How ACOs change their workforces to manage risk

Value-based care models have led accountable care organizations to change how they utilize their workforce through interdisciplinary teams and managing care by focusing on the highest-risk, and highest-cost, patients.

The findings were gathered in a survey of 17 clinical or administrative ACO leaders published in the American Journal of Managed Care. The organizations selected were either high performers on quality and cost savings or showed evidence of “novel use” of the healthcare workforce. The 17 participants were from a variety of payment models: seven Medicare Shared Savings Program ACOs, five Pioneer ACOs, four commercial ACOs, and one county-based ACO. Six of the organizations were visited in-person, in addition to the phone interviews.

While specific staffing decisions were left up to individual practices, the survey found that, across sites, interprofessional healthcare teams were being used more frequently. This involved both hiring new employees, such as additional care coordinators, and expanding existing roles, such as “using pharmacists to perform medication reconciliation and improve adherence.”

“The addition of new workers and expansion of roles tended to be concentrated around care for the highest-cost patients in recognition of the potential to significantly lower the cost of care through enhanced care coordination,” wrote Shana Sandberg, PhD, research scientist at the National Committee for Quality Assurance, and her coauthors. “All sites reported using risk-stratification techniques to identify the patients at highest risk of hospitalization and directed increased services to these patients.”

Most of the time, the care coordinators for high-risk patients were registered nurses or social workers. Most ACOs embedded these employees at some of their primary care practices, while others used centralized managers or a hybrid approach “because not all practices had the patient volume to support an on-site person.”

Across the organizations, it was generally agreed that a single coordinator could manage between 100 and 150 high-risk patients. In some cases, coordinators were assigned up to 1,500 patients, but those tended to include 90 to 95 percent lower-risk patients who didn’t require active management. Four of the sites went for a more resource-intensive solution to lowering hospitalizations for high-risk patients, developing “ambulatory intensive care units” for intensive outpatient care management services.

Going even deeper, 11 ACOs used social workers, navigators and community health workers to match complex patients with appropriate community resources, like housing. Seven organizations used workers to conduct home visits, and another six were trying to coordinate care more closely with home health agencies to increase adherence to their plans from patients.

For moderate- and low-risk patients, the coordination strategies appeared far more traditional. Some ACOs had developed more “modest” programs tailored to this more stable patient population, such as smoking cessation or diabetes management. One exception to this was increasing access to behavioral health services, with eight ACOs embedding those specialists in primary care clinics or teams.

The biggest takeaway from the survey, according to Sandberg and her coauthors, was that no single model worked equally well for all sites. Instead, sites tailored their teams to be a good fit for available providers as well as local populations. 

“Making significant changes to payment and delivery models takes time; even the sites most experienced in bearing financial risk are still experimenting, measuring, and refining their service models,” the study concluded. “As payment and delivery models continue to evolve, it will be important to monitor the impact on healthcare providers and patients.”