An accountable care organization (ACO) is a health care organization that follows a model where reimbursements are directly tied to quality metrics and reduced costs. Or, according to the Centers for Medicare and Medicaid Services, “Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.”
Not all health care organizations are ACOs. In order to become an ACO, health organizations may need to make quality improvements—and in order to make these improvements, they may need to track their quality metrics better in order to document the kinds of changes they need to make. This can be a challenge at small rural hospitals where quality metrics have not been tracked well in the past. Because care coordinators work closely with patients are aware of barriers to care and other community issues, they may be asked to assist in the process of helping to devise a better metrics tracking system so that the hospital might qualify to become an ACO.
After completing the activity, you will be prepared to:
Investigate strategies for expanding the health information technology (HIT) at a small rural hospital to better track quality metrics.
Recommend strategies for improving the tracking of quality metrics at a small rural hospital so that this hospital can qualify to become an ACO.
Challenge Details
You continue your work as a newly hired case manager at Sacred Heart Hospital, located in Valley City, North Dakota. As you know, SHH was recently acquired by Vila Health, a large health care system that operates hospitals and clinics in several Midwestern states.
Vila Health wants all of its hospitals to be Accountable Care Organizations. However, as a small rural hospital, SHH will have to make many improvements in order to qualify for ACO status. In order to develop a strategy for making these improvements, the first step will be to track quality metrics better so that the hospital will have data to work with to measure problems and to track improvements. You, the new case manager, will be asked to develop a strategy for tracking quality metrics to help facilitate the hospital’s qualification for ACO status.
Exterior image of Sacred Heart Hospital.
Your Office
It looks like you have email from Karen Dellington, Admissions and Discharge Director. Read the message, then review the documents below.
Email
From: Karen Dellington, Admissions and Discharge Director
Subject: Quality Metrics Tracking
Hello! Thank you so much for all your hard work in helping SHH to develop a strategy for achieving Triple Aim Outcomes. The hospital has another, similar project, and we need your help to complete it.
As you know, SHH was recently acquired by Vila Health. Vila Health wants all of its hospitals to become Accountable Care Organizations (ACOs). However, in order to qualify to become an ACO, SHH will have to make a number of quality improvements.The Center for Medicaid and Medicare Services says that an organization has to show quality improvements in the following areas in order to become an ACO:
Patient experience.
Care coordination/patient safety.
Preventative health.
At-risk population health.
For more information on ACOs, please read the Accountable Care Organizations: What Providers Need to Know document, which I will be sending to you.
After reading through the Barnes County Community Health profile, and after interviewing various stakeholders at the hospital and in the community, I know you’re already aware of some of these needed improvements. For example, preventative care is an issue in this region. Patients are not seeing their primary physicians often enough—or they don’t have primary physicians—and they aren’t getting diagnostic tests like mammograms or colonoscopies at a satisfactory rate.
Here’s where we need your help. In order to make the improvements we need to qualify as an ACO, we need to improve our Health Information Technology (HIT) system so that we are tracking quality metrics data better. We are not doing a good job with this. Our EHR is out of date, and we’re not gathering nearly enough data from patients. We need you to give us recommendations for how to improve our HIT so that we track the information we need to understand fully how to make the improvements we need to become an ACO.
So, here’s what I’d like for you to do:
First, I’d like for you to meet with a patient named Caroline McGlade, who has recently been diagnosed with breast cancer. Mrs. McGlade is a typical example of one of our patients who hasn’t gotten enough preventative care. I’d also like for you to look at her EHR—which, as you’ll see, isn’t very thorough. As you think about this case, ask yourself this: how could we be tracking data in cases like this one better to help us to make the improvements we need to qualify for ACO status?
Second, I’d like for you to interview a series of stakeholders who can provide you with information about changes that need to be made in our HIT.
After completing these tasks, I need you to write recommendations for how we can expand our HIT to better include quality metrics—with the ultimate goal of qualifying for ACO status.
This is a challenging assignment, but I know that you’re up to it! Best of luck.
Thanks,
Karen
Accountable Care Organizations: What Providers Need to Know
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health & Human Services (HHS), finalized regulations under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Provider participation in an ACO is purely voluntary.
In developing the program regulations, CMS worked closely with agencies across the Federal government to ensure a coordinated and aligned inter- and intra-agency effort to facilitate implementation of the Shared Savings Program.
CMS encourages all interested providers and suppliers to review this program’s regulations and consider participating in the Shared Savings Program.
This fact sheet provides an overview of ACOs.
Please download the PDF for more information from The Centers for Medicare & Medicaid Services (CMS).
Caroline McGlade-EHR
Patient Information – 04/24/19
Patient Name: Caroline McGlade
Patient ID:
DOB:
Gender:
Phone:
Address:
Insurance:
Primary Care Provider: Dr. Brown
Contact Permissions: Mike McGlade, husband
History – 04/24/19
H&P: Mrs. McGlade is a 61-year-old woman with a PMH of breast cancer.
Family Hx Mother:
Father: Alive.
Sister:
Meds on Adm:
Neuro:
Cardio: EKG Normal.
Respiratory:
GU: Menses have ceased.
GI:
POC:
Allergies & Medication – 04/24/19
Allergies: NA.
Medication: Estrogen
Lab – 04/23/19
CBC:
RBC: 5.1
HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301
BMP:
Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2Chloride: 106
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U
Primary Care Notes – 04/24/19
04/21/19: Mrs. McGlade is a 61-year-old woman with a lump that may be breast cancer. DX: Dr. McCall, suspected breast cancer
Called Dr. Brown-GYN ONC. Consult expected for tomorrow. Suggested CA-124, HCG, AFP prior to consult.
04/23/19:
04/24/19: MRI negative for spinal cord or brain lesions.
Plan of care: Breast oncology consult.
CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.
GYN/ONC Note – 04/24/19
61-year-old woman with a possible PMH of breast cancer.
Her initial exam revealed an enlarged mass in right breast. GYN/ONC physical exam. Based on physical presentation, blood work and radiology studies, breast cancer is confirmed. Discuss with pt. treatment options such as surgery and/or chemotherapy and radiation.
Barnes County Community Health Profile
Barnes County, North Dakota Community Health Profile by Age Group, 2000 Census
Age Group Barnes County North Dakota
0-9 1288 10.9% 82,382 12.8%
10-19 1811 15.4% 101,082 15.7%
20-29 1371 11.6% 89,295 13.9%
30-39 1303 11.1% 85,086 13.2%
40-49 1803 15.3% 98,449 15.3%
50-59 1327 11.3% 66,921 10.4%
60-69 1057 9.0% 47,649 7.4%
70-79 998 8.5% 29,492 4.6%
80+ 817 6.9% 29,492 4.6%
Total 11,775 100% 642,200 100%
0-17 2624 22.3% 160,849 25.0%
65+ 2332 19.8% 94,478 14.7%
Barnes County, North Dakota Community Health Profile by Race, 2000 Census
Race Barnes County North Dakota
White 11,775 97.9% 593,181 92.4%
Black 53 0.5% 3916 0.6%
American Indian 90 0.8% 31,329 4.9%
Asian 22 0.2% 3606 0.6%
Pacific Islander 0 0% 230 0%
Other 14 0.1% 2540 0.4
Multirace 67 0.6% 7398 1.2%
Total 11,775 100% 642,200 100%
Marital Status of Persons Age 15 and Older, 2000 Census
Marital Status Barnes County North Dakota
Total Age 15+ 9693 100% 512,281 100%
Never Married 2565 26.5% 141,300 27.6%
Now Married 5486 56.6% 290,833 56.8%
Separated 69 0.7% 3610 0.7%
Widowed 863 8.9% 36,702 7.2%
Widowed-Female 716 7.4% 30,346 5.9%
Divorced 710 7.3% 39,836 7.8%
Divorced-Female 381 3.9% 21,235 4.1%
Barnes County Community Health Profile (PDF)
It looks like you have a challenging task! You need to figure out how to improve the collection of quality metrics at SHH so that the hospital can become an ACO.
Sacred Heart Hospital
It’s time to meet Caroline McGlade, a 60-year-old patient who has breast cancer. Remember, you’ve been asked to talk with this patient because she’s a typical example of someone who hasn’t been getting preventative care—a factor that makes it difficult for the hospital to qualify for ACO status. Be sure to refer back to her EHR, and think about ways the EHR could be modified to better collect qualify metrics for patients like this one.
Caroline McGlade
Patient, Sacred Heart Hospital
Mrs. McGlade, how are you feeling?
Caroline: I feel just fine. A little scared, I guess. But it’s hard to believe I have cancer. I mean, I don’t feel sick at all. I guess I’ll start feeling sick once they start giving me that chemo. I’m not looking forward to that, believe me!
Can you tell me a little bit about yourself?
Caroline: I guess you could say I’m a pretty typical lady from Valley City—not very exciting! I’ve lived in this county all my life. I grew up on a farm near Tower City. Then I got married to my high school sweetheart and we live on a big plot of land about 45 minutes from here. I wouldn’t want to live anywhere else. Sometimes I wish we had more neighbors, but Mike and I like living in the middle of nowhere! I guess you could say we’re independent spirits? That’s how we were raised—we don’t like to be dependent on other people. We have four kids—our son lives in Valley City and our three girls live in the Fargo-Moorhead area. Nine grandkids so far.
How did you discover the cancer?
Caroline: I felt a lump. It wasn’t big and at first I didn’t think it was anything to worry about. I don’t like running to the doctor every time something feels weird in my body—I mean, that’s just part of getting old, right? But my daughter finally convinced me to get checked. And I guess I’m glad I did. Stage 3 breast cancer—that’s pretty serious.
Have you ever gotten a mammogram?
Caroline: Yeah. I think twice? Maybe three times? It’s been a long time though. I don’t know…I guess they could’ve caught the cancer earlier if I went more often. But I’ve heard that mammograms aren’t all that important. You can find a lump pretty easy by checking your breasts, right? And I do that once a month or so.
Do you regularly see a gynecologist?
Caroline: Well, I did when I was pregnant—but that was a long time ago. My youngest daughter is 30 years old. And when I needed birth control pills—then I used to go. But there’s no reason for me to go at my age, right? It’s not like I need birth control pills anymore—I mean, I finished with menopause when I was 47! I don’t know—I guess maybe I should have gone more often. But I really hate … you know, putting my legs in those icky metal things? I just don’t like having doctors poking around my private parts. Maybe if there were a woman doctor around here I might have gone more often, but around here there’s not a lot of choice who you see. All the gynecologists I’ve ever been to, they’re old guys who are kind of creepy.
Do you regularly see a primary care physician?
Caroline: No, not anymore. When Dr. Tucker was alive my husband and I used to go… but he died about seven, eight years ago? And we’ve never bothered finding a new doctor. Like I said, there aren’t a lot of doctors around here, and we’d have to drive 45 minutes to get to one. Gas is expensive, so we don’t like to go on trips that aren’t necessary. And I don’t want to go to someone I don’t know. Dr. Tucker, he was my doctor since I was a teenager. I guess we ought to find a new doctor, but we just don’t get sick very often. A few times we’ve gone to Urgent Care, but we don’t like to go running to the doctor every time we have some aches and pains. We can’t stand people who do that.
Have you ever gotten a colonoscopy?
Caroline: NO! No no no. Nobody’s sticking a camera up in there, or whatever it is they do. My husband’s never gotten one either–I’m pretty sure he’d rather die! Besides, those tests costs a fortune.
How do you feel about preventative care?
Caroline: You mean, like shots and such? We got all the immunizations for our kids. Oh, do you mean, like preventative care for adults? Like getting your cholesterol checked and all that? I don’t know. I guess I kind of feel like that’s a waste of time. And it’s expensive too. We just try to eat healthy and get some exercise. Neither one of us is overweight, so it’s not like we’re going to get diabetes or anything like that.
Why haven’t you gotten more preventative care?
Caroline: Well, why would we? Like I said, we’re pretty healthy and we don’t like to run to the doctor for every little thing. If there were a doctor around who I trusted, I guess I would go more often. Plus going to the doctor is expensive. It didn’t used to be so bad when we were younger, but now going to the doctor costs a fortune. My husband and I are doing okay, but we definitely don’ t have money for extras.
Have you always had health insurance?
Caroline: No, we’ve almost never had health insurance. Just during this one period when my husband was working in town for a factory that closed down. But we have health insurance now, thanks to that Obama! We don’t have a choice anymore, do we? Although much as I hate to admit it, maybe it’s a good thing we have insurance. Otherwise I don’t know how we’d pay for cancer treatments.
Do you think your views about health care and preventative care are typical for people in this area?
Caroline: Yeah. I don’t know anyone who goes to the doctor a lot. Most of the people I know, they have even less money than we do. And like I said, people are independent around here. People don’t like to ask for help unless we really need it. So going to the doctor a lot… I guess that’s not something people like to do around here.
Check Your Email
It looks like you have another email from Karen Dellington, Admissions and Discharge Director.
Read the message below.
Email
From: Karen Dellington, Admissions and Discharge Director
Subject: RE: Quality Metrics Tracking
I see you’ve spoken with Caroline McGlade! I wanted you to meet with her because her case is typical of so many that we see around here. We need to address the types of issues you encountered with this patient—especially regarding preventative care—if we’re going to become an ACO. And before we can do that, we need to gather data on these issues.
I’ve arranged for you to meet with a panel of four people at SHH so you can ask them some questions about the strategies we need to develop in order to better track quality metrics. The panel will consist of:
Todd Chester, Director of Quality Assurance
Mary Loudsinger, a social worker
Pete Wade, Director of Information Technology
Trish Walstrom, the Care Coordination Manager
Thanks again for your hard work!
–Karen
EHR Meeting
It looks like you’ll be listening in on the SHH panel meeting.
Read the discussion around each question below.
Panel Participants:
Todd Chester: Sacred Heart Hospital Director of Quality Assurance
Trish Walstrom: Care Coordination Manager
Mary Loudsinger: Sacred Heart Hospital Social Worker
Pete Wade: Director of Information Technology
What is your opinion of the hospital’s EHR?
Trish: Um, well…
Pete: It’s okay, Trish. You don’t have to hold your tongue around me. I know the hospital’s EHR has a lot of problems.
Todd: In all fairness, Pete, it’s not worse than EHRs you’d find at many small-town rural hospitals. We simply haven’t had the budget to improve it.
Pete: That’s for sure. I don’t have the budget to do much of anything.
Todd: We just haven’t made the EHR much of a priority. The wish list of things we need at this hospital is pretty large, and that’s always lower on the list than things like new equipment. But now that there’s this push to become an ACO, we’re going to have to find the funds to upgrade the EHR. Otherwise, we’re never going to be able to track the metrics we need to make improvements.
Trish: And that’s the problem with the EHR, in my opinion. It’s not set up to track much of anything. Patients come in here multiple times, and we have to ask them the same questions over and over again because the EHR just isn’t comprehensive enough. And if the EHR isn’t comprehensive enough to help patients on an everyday basis, it sure isn’t comprehensive enough to be used for data collection purposes.
How would you recommend updating the hospital’s EHR?
Mary: Well, in my opinion, one of the biggest problems is that there simply aren’t enough categories to enter information. I wish there was a social work tab so that I could keep track of visits with patients. If we had that tab, we could record things like patient barriers to care, and other important information that might impact their treatment.
Trish: Oh, I totally agree, Mary. There’s just not a lot of places to add non-medical information.
Pete: I’m not sure what to do about that. it would be great if we could add more categories, but that’s not easy. We’d have to work with the vendor, and that could be expensive.
Todd: Oh, I know, Pete. But if we’re ever going to become an ACO, we might need to find a way to make this investment.
Trish: So, here’s a suggestion for you, since you’re the one coming up with a strategy for tracking metrics. Why don’t you take a good look at our EHR and think about places where we could add more categories? And other updates too.
Are there changes that need to be made in how the EHR is used?
Trish: I’ll say! The system takes a long time to navigate. It’s not the least bit intuitive. And that means that nurses and case managers sometimes don’t enter information as thoroughly as they need to.
Pete: Aren’t they required to fill it out in detail?
Trish: Well, yes. But this hospital is understaffed. Sometimes the EHR isn’t filled out as completely as it ought to be.
Pete: What? Now that sounds like a serious problem. How are we ever going to use the EHR to track quality metrics if people aren’t even using it correctly?
Todd: I’m really glad you brought that up, Trish. We should discuss this further. I know that part of the problem is technical; we’re going to need to spend some money to make the system more user-friendly. But it sounds like we’re going to need a change management strategy as well. We need it to be the norm for people to use the system correctly.
Trish: I’m fine with that. But are you going to address the reasons why people aren’t filling the EHR out completely? It’s not because anyone is lazy. It’s because they’re busy.
Todd: I understand that. And we do need to be cognizant of people’s schedules as we develop our change management strategy.
How can we better track issues related to preventative care?
Todd: Well, like we’ve already discussed, we need to include more fields on the EHR so we can track more kinds of information. Other than that, well, that’s something we’re really going to need to discuss. I don’t have all the answers. But I can’t emphasize enough what an important issue this is. People are not getting the preventative care they need in this county, and that’s driving up costs and driving down quality of care.
Pete: But how do we measure that?
Todd: Well, we do have data from Barnes County that measures some statistics. For example, the data shows that women aren’t getting Pap smears and mammograms, and that people aren’t getting enough colonoscopies. That’s a start. But I think we need more nuanced data.
Trish: I agree. For example, the county data doesn’t track what percentage of women are seeing gynecologists, or how often they’re going. There’s data about how many people don’t have a primary physician, but there’s not data about how many women see a gynecologist. And I’d like to see more nuanced data in relation to mammograms. The only stat they provide is how many women over 40 have had a mammogram in the past two years. I’d like to know how often they get mammograms, and how many women have never had one.
Mary: And in addition to these numbers, I’d like to know why. Are women not getting mammograms because of cost? Or because there aren’t enough providers around here? Or because they just don’t think it’s important? I mean, based on my experience, I can tell you why I think women aren’t getting mammograms.
Pete: But we need nuanced data to back that up.
Mary: Exactly!
Trish:And I think that’s true for a lot of the county data. There’s good surface information in there, but we need more nuanced data on a lot of different things. I recommend that you take the time to read through the data carefully, and come up with some ideas for areas where we need to do more nuanced research.
Are there social factors that the hospital could be tracking better?
Mary: Yes! Where do I ever start?
Trish: You could start with barriers to care. As a care coordinator, I see every day that there are barriers to care that make it difficult for people to get the care they need.
Mary: Absolutely. Poverty, lack of transportation, lack of access to providers and specialists in this region—those are the big barriers to care that we see all the time.
Trish: And there are other issues too, like our large population of vets with PTSD—some of them don’t want to go into town and see a health provider.
Mary: Plus there’s just the general attitude of distrust that a lot of people around here have in regard to the health care system.
Pete: But how do you measure that in terms of quality metrics?
Mary: That’s a good question, Pete. I don’t know how to measure that attitude, but I know from experience that it serves as a very real barrier to care.
Pete: I don’t mean to be a downer here, but I’m confused. I know it’s important for you all to track social factors so you can treat patients better. But what does that have to do with tracking quality metrics that would help us to become an ACO?
Todd: Good question, Pete. The thing is, we need to track problems that are making it difficult for us to give the best health care experience we can. And a lot of those problems are directly related to social issues, like poverty and other barriers to care. If we can figure out how to measure these problems more effectively as they relate to health care, we could come up with effective strategies for improving people’s health care experiences.
Are there special population needs we could be tracking better?
Mary: We need to track the needs of returning vets. That’s pretty obvious to everyone around here.
Todd: Well, that’s the thing, Mary. It’s pretty obvious to the people at this hospital that we need to be serving the needs of vets better. But an outsider wouldn’t know that because we’re not tracking that very well.
Pete: Doesn’t that Barnes County Community Health Profile have information about vets?
Trish: No, it actually doesn’t, Pete! They have statistics about suicides. And we know anecdotally that a lot of those suicides are vets with PTSD, but we don’t have stats to back that up.
Mary: And we’re not tracking other things either, like home care needs for disabled vets.
Pete: For starters, we could add a demographic box for veterans on the EHR.
Mary: Great idea. And I hate to bring this up repeatedly, but if there were a field in the EHR to enter information about social work concerns, we could enter that information there as well.
Trish: Are there other special populations we need to be tracking?
Mary: Of course. This county may be over 90 percent white, but that doesn’t mean there aren’t people of color around here. We need to do a better job tracking the needs of everyone in this county.
Are there partnerships that the hospital could form with other organizations to track metrics better?
Mary: I think teaming up with the public health department would be a good start, don’t you? They’re already collecting data that we can use. Maybe we could work with them to collect more nuanced data, or different kinds of data.
Todd: That’s a very good idea, Mary. In addition, one thing I think we really need to do is link our EHR with some of the clinics in the area.
Pete: And like I said, that could be expensive.
Todd: I know. But we have to prioritize this.
Trish: I think we could do more than just linking the EHR. We could work with clinics in the area to help us collect data about things like barriers to care and other patient information.
Write a quality improvement proposal, 5-7 pages in length, that provides your recommendations for expanding a hospital’s HIT to include quality metrics that will help the organization qualify as an accountable care organization.
Introduction
Health care has undergone a transformation since the release of the Institute of Medicine’s 2000 report To Err Is Human: Building a Safer Health System. The report highlighted medical errors as a contributing factor leading to poor patient outcomes. The Institute of Medicine challenged organizations to implement evidence-based performance improvement strategies in order to improve patient quality and safety. Multiple governmental and regulatory agencies, such as the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Quality and Research (AHRQ), vowed to strengthen and improve incentives for participation, safety, quality, and efficiency in accountable care organizations (ACOs).
Health information technology (HIT) performs an essential role in improving health outcomes of individuals, the community, and populations. Health organizations, consumer advocacy groups, and regulatory committees have made a commitment to explore current and future opportunities that HIT offers to continue momentum to meet the Institute of Medicine’s goal of improving safety and quality.
Understanding HIT is important to improving individual, community, and population access to health care and health information. HIT enables quick and easy access to information for both patients and providers. Accessible information has been shown to improve the patient care experience and reduce redundancies, thereby reducing health care costs.
This assessment provides an opportunity for you to make recommendations for expanding a hospital’s HIT in ways that will help the hospital qualify as an ACO.
Reference
Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press.
Preparation
In this assessment, you will again assume the role of case manager at Sacred Heart Hospital. This time, you are asked to develop a strategy for tracking quality metrics to help facilitate the hospital’s qualification for ACO status.
Before drafting your proposal, complete the following simulation exercise:
Vila Health: Quality Metrics Tracking.
Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.
assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 2: Explain the relationship between care coordination and evidence-based data.
Recommend ways to expand an organization’s HIT to include quality metrics.
Identify potential problems that can arise with data gathering systems and outputs.
Competency 3: Use health information technology to guide care coordination and organizational practice.
Describe the main focus of information gathering in health care and how it contributes to guiding the development of organizational practice.
Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Write clearly and concisely, using correct grammar and mechanics.
