Case Studies

Each ACLC Case Study spotlights a single provider organization’s efforts in developing a specific value-based competency. Each case study includes the following: important information about the provider organization (demographic and background context), its approach to the competency including any tools and vendor partners used, the results experienced to date, challenges and barriers, and key learnings. Contact information for contributors is also included. The case study is a concise, two-page document created for health care industry executives to gain quick and important lessons that they can apply to their own organization.

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Case Study Example:

Title: Deploying a Patient Risk Stratification Tool to Inform Care Management - OneCare Vermont

Provider: OneCare Vermont

Background: OneCare Vermont is a statewide ACO comprised of a large and diverse provider network who together contract with numerous payer types, thereby covering a wide range of patients and populations. At the time of its inception in 2012, OneCare had been relying on the Hierarchical Conditions Category (HCC) risk adjustment model to estimate patient clinical risk and costs across the health system. However, in 2014 when the ACO entered into its first contract with Vermont Medicaid, it found that the risk adjustment model was insufficient for the new population of patients, particularly pediatric patients, as the HCC model was designed for the Medicare senior adult population. In order to most efficiently allocate resources across its diverse patient population and identify high-risk individuals who could most benefit from enhanced services, OneCare Vermont sought to utilize a risk stratification tool that would apply to all populations.

Case Study Topics: 

Advocate Health Care, Creating a Culture of Engagement

Allina Health, Engaging Physicians in the Design and Direction of a Clinically-Integrated Network

Arizona Connected Care, Home-Grown Solutions for Tracking Total Cost of Care

Ascension Care Management, Selecting and Supporting High-Value Leaders for Accountable Care

Atrius Health, Developing a Real-Time Predictive Model for Identifying High-Needs Patients

Centura Health, Building Custom Solutions for Real-Time Care Coordination

Children's Hospital of Orange County, Standardizing Best Practices Through Care Guideline Integration

Cornerstone Health Care, Designing an Extensivist Model for High-Needs Patients

Facey Medical Group, Serious Illness Approaches by ACOs

Hackensack Alliance, Starting Small to Save Big: Selecting and Sequencing Initiatives Wisely

Henry Ford Health System, Relationship-Based SNF Collaboration

Hill Physicians Medical Group, Engaging Physicians and Payers in Innovative Oncology Payment Models

Illinois Critical Access Hospital Network (ICAHN), Developing a Quality-Reporting System for a Critical Access Hospital ACO

Integra Community Care Network, Palliative Care Education for Care Managers in a Medicare ACO

Intermountain Healthcare, Engaging Clinical Staff in Sepsis Detection and Intervention

Lehigh Valley Health Network, Optimizing a Patient Portal to Increase Engagement

MaineHealth, Developing a Quality Heat Map to Drive Cross-Contracts Quality Improvement

MaineHealth, Serious Illness Approaches by ACOs

Mayo Clinic, Generating Value by Integrating Palliative Care into Primary Care Workflows

Memorial Hermann Health System, Defragmenting the Delivery System Through Quality and Contracting Alignment

Mission Health, Utilizing Innovative HIT Partnership to Reduce Inpatient Falls

Moffitt Cancer Center, Standardizing Palliative Care and Oncology Integration Using Assessments and Care Pathways

Montefiore Health System, Leveraging Digital Technology to Improve Behavioral Health Integration with Primary Care

MyHealth First Network, Utilizing Teams to Improve Transitions of Care

New West Physicians, Accelerating the Adoption of Evidence-Based Practices

New West Physicians, Creating a Physician-Led Value-Driven Compensation Model

Northern Arizona Healthcare, Developing Partnerships to Strengthen Individuals and Communities

NYC Health + Hospital, Serious Illness Approaches by ACOs

OneCare Vermont, Deploying a Patient Risk Stratification Tool to Inform Care Management 

OneCare Vermont, Reducing Variations in Care through Transparent Data Reporting

OSF HealthCare, Optimizing Technology and Staff for Advance Care Planning

Park Nicollet Health Service, Leveraging Pharmacists in Ambulatory Care Teams to Optimize Medication-Related Health Outcomes

Parkview, Developing a Paramedic Response Team to Support SNF Partners

Pioneer Valley ACO, Leveraging Technology for Real-Time Care Coordination

Presbyterian Healthcare Services, Serious Illness Approaches by ACOs

ProHEALTH, Delivering Home-based Palliative Care within an ACO

Sharp HealthCare, Providing Early Palliative Care Interventions for Patients with Serious Illnesses

Signature Medical Group, Designing a Biopsychosocial Care Model for High-Risk Maternity Patients

Signature Medical Group, Designing a Provider-Driven Platform

St. Vincent's Health Partners, Designing a Communication Strategy for a Clinically Integrated Network

Summit Medical Group, Designing a Self-Funded Rewards Program to Engage Physicians in Risk Adjustment

Total ACO, Building Internal Quality Reporting Expertise

U.S. Medical Management, Serious Illness Approaches by ACOs

UT Southwestern, Designing Governance for Bottom-Up Innovation

Vidant Health, Serious Illness Approaches by ACOs