ST JOSEPH REGIONAL HEALTH PARTNERS ACO

ST. JOSEPH REGIONAL HEALTH PARTNERS ACO IS AN ACCOUNTABLECARE ORGANIZATION WHICH HAS BEEN APPROVED BY CMS TO PARTICIPATE IN THE MEDICARE SHARED SAVINGS PROGRAM ("MSSP"). WE ARE COMMITTED TO LESSENING THE BURDENS OF GOVERNMENT BY PROVIDING, AND BEING ACCOUNTABLE FOR, HIGH QUALITY, EFFICIENT AND COORDINATED CARE TO ITS ASSIGNED MEDICARE BENEFICIARIES IN THE BRYAN, TX AREA AND EDUCATING PATIENTS SO THAT THEY LEAD HEALTHIER, HAPPIER LIVES. THE WAYS THE ACO ACHIEVES BETTER CARE FOR INDIVIDUALS, BETTER HEALTH FOR POPULATIONS, AND LOWER GROWTH IN MEDICARE EXPENDITURES AS ENVISIONED BY THE MSSP ARE THROUGH (1) THE PROMOTION OF EVIDENCE-BASED MEDICINE; (2) THE PROMOTION OF BENEFICIARY ENGAGEMENT; (3) BY REPORTING INTERNALLY ON QUALITY AND COST METRICS; AND (4) COORDINATING CARE.OUR TEAM CONSISTS OF RN CARE MANAGERS SPECIALIZED IN PROVIDINGTELEPHONIC CARE COORDINATION. THIS CARE IS PERFORMED IN COLLABORATION WITH OUR PATIENT, PATIENT'S FAMILIES AND OUR MSSP ACO HEALTHCARE PROVIDERS. OUR MSSP PROGRAM FACILITATES BETTER COMMUNICATION BETWEEN PROVIDERS ACROSS THE CONTINUUM, AN INCREASE IN QUALITY OF CARE AND THE AVOIDANCE OF EXCESSIVE COSTS TO MEDICARE AND THE PATIENT. WE ARE COMMITTED TO ENSURING THE PATIENT HAS A SMOOTH, SAFE AND POSITIVE PATIENT EXPERIENCE. THE OVERARCHING GOAL IS TO PROVIDE THE RIGHT CARE IN THE RIGHT PLACE AT THE RIGHT TIME. WE SERVE A MEDICARE POPULATION OF 4,748 BENEFICIARIES.ACTIVITIES TO ACHIEVE THIS INCLUDE:- RN OUTREACH CALLS ASSIST IN INDIVIDUAL PATIENT HEALTHCARE NEEDS, HELPING PATIENTS NAVIGATE THE HEALTHCARE SYSTEM, IDENTIFY RISING RISKS THAT MAY POTENTIALLY AFFECT THEIR HEALTH AND FORMULATE SOLUTIONS, ASSIST IN SCHEDULING PROVIDER APPOINTMENTS, SET REALISTIC HEALTHCARE PATIENT SPECIFIC GOALS, AND ANSWERING QUESTIONS THEY HAVE ABOUT THEIR HEALTH.- ENGAGE HEALTHCARE PROVIDERS ACROSS THE CONTINUUM OF CARE TO PROVIDE HIGH QUALITY SERVICES AND REDUCE COST TO OUR ASSIGNED MSSP ACO POPULATION. RN CARE MANAGERS PROVIDE FEEDBACK TO THE PROVIDERS ABOUT THEIR PATIENT'S HEALTH STATUS, RECENT HOSPITALIZATIONS, ER VISITS, OTHER HEALTHCARE NEEDS IDENTIFIED BY THE PATIENT AND OR RN, AND FILL GAPS IN CARE AND COMMUNICATION AS APPROPRIATE. RNS ALSO SERVE AS HISTORIANS AND PROVIDE UPDATES TO THE PROVIDERS REGARDING THE PATIENT'S PAST MEDICAL CARE.- REPORTS OF QUALITY PERFORMANCE ON THE MSSP ACO POPULATION ARECOMMUNICATED TO PROVIDERS. WE HELP EDUCATE AND COMMUNICATE TO THEPROVIDERS THE QUALITY METRICS AND STANDARDS FOR THE MSSP ACO.