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A Tale of Two Patients: What Happens in an ACO

Accountable care organizations (ACOs) are continuously evolving, as early adopters innovate and refine care delivery models. Our goal in this series is to give you examples of how accountable care is actually working in the real world. In Part One of our series, we met Patricia and Frank, two patients (whose names have been changed for confidentiality purposes) that benefited in significant ways from some relatively small adjustments to their care.

In this post, you'll meet Margaret and Holly (names have been changed for confidentiality purposes). Their stories illustrate the value of communication, collaboration, and coordination in keeping patients healthier. Care managers provide the necessary linkage, identifying critical gaps, and taking actions to close them.

Margaret: Support for a Patient with a New Diagnosis

Margaret, a 41-year-old woman, was hospitalized for treatment of congestive heart failure (CHF), a new diagnosis for her. CHF is a chronic disease that is manageable, but requires vigilance – tracking weight changes daily, sticking to a low-sodium diet, and taking prescribed medications.
When Margaret was discharged from the hospital, she forgot to bring her new prescriptions home, putting her in jeopardy of complications. Transitions between care settings are often the most critical time for patients, particularly in cases such as this, where the patient has a new diagnosis and needs to incorporate new habits. Support and education could make the difference between a successful transition and a readmission.
Fortunately, Margaret is a member of an accountable care organization and is in a case management program. Once she was discharged from the hospital, she was identified through a daily medical management report and contacted by a registered nurse (RN). The nurse helped Margaret refill the needed prescriptions, and coached her on diet and lifestyle changes, helping her keep her symptoms under control to avoid more costly hospital visits. 
Holly: A Single Point of Contact Helps a Little Girl
Clinical transformation is helping to cut through the red tape that may get in the way of good care. Holly is a one-year-old with a stomach problem. She had reached her coverage limit on prescription refills for her Zantac after her doctor adjusted her dosage.
Under the old rules of engagement, Holly’s physician might have had to speak with multiple individuals to get permission to override the limit. However, Holly’s health plan fosters collaboration and care coordination. Her physician raised the issue during a regularly scheduled clinical meeting, and a care manager worked behind the scenes to get the clinical exception approved. Having a single point of contact saved the physician time, and enabled Holly’s parents to refill her medication without any interruptions in treatment.
Creating Real Change Through Clinical Transformation
With outdated care delivery models, Margaret might have ended up right back in the hospital. Holly could have gone without medication for a period of time, with worsening symptoms. Her doctor, already spread thin, could have spent precious time fighting for a clinical exception. Clinical transformation is about creating a more efficient and higher quality health care system and ultimately providing a better patient experience.

Categories: Accountable Care, Consumer Engagement


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