ACO Quality Improvement Methods

Since the passage of the Patient Protection and Affordable Care Act (ACA) in March 2010, the healthcare industry has seen a renewed emphasis on the quality and efficiency of providing healthcare services. Accountable Care Organizations (ACO) in particular have been a popular model for implementing innovative ideas, due in part to their focus on “coordinated, high quality care” and financial incentives for achieving quality care benchmarks.1 This last article in this three-part Health Capital Topics series focusing on ACO quality trends will describe what methods ACOs are using to achieve quality care.

As discussed in the first installment of this three-part series, ACOs only save money when the organization reduces cost and “quality performance standards have been met.”2 According to the Centers for Medicare and Medicaid Services (CMS), these quality performance standards fall into four domains, which together are expected to include a total of 37 measures by 2015.3 Since satisfaction of these measures is a prerequisite to achieving financial savings, healthcare organizations have allocated resources to determine ways to satisfy these benchmarks. Coupled with the leeway given to organizations to develop many of the methods and mechanisms actually used to meet these quality performance standards, the ACO environment has become grounds for potentially ground-breaking innovations relating to the quality delivery of
healthcare today.

Most of these innovations are driven by physicians. As providers shift their focus to a more comprehensive view of healthcare, ACOs creating a collaborative network of providers and other players in the healthcare industry who emphasize prevention and wellness services to more effectively manage chronic diseases.4 This is exemplified by many ACOs developing specialized chronic disease management programs which increase patient involvement; provide trained staff members to help monitor the patient’s adherence to protocols; and, improve patient accessibility to healthcare providers.5 Many of these programs rely on the use of mobile health technology and improved Electronic Health Records (EHRs) systems to provide pertinent data to patients quickly and support efficient population surveillance by the provider.6 These systems enable physicians and other care providers to track patients with multiple chronic diseases, provide lifestyle goals, and properly identify patients in higher risk groups who could benefit from more specialized care.7

It is important for ACOs to identify those patients in higher risk groups in their efforts to increase care quality and efficiency. Patients in high-risk groups for chronic diseases can become “super-utilizers” of healthcare services, a broad term signifying the sickest five percent of patients nationally who, on average, account for more than 60% of total healthcare costs nationally.8 Traditionally, these super-utilizers have suffered from poor care-coordination, many complex medical issues, and multiple chronic diseases that, together, have increased their visits to hospital emergency departments relative to the general population.9 Many ACOs seek to intervene and provide care for these super-utilizers before an emergency room visit is necessary. Making these initial investments and “picking the low-hanging fruit” can increase overall quality; reduce the caseload of a hospital’s emergency department; and, lessen the financial burden for both the patient and the ACO in the long run.

Another technique many ACOs have used to provide early intervention and better disease management has been through the use of “embedded nurses.”10 An embedded nurse, also known as a care coordinator for some ACOs, works to bridge the quality and communication gaps that often exist between patients and physicians. Care coordinators act as the link between the patient and the physician, and are typically the first person a patient will reach out to with questions or trouble with their care.11 An example of this is Hackensack Alliance Accountable Care Organization (Alliance), which was the first ACO in New Jersey to receive accreditation from the National Committee for Quality Assurance (NCQA).12 Alliance utilizes care coordinators to improve communication with patients, and to “empower the patient to take better care of themselves, particularly those with chronic conditions.13 ACOs have developed many techniques for care coordinators to accomplish these goals. One technique these care coordinators use to improve patient outcomes is to provide patients with a home monitoring system, often as an application on a tablet computer, that supports the patient’s need to take their medications and monitor their health changes (e.g., weight, blood pressure, and blood sugar levels).14 This information is transmitted to the care coordinator, who can take action as appropriate for the nurse’s clinical skill level. For example, home monitoring systems can alert care coordinators when a patient with congestive heart failure gains weight over a short period of time.15 The trained care coordinator may recognize this as a sign of fluid retention and can quickly contact the patient to identify the problem and adjust his or her medications appropriately. This immediate response can decrease the potential for an avoidable emergency room visit by a super-utilizer, benefiting both the ACO and
the patient.16

While disease management is a cornerstone to quality care, prevention efforts, including routine immunizations, disease screenings, and medication reconciliation, also support ACO efforts to reach quality benchmarks. Walgreens has formed three ACOs with primary care providers, with the aim to make preventative health services a more integrated component of a patient’s treatment plan.17 Through its partnership with primary care physicians, Walgreens will now conduct medication counseling, administer immunizations, and offer testing for conditions such as diabetes and hypertension.18 Walgreens is the first pharmacy to participate in an ACO and represents the first formal collaboration of a retailer with primary care providers.19

The climate for innovation within an ACO may also be starting to spread to other areas of the healthcare industry. Other retailers are also finding new opportunities under the ACA to enter into the healthcare market. Recently, Walmart opened primary care clinics in a portion of its retail locations to serve more rural populations.20 The retail conglomerate has also begun to implement their “Healthcare Begins Here” program, which aids consumers in acquiring health insurance.21 While retailers are still testing the waters of the healthcare industry, there is evidence that consumers are embracing this type of convenient care, and these retail innovations could be beneficial for supporting the aims of the ACA.22

Whether through improved care coordination, retail innovations, or mobile health technology, ACOs will likely continue to play a pivotal role in identifying the key innovations that can improve patient outcomes. While increasing mobile technologies and innovative delivery models have already seen their introduction to the healthcare industry, a continuation in the commitment toward quality and the ACO model is still necessary to determine whether these or other innovations will redefine the delivery of quality healthcare in the near future.

“Accountable Care Organizations (ACO)” Centers for Medicare & Medicaid Services, March 22, 2013, (Accessed 11/14/2014).

“ACOs Achieving Quality with Shared Savings” HC Topics Vol. 7, Issue 10, October 2014; "Methodology for Determining Shared Savings and Losses under the Medicare Shared Savings Program" Department of Health and Humans Services: Centers for Medicare & Medicaid Services, April 2014, (Accessed 10/3/14).

HC Topics, October 2014.

"Accountable Care Organizations and Innovation: A Changing Landscape" By Erin Bartolini, HealthAffairs Blog, June 28th, 2013, (Accessed 11/17/2014).

"ACO Programs and Services" UnityPoint Health Fort Dodge, 2014, (Accessed 11/17/2014).

Bartolini, June 28th, 2013.

"ACO rule has big implications for IT" By Ron Parton and Subbu Ravi, Health Management Technology, April 2012, (Accessed 11/17/2014); Bartolini, June 28th, 2013.

"'Super-utilizers' place huge burden on health-care system" By Jennifer LaRue Huget, The Washington Post: The Checkup, Health in the News-and in Your Life, October 22, 2012, (Accessed 11/17/2014).



"Nurses, Care Coordinators Are Gaining Importance in ACOs" By Jennifer Lubell, ACO Business News: Health Business Daily, February 9, 2012, (Accessed 11/14/2014); "The Value of Nursing Care Coordination" American Nurses Association, June 2012, (Accessed 11/14/2014).

"Accountable Care Organization's Innovative Approach Gets Results" By Andrew Kitchenman, NJSpotlight: News, Issues and Insight for New Jersey, December 9, 2013, (Accessed 11/14/2014).






"Walgreens forms three new ACOs" American Pharmacists Association, January 22, 2013, (Accessed 11/14/14).



“Walmart Wants to Help You Shop for… Health Insurance" By Stav Ziv, Newsweek, October 6, 2014, (Accessed 11/14/14).


"Retail clinics at tipping point: Pharmacies, chains answering demand for access and affordability" By Andis Robeznieks, Modern Healthcare, May 4, 2013, (Accessed 11/17/2014).

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