PRACTICE: Serious Illness Approaches by ACOs

Vidant Health Coastal Plains Network's Approach

  • Published on:
  • July 10, 2019


Vidant Health is a large, not-for-profit health system in Eastern NC, which provides care for more than 1.4 million residents who live in a highly rural area with many unmet social needs. Vidant Health offers services through 87 practice locations and 9 hospitals, which are comprised of approximately 485 providers. Vidant Health formed an integrated ACO (Coastal Plains Network [CPN]) in 2015, which currently has about 37,000 attributed patients in the Medicare Shared Savings Program (MSSP).


Vidant CPN ACO’s serious illness program starts by identifying those people with high medical risk who have been recently hospitalized or seen by Vidant ambulatory clinics. The care management staff calculates whether people have high risk of future inpatient utilization and would benefit from increased care management or other services. The program then provides home risk assessments, medication reconciliation, conversations about care goals, in-home remote monitoring, or access to health coaches depending on the particular patient’s needs. Given their service area is extremely large, sparsely populated, and resource constrained, Vidant partners with numerous community partners (largely faith-based organizations) to provide additional services to patients, especially for social drivers of health.


Vidant CPN ACO has generated net savings in all 3 years of their MSSP participation and has achieved shared savings in 2 of those years. Their average composite quality score over the past 2 years (which is the time frame for which data are available) was 93%. The ACO also has decreased readmission rates and emergency department (ED) visits; readmission rates were 10–20% across facilities at the inception of the ACO, but have since dropped to 1.5–5%. The ACO also reports that high percentages of their enrollees obtain their health goals.


The ACO uses a variety of data types and platforms to identify high-risk patients and monitor their care and outcomes, including data from insurance claims, electronic health records (EHRs), and local health information exchanges (HIEs). To adequately identify care for their high-risk and seriously ill populations, Vidant had to make significant investments in their data infrastructure. These investments included combining multiple products and data sources (since no single product could fulfill all their needs) and purchasing a data platform that supplements their EHR to provide actionable data for population health management. Using these data, the ACO has implemented a risk-stratification algorithm that considers 9 factors, including age, social status, number of conditions, and number of ED visits and hospital admissions. Patients with 4 or more risk factors are then screened by a nurse to see whether they would potentially benefit from the transitional care serious illness program. Vidant relies heavily on telehealth to overcome travel challenges associated with their rural service area. Telehealth can include remote monitoring where providers are able to view biometric information drawn from various electronic devices from home, such as weight gain for heart failure patients. In addition, a telehealth platform allows patients to receive specialty services by connecting a remote specialty physician to an exam room where a nurse is physically present to provide medical examinations or tests. These telehealth approaches provide more consistent services for patients in extremely rural areas, who may have to take a ferry and drive several hours to see a provider in person in a clinic.


Given that Vidant’s service area is extremely rural, it is difficult for patients to engage in their health care or with the ACO. Patients and providers cite transportation as a significant challenge, and no clear solution is available. Adequate resources are another challenge, especially as patients may not have access to healthy food, transportation, or other social drivers of health. There are further challenges in recruiting providers to rural areas, which translates to limited numbers of clinicians for high-touch care interventions.



Building programs from existing infrastructure improves the business case – The serious illness program was built off of infrastructure created from multiple complex care management programs, along with care coordination developed for their patient-centered medical home. The ACO brought together all existing programs aimed at higher-risk patients and identified how these different programs could work together to avoid duplication and provide the specific services patients needed for their circumstances. • Appealing to their mission and values drove leadership buy-in – The system leadership bought in to the serious illness programs based on recognizing: 1) that in rural areas, patients are often neighbors and family members; and 2) how the program advanced the broader organization’s mission and historic culture. • Creating community partnerships can help to overcome the challenges of a rural service area – As Vidant’s service area is too large and sparsely populated for the organization to directly offer social support services for all of their patients, they relied on connections with churches, schools, and community organizations to help guide patients to resources and address unmet social drivers of health.