Practice-based pilots and population-based interventions of varied intensity

1. OUR INITIATIVE OUR IMPACT Cost Early data shows directionally lower costs and reduced utilization of unnecessary care (hospital admissions, ED visits, and ECF days) Care plans indicate provider awareness of ASAP services Quality and Patient Experience of Care Enhanced support for caregivers and family Positive patient feedback and enhanced access to ASAPs Potential for improved health outcomes through programs and services that assist patients in managing their health • Atrius Health medical groups are collaborating with local Aging Services Access Points (ASAPs) to develop best practices for communication, care delivery, and integration of medical and functional supports to a population of complex and high risk individuals. This effort fits into an AtriusHealth Pioneer Accountable Care Organization (ACO) goal to broaden the “care team” to include • community-based networksand supports. • Goals • Explore how an ACO can work closely with ASAPs to deliver the Triple Aim of improving patient experience and population health while reducing costs • Connect medical, social, and functional supports for the patient • Integrate community-based providers into the care team Integrating Care: Partnerships between Community-Based Organizations and an Accountable Care Organization OUR PARTNERSHIPS INSIGHTS AND FUTURE DIRECTION • Practice-based pilots and population-based interventions of varied intensity • Creation of patient centered care plans with resources for implementation • Development of standard work processes for optimal care coordination Community-based organizations can be leveraged to achieve the Triple Aim Practice and ASAP partnerships provide practical, targeted solutions to address many social determinants of health Practices value ASAPs for serving as the “eyes and ears” in the home and community to provide a picture of the whole patient Practice and ASAP partnerships can support “aging in place” and shared decision-making Community-based partnerships can reduce barriers between the practice, patient and community • Harvard Vanguard Medical Associates- Wellesley and Watertown with Springwell • Harvard Vanguard Medical Associates- Chelmsford with Elder Services of Merrimack Valley • Southboro Medical Group with BayPath Elder Services ASAP provided Social Worker embedded and integrated into the practice Enhanced care coordination and communication between practice Social Worker and ASAP to “close the loop” on services provided Direct communication between practice and ASAP via secure e-mail PROGRESSION OF SERVICE DELIVERY For more information, please contact Emily Brower, Atrius Healthat Emily_Brower@AtriusHealth.org or Amy MacNulty, Community Care Linkages/Mass Home Care at amy@macnultyconsulting.com