the value of them," she said.

Finally, Mercy relies on patient advisers to find out what the organization can do to offer greater service to patients and the community. In addition to a patient advisory committee, several medical home clinics have their own advisory groups and bring in patients to develop a true partnership with them, she said. 

The Triad Healthcare Network in Greensboro, North Carolina, is also an MSSP ACO participant. Its initial patient engagement efforts focused on care management for high healthcare utilizers, according to William A. Hensel, M.D., a member of Triad's operating committee. But that only represented a small portion--about 5 percent to 10 percent--of its patient population.

To better engage a larger segment of its patients, Hensel said that the ACO has reached out via telephone to "under-utilizers," patients with chronic illness who haven't had an appointment in several months. "This way we can better manage their care," he said.

But because these patients may not have a deep personal relationship with providers, Hensel said the ACO has developed partnerships within the community to create a level of trust that didn't exist before. "Why do patients want to trust this new network? But if we partner with a church community, we have an automatic inroad with the trust," he said.

Terri L. Postma, M.D., medical officer for the performance-based payment policy group at the Centers for Medicare & Medicaid Services, said other Medicare ACOs have used similar patient engagement approaches as Triad and Mercy.

Other successful methods include expanding patient education to families and the communities via health fairs at local health centers and senior centers, providing pocket cards about certain conditions that providers can hand to patients at the point of care, and creating web-based portals that feature information on healthcare topics and resources. Some ACOs partner with pharmacies to provide education and others created 24-hour telephone hotlines. Other best practices  include scheduling patient visits with several providers on the same day rather than over the course of several days.

"Basically they are providing good customer service," Postma said. 

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