ACOs Share Secrets to Better Patient Care

At its recent fall meeting, the National Association of Accountable Care Organizations (NAACOS) honored three ACOs with awards. On October 16, representatives from Bryan Health Connect ACO in Nebraska, Ochsner Accountable Care Network in Louisiana, and TriValley Primary Care in Pennsylvania shared insights during a panel, highlighting their achievements and lessons in accountable care across various business lines and payers.

NAACOS described Bryan Health Connect ACO as having built a scalable, technology-enabled infrastructure that integrates real-time data, care coordination, and partner engagement across its value-based care network in Nebraska. By leveraging advanced analytics, automated patient transition alerts, and strong collaboration with post-acute providers, the organization has achieved sustained improvements in quality, utilization, and total cost of care.

Quality Initiatives and Achievements

Jessica Heckman, M.D., vice president of medical affairs, said Bryan has about 2,000 providers in its ACO across the state of Nebraska. Among their quality initiatives was a focus on the three-day waiver rule, which they started in late 2023, and saw a really good uptake over the course of two years. “We reduced our SNF spend by $4.7 million while also reducing our inpatient length of stay and our SNF length of stay,” Heckman said.

Heckman attributed this success to several measures, including engaging with their SNF partners and utilizing care navigators. “Our care navigators have been really helpful in that regard,” she said. Bryan also saw improvement in their 30-day readmissions rates, decreasing it by 60% over the course of two years. “Our care navigators were really integral in this, focusing on making sure we have immediate reach-out touch points, particularly for our high acuity, high-need patients,” Heckman explained.

Bryan used Bamboo Health to track patient admissions and transitions, which allowed them to respond quickly to patient needs. “It lets us know when our patients are being admitted immediately, when they’re transitioning to a SNF, or when they are returning home….That’s so much more helpful than finding out two weeks after the fact,” Heckman said.

Heckman emphasized the importance of engagement from both the Bryan team and physician members in the ACO, focusing on “what can we do to be doing the right thing at the right time for the right patient.”

Ochsner Accountable Care Network

Ochsner Accountable Care Network (OACN) serves more than 60,000 Medicare beneficiaries and more than 535,000 patient lives across all lines of business through more than 3,500 clinicians. Their population health model operates in Louisiana, Mississippi, Alabama, Florida, Georgia, and South Carolina to integrate clinical care teams, post-acute providers, and community organizations around patient needs.

Beau Raymond, M.D., chief medical officer for population health at Ochsner, said the organization has two ACOs: The OACN is in the enhanced track of MSSP; the other is called the Ochsner Senior Care Network, which is in Track A and is considered as sort of an ACO with training wheels. “It’s where we have people who are new or people who weren’t doing well beforehand. We place them into that ACO, work with them, help develop them, and then move them into the enhanced track as they get better,” he explained.

Ochsner has a dedicated team that reviews health system data to find opportunities for improvement on things such as risk adjustment, pharmacy spending, or care spending. “We’ll review that information and decide whether it’s something we can actually act upon,” Raymond said. After making a change, they look to see if that worked, and go back and do it all over again. “It’s a constant cycle to make sure we get to what we were looking for,” he added.

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One key aspect of Ochsner’s approach is the use of advanced technology to support care coordination and population health management. By leveraging data analytics and care management tools, Ochsner aims to improve preventive care, chronic disease outcomes, and patient experience while reducing costs across government and commercial contracts.

As healthcare continues to evolve, ACOs like Ochsner and Bryan Health Connect are at the forefront of innovation, using data-driven approaches to improve patient outcomes and reduce costs. The success of these organizations can be attributed to their commitment to collaboration, care coordination, and continuous improvement.

Investing in Population Health

Natalie McGann, D.O., medical director for Tandigm Value Partners, emphasized the importance of investing in population health management and care coordination. “You need to invest to earn,” she said. “Physicians and particularly independent physicians are thrifty, so it’s amazing we have great results on shared savings because we do it on really lean margins.”

McGann’s organization, TriValley Primary Care, has developed a scalable, team-based approach to value-based care that combines physician leadership, care management, and population health expertise across practice sites. Their MSSP performance has improved from 6.4% in 2022 to more than 13% in 2024, while sustaining strong quality performance.

Each TriValley office has a population health specialist whose job it is to make sure care gaps are closed. They also employ teams of care managers, using population health analytics to identify high- and rising-risk patients and develop targeted interventions. “We look at it a lot as we figure out: Are we touching these people the right way? Are they enrolled in care management? Are they in the ACO care management? Are they in the practice care management?” McGann explained.

New Standard for Value-Based Care

With their focus on care coordination, population health management, and continuous improvement, TriValley Primary Care and other award-winning ACOs are setting a new standard for value-based care.

According to Natalie McGann, one key to success is to “do your best to get the patient the care they need at the right place, at the right time, for the right cost. Go to great lengths to keep your patient out of the ER. But when push comes to shove, it’s not about the dollars; it’s about making sure that your moral compass is pointing true north.”

NAACOS noted that Pennsylvania-based TriValley Primary Care, a participant in Tandigm Value Partners ACO, cares for more than 9,000 Medicare beneficiaries in southeastern Pennsylvania.