Editor's note: This is the second of a two-part series based on an interview with Emily Brower, vice president of population health for Atrius Health. Part one discussed the lessons the ACO learned on population health and end-of-life care.
Although Atrius Health--the Northeast's largest nonprofit independent multi-specialty medical group--has long promoted shared learning within the healthcare community, it's participation as one of the original 32 Pioneer accountable care organizations gave it a new venue to share best practices with other delivery systems.
Such exchanges among Pioneer ACOs was an early part of the Center for Medicare and Medicaid Innovation's formal learning collaborative, where ACOs solve problems related to a particular topic. But these formal discussions inspired Atrius to have informal talks and one-on-one discussions with other Pioneer ACOs, as well.
The willingness of other organizations to share their strategies, tools and results helped Atrius employees try new solutions to common problems and created a sense of excitement within the improvement teams, Emily Brower, vice president of population health for Atrius Health, told FiercePracticeManagement in an exclusive interview.
Because Atrius formed close working relationships with the other Pioneer ACOs, they developed a network of people that they could rely on when they encountered a problem, Brower said.
"We've had this unique opportunity as a Pioneer ACO to have regular conversations with other Pioneer ACOs on all the work we are doing. We all have the same goals we are trying to accomplish, so this has been incredibly valuable," she said.
And the exchanges aren't only about delivery approaches for Medicare patients, according to Brower. An Atrius team member can call another Pioneer ACO to ask about successful strategies to transition patients from hospital to home, for example. "Organizations are incredibly willing to share--as is Atrius Health--on what is working and what is not," she said. The ACOs have shared predictive risk models, care coordination tools and templates developed in electronic health records.
Partnerships help ensure care coordination
As a Pioneer ACO, Brower said, Atrius is responsible for the total care of patients--even when that care takes place beyond its walls. But care of patients is often fragmented under the traditional fee-for-service care model, with patients receiving care from multiple providers who prescribe multiple prescriptions.
Atrius advocates communication with the primary care team to develop one plan of care and one safe list of medications.
The Pioneer ACO model has encouraged partnerships across the delivery system to ensure care coordination for Atrius' 675,000 patients across eastern Massachusetts. Although the physician-centered delivery system doesn't own hospitals, Brower said it partners with them to coordinate care for their patients. The Atrius team works with specialists, hospitals and skilled nursing facilities to share data, develop care plans and manage transitions so patients seamlessly flow through the care continuum.
When one of its patients is admitted to a hospital, for example, an Atrius Health nurse manager reaches out to the facility to understand the patient's treatment and work with the hospital to prepare an appropriate discharge plan.
"The main point is that healthcare is a team sport and if we are going to change healthcare in this country, then the delivery systems need to work with teams. We don't have to reinvent the wheel," she said.