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Atrius Health is a non-profit, Pioneer ACO formed by an alliance of six leading independent medical groups in Eastern and Central Massachusetts. In its first-year results, released in March 2013, the non-profit ACO reported that it had spent an average of $10,700 per patient. The benchmark is slightly over $12,000. That difference, about $1,300, may not seem like much, until you multiply it by a million covered lives.

Emily Brower is the Executive Director of ACO programs for Atrius Health. Speaking to a home health audience at an event hosted by the Home Care Alliance of Massachusetts last week, she attributed a large part of the organization's early success to its home health partner, the VNA Care Network, which now include the VNA of Boston.

"By establishing a stronger collaboration between our primary care physicians and the VNA," Ms. Brower explained, "we have observed a decrease in Home Health per member per month expenditures and a decrease in hospital readmissions during a VNA episode." Eventually, Atrius will participate in the incentives that CMS sets aside from such cost reductions. The VNA benefits as well; referrals rose 144% from 2011 to 2012.

In spite of the close affiliation with VNA Care Network, Atrius still competes for referrals. "Patients can take their payer and go anywhere," she said. "When they do go from our physicians to our partner home care agency, it is worth taking on a lot of risk because you get the benefit of one model of care. Our physicians see VNA nurses as an extension of their care team."

One example of that benefit is that falls risk assessments completed by home health nurses now "count" as far as Atrius physicians are concerned. Previously, they would ignore assessments by outsiders and duplicate them with their own staff nurses. "We were working separately, in parallel tracks," Ms. Brower recalled. "Now we are working together."

Collaboration between Atrius physicians and VNA nurses is the key to making the ACO cost/benefit arrangement work. As per its 3-year contract with the Centers for Medicare and Medicaid Innovation, the ACO has to identify patients that seem to be getting most of their care from Atrius, then "claim" them as patients to manage. A benchmark is set based on those patients' previous costs plus an inflation factor of 5%. The goal is to come in under that, based on 33 quality measures.

Emphasis on accurate documentation
Atrius developed an Advanced Care Planning curriculum for its staff and attached CME/CEU credits. Using site-based ACP champions to train and provide ongoing local support, and by extending EHR access to VNA clinical staff, Atrius has enabled home health nurses to know what every patient has told other clinicians, including physicians. "It gives the home health nurse the ability to talk intelligently to a patient in the home and to relay updates and corrections to physicians," Brower added.

Asked about openness to patients electing services from another home health agency, Brower said Atrius always follows Medicare rules. However, she added, they do advocate for patients to choose the VNA Care Network. "We have found," she told the audience, "that, although all home health agencies are on the same CMS pay schedule, the VNA Care Network was found to be less likely to have an unnecessary second consecutive episode, which reduced our all-important per-patient costs.

Results
Over the first year, Atrius has recorded no significant savings or loss over previous years – though Ms. Brower fully expects that will gradually improve as the ACO grows – but they have seen huge increases in quality of care and patient outcomes. She displayed a chart that showed an example of this improvement from Atrius' diabetes population.

Measuring hemoglobin A1c control, low density lipoprotein, blood pressure, tobacco cessation and aspirin use, Atrius patients score in the 80th-90th percentile where the mean performance of all patients in the region ranges from the 50th to 60th percentile.

Ongoing problems
The ACO arrangement is not without challenges, Ms. Brower added. "Since we have no hospitals in the ACO, there are issues that arise. For example, with joint replacements you want to see the patient go home as soon as possible but the hospital wants to reap the profit that comes from sending them to its own rehab hospital first."

To solve the problem and continue to keep costs under control, Atrius started a new program. They have a home health nurse talk with the patient about rehab before the day of surgery. This sets their expectations and gives them a response when someone proposes an inpatient rehab facility. "There are issues with this approach," she added. "This conversation is not a reimbursable visit. And, of course, the VNA is not allowed to provide free visits. So the ACO entity reimburses the VNA for that pre-surgery visit, which comes back to the ACO as an average $5,000 benefit.

Another workaround helps block hospital admissions that originate from an emergency department visit. When alerted to a trip to the ER, the ACO communicates with the ER physicians, saying, "This patient's plan to go home with home health nursing services is 'all set.'" They have found that ER physicians willingly sign the patient out instead of admitting him when this message is delivered.

Lessons learned
Ms. Brower concluded with a list of insights that have been gained since the ACO was formed. First and foremost, they learned that collaboration between referring physicians and home health is a nice theory but, in practice, physicians really did not know what was going on. Nurse to doctor conversations were rare at best. Other lessons, in summary, included:

• Physician engagement is key to driving change
• Wide adoption of Lean problem solving methodology created a strong foundation for change
• "One Model, One Contract" provided burning platform
• Making long-lasting change takes time
• The ability to partner effectively is the key to success

Atrius Health Pioneer ACO serves Eastern and Central Massachusetts.

©2013 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com