Closing care gaps with Keystone ACOs health navigator program
The Keystone Accountable Care Organization (KACO) is a partnership between Geisinger and doctors, hospitals and other healthcare providers to better coordinate care for Medicare fee-for-service patients in mostly rural areas of Pennsylvania. KACO serves more than 78,000 Medicare beneficiaries in central and northeast Pa. and surrounding states (New York, New Jersey and Maryland).
The group, started in 2013, works to provide high-quality, efficient care while lowering healthcare costs. Population health is a primary focus.
The problem
In 2013, Geisinger designed a program to improve patient outcomes by addressing social detriments to health. The program sought to help patients in the following nonclinical areas:
- Housing instability and quality
- Food insecurity
- Utility needs
- Interpersonal violence
- Transportation needs beyond medical transportation
To address these care gaps, Geisinger created a grant-funded pilot program featuring community health assistants who would conduct home visits to better understand patients’ environments, how they impact total health and how to connect patients with community resources.
The three-year pilot program was a success, closing 20,000 care gaps for 15,000 patients. After funding ended, the question remained: How can the system expand this program to reach even more patients through KACO?
The solution
The Keystone ACO relaunched in 2017 as a component of the ProvenHealth® Navigator Medical Home program, and community health assistants were embedded in primary care offices to maintain a strong connection between the health navigator program and the rest of a patient’s care team. This meant more collaboration between the community health assistants and nurse case managers, social workers and primary care providers.
- Beneficiaries of the program are identified in a few ways:
- Internal referral from providers and nurse case managers
- External referrals from community organizations
- Predictive analytics, which considers:
- Hierarchical condition coding score
- Internal risk score
- Past utilization (such as repeat emergency department visits or a recent hospital discharge)
The community health assistant then gathers background information from these sources and conducts a home visit. Afterward, the care team works with the community health assistant to close the medical and nonclinical care gaps through interventions and by connecting the patient with community resources.
The community health assistant also works closely with the nurse case manager, especially during the home visit. The community health assistant will review patient medications and other factors with the nurse case manager, resulting in real-time interventions.
Through emphasis hiring practices and continued training for community health assistants, deploying a program infrastructure that suits the needs of employees working in the field and promoting a strong collaboration between the healthcare team and community organizations, KACO improved on this pilot program to increase its outreach.
The outcome
KACO conducted 23,750 interventions in 2017 and 2018, and community health assistant-led interventions grew by 29 percent in those years. The ACO believes this doesn’t account for the community health assistants’ total reach and volume, as it’s difficult to measure the employees’ indirect impact.
Currently, KACO is enhancing an existing program that sends community health associates into the homes of beneficiaries with congestive heart failure to collect clinical information that will support cardiologists’ treatment plans.
