Accountable Care Organizations

Learn more about how WellTrackONE & THEO can help your ACO

What are the ACO 33 measures?

Before an ACO can share in any savings created, it must demonstrate that it met the quality performance standard for that year. CMS will measure quality of care using (33) nationally recognized quality measures in four domains:

  • Patient/caregiver experience (8 measures)
  • Care coordination/patient safety (10 measures)
  • At-risk population (7 measures)
  • Preventative care (8 measures)

Without WellTrackONE, ACOs can only look at claims and administrative data to identify patients that are have a chronic issue and generating the highest costs and look to get them into a care plan to control their chronic issues. But the problem with this approach is that the ACO is looking at patients that already have a chronic issue and it is often too late to get the patient into a care plan to avoid the chronic issue.  Necessarily they have no way of screening their patients in a consistent manner to identify the patients with the highest risks.

How does WellTrackONE meet CMS’s Quality Measures?

WellTrackONE helps ACOs converge on (29) of the required (33) measures.

  • WellTrackONE systematically schedules patients every year for their annual wellness visit.
  • Patients have a brighter perspective and more positive feeling about their doctor after a WellTrackONE experience.
  • After the WellTrackONE report is generated, physicians use it to refer the patient out to specialists to help with chronic disease risk-factors.
  • WellTrackONE produces an individualized patient report tailored to the risk factors of the patient. This report contains valuable education and information for the patient. The report is currently available in English and Spanish.
  • The doctor and the patient discuss the WellTrackONE report and risk factors and make a collaborative set of decisions together to arrive at a set of problem-focused treatment plans.
  • WellTrackONE assesses the health and functional status of every Medicare patient in the practice annually.
  • WellTrackONE produces a standardized set of risk factors for the Medicare population in a practice.
  • WellTrackONE screens for the risk of falls through its “Cognitive Assessment”.
  • WellTrackONE determines scheduled and administered influenza immunizations.
  • WellTrackONE determines scheduled and administered pneumococcal immunizations.
  • WellTrackONE determines BMI calculations yearly.
  • WellTrackONE determines smoking status yearly.
  • WellTrackONE determines depression risk yearly.
  • WellTrackONE determines colorectal cancer risk yearly.
  • WellTrackONE promotes mammography screens after the Annual Wellness Visit yearly for each female patient.
  • WellTrackONE determines B/P yearly.
  • After each WellTrackONE visit, doctors are encouraged to have each diabetes risk patient screened for HbA1c.
  • After each WellTrackONE visit, doctors are encouraged to have each CVD or CF risk patient screened for LDL/HDL.
  • WellTrackONE determines tobacco use yearly.
  • WellTrackONE determines use of aspirin on a daily basis in conjunction with each WellTrackONE visit and as a measure of stroke prevention.
  • Patients with risk factors for diabetes as determined by WellTrackONE are put into a problem-focused treatment plan that 
measures HbA1c regularly and measures compliance.
  • Patients with risk factors for Cardiovascular Disease (CVD) as determined by WellTrackONE are put into a problem-focused 
treatment plan that measures B/P regularly and measures compliance.
  • Patients with risk factors for Cardiovascular Disease (CVD) as determined by WellTrackONE are put into a problem- focused 
treatment plan that administers Lipid Profiles and measures LDL control.
  • Patients with risk factors for Cardiovascular Disease (CVD) as determined by WellTrackONE are put into a problem- focused 
treatment plan that considers the use of Beta-blocker therapy for LVSD.
  • Patients with risk factors for Cardiovascular Disease (CVD) as determined by WellTrackONE are put into a problem- focused treatment plan that considers drug therapy for lowering LDL.
  • Patients with risk factors for Cardiovascular Disease (CVD) as determined by WellTrackONE are put into a problem-focused 
treatment plan that considers Angiotension Converting Enzyme (ACE) inhibitor therapy or Angiotension Receptor Blocker (ARB) therapy.

How does WellTrackONE help ACOs in Share Savings Programs?

WellTrackONE enhances a ACOs ability to ensure the highest return on in a Shared-Savings Program.

Manage Risk to Maximize Shared-Savings

Use the WellTrackONE Reportal as a Population Management Tool to Risk Stratify your Medicare patient population.

WellTrackONE provides ACOs a comprehensive, end-to-end service and product solution to administer the Medicare Annual Wellness Visit.  This service requires no additional effort by the physician or their staff.  WellTrackONE helps ACO physicians to identify and modify risk factors of their patients. ACO Physicians who have access to risk factor data yearly for their Medicare patients are be able to intervene regularly to modify those risk factors.

What this means simply is that when they use WellTrackONE to process the AWV on their ACO’s Medicare patients every year, and give that data and the trends in risk factors to their physicians, they will be inclined to intervene.

Those interventions lend themselves to further diagnoses of chronic illnesses and provide for the treatment options to prevent the onset of chronic illnesses.  These actions will directly reduce the costs associated with prescriptions, hospital admissions, skilled nursing care and other Medicare services.  The net effect is that the ACO’s shared savings will increase.

Population Health

WellTrackONE provides an ACO and its physicians a robust reporting system that is simple to use and offers valuable metrics for their physicians. WellTrackONE does not pretend to be a Health Information Exchange (HIE), but the facts are that we collect a significant amount of important data on each patient. Each AWV report generates over (350) data points of information ranging from risk factors to BMI, B/P, Diet, Smoking, Meds, Exercise, Activities, Functional Capacity, Safety, Cognition and Depression.

Types of reports available to an ACO include:

  • Demographic Pie Chart
  • Functional Capacity Trend Report
  • Risk Factor Matrix
  • Safety Trend Report
  • Risk Factor Trend Report
  • Cognitive Trend Report
  • Body Mass Index Trend Report
  • Depression Trend Report
  • Waist Size Trend Report
  • Self-Reported Problem Trend Report
  • Blood Pressure Trend Report
  • Review of Systems Trend Report
  • Smoking Trend Report
  • Dietary Intake Trend Report
  • Alcohol Trend Report
  • Exercise Level Trend Report

The data is available to every provider as part of the WellTrackONE service providing significant value to an ACO.  As anyone who has ever operated an ACO knows, the data is very complex and very expensive.  The task of gathering and normalizing data from dozens of disparate EHR systems is overwhelmingly complex and expensive.  WellTrackONE provides data on the ACO’s patients immediately and on-demand, and the ACO gets its data back in a form that it can use and whenever they need it.

How Does WellTrackONE Improve CAHPS Scores?

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is required by Medicare. ACOs are responsible for selecting and paying for a CMS-approved vendor to administer the CAHPS for ACO survey.

The survey has (12) patient experience of care measures:

  • Getting Timely Care
  • Provider Communication
  • Rating of Provider
  • Access to Specialists
  • Health Promotion and Education
  • Shared Decision-making
  • Health Status/Functional Status
  • Courteous/Helpful Office Staff
  • Care Coordination
  • Between Visit Communication
  • Education About Medication Adherence
  • Stewardship of Patient Resources

ACO reimbursement are affective by CAHPS scores, so it is important that they score high to ensure maximum reimbursement.

Citation: CAHPS Survey for ACOs Participating in Medicare Initiatives

Request an Annual Wellness Visit Demo

WellTrackONE provides a Pre-CAHPS survey that allows ACOs to pre-survey their patient population before they CAHPS survey and take corrective action if needed to ensure an effective CAHPS score.

 

 

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