Meritage ACO Care Transitions Program Leads to Stunning Results

Despite all the advances in healthcare and technology that have been developed in recent years, preventable hospital readmissions are still a surprisingly widespread problem in the medical field. For example, 17.5% of Medicare fee-for-service beneficiaries who are discharged from hospitals are readmitted within just 30 days, and about 75% of those readmissions are completely preventable. In fact, preventable readmissions cost approximately $25 billion per year in wasted spending. All of these numbers, of course, don’t even take into account the amount of preventable harm that patients suffer as a result of these missed opportunities for better care.

In light of this problem and with the hope of creating a better experience for patients, Meritage ACO developed a new model of care with the following goals:

  1. To reduce preventable readmissions among populations with the highest risk
  2. To improve patient safety via medication reconciliation
  3. To increase patient satisfaction by improving communication and coordination between providers and care settings
  4. To ensure that patient end-of-life preferences are taken into account.

These goals were created in line with the Institute for Healthcare Improvement’s Triple Aim: improving the health of the population, enhancing the experience and outcomes of patients, and reducing per capita costs of care to benefit communities.

In order to achieve these goals, Meritage ACO created a hybrid model with three distinct elements: care transitions coaching, complex care management, and care coordination between settings. In addition to creating a well-thought-out and comprehensive care model, Meritage ACO adopted new technology such as a cloud-based, HIPAA-compliant network to bring all the participants in a patient’s care onto a unified information-sharing platform.

Because of these efforts, outstanding results have been achieved in just two years since the first changes went into effect. The readmission rate for Meritage ACO’s highest-risk patients dropped to 10.2 percent, which is considerably lower than the national average, and Meritage ACO is close to the 90th percentile for chronic heart failure, asthma, chronic obstructive pulmonary disease, and all-cause 30-day readmission avoidance. Patient satisfaction has also increased.

Meritage ACO is continually analyzing and implementing new changes to improve their care transitions program and further improve patient outcomes, lower risk, reduce costs, and increase patient satisfaction. To read the fascinating, in-depth discussion of Meritage ACO’s journey and outcomes, click here. And if you’d like to receive care from a leader in healthcare innovation, visit today!

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