2023 NAACOS Leaders in Quality Excellence Awards

About the Award

Established in 2021, the NAACOS Leaders in Quality Excellence Awards recognize ACOs working to improve the quality and safety of patient care and advance population health goals. Following an open call for nominations, the NAACOS Quality Committee selected the top three submissions to showcase the quality improvement efforts undertaken by NAACOS members and to disseminate best practices among ACOs. The three 2023 winners—Delaware Valley ACO, UT Southwestern ACO, and University of California San Francisco Health—exemplify how ACOs across the country are closing gaps in care, improving care coordination for complex patients, and addressing disparities in care.

Home-Based Palliative Care—Delaware Valley ACO created a home-based palliative care strategy to improve care for patients and families facing serious illness or nearing the end of life. A collaborative team of clinicians and analysts built clinically relevant claims-based views of end-of-life care among the ACO’s Medicare patients and national benchmarks, finding, for example, that almost half of the ACO’s patients (47%) received hospice care for a week or less before death, much higher than the 28 percent nationally. Further analysis showed that longer hospice stays helped reduce the total cost of care. The ACO used the findings to build the case with key stakeholders for earlier activation of palliative care. Along with providing more positive end-of-life experiences for patients and families, the ACO found that the share of patients receiving hospice for one week or less before improved from 47 percent to 32 percent. An analysis also found that patients receiving home-based palliative care resulted in savings of about $9,000 in the last 90 days of life compared to similar patients who didn’t receive palliative care.

Using Machine Learning to Pinpoint Patients at High Risk of Unplanned Hospitalizations—UT Southwestern ACO, also referred to as Southwestern Health Resources, developed a novel risk stratification algorithm using artificial intelligence machine learning techniques to identify and match high-risk patients with complex care management services to prevent avoidable hospitalizations and emergency department visits. The ACO built predictive models integrating claims and electronic health record data with information from publicly available health data sets, such as the Social Vulnerability Index and the Area Depravation Index, to identify socioeconomic barriers to care at the individual level. The ACO then encouraged patients to enroll in a longitudinal complex care management program. Patients received tailored support and care coordination for clinical, social, pharmaceutical, and behavioral health needs. An analysis six months after the intervention found two unplanned hospital admissions among the 25 patients who received complex care management compared to 31 unplanned hospital admissions among 91 patients who did not receive enhanced care management. The ACO is scaling the intervention and plans to enroll 1,800 people in complex care management in 2023.

Reducing Disparities in Hypertension Control—After identifying a 10-point gap in 2020 between Black/African-American (67.6%) and White patients (77.8%) with controlled high blood pressure, University of California San Francisco Health made reducing disparities in hypertension a key health equity goal. Working with UCSF health disparities researchers, the ACO conducted interviews with Black/African-American patients to better understand their preferences, barriers, and competing priorities. Based on patient input, the ACO designed interventions, including culturally tailored hypertension educational materials. The ACO also designed a team-based intervention among primary care, pharmacy, and population health to help patients manage their hypertension. Patients with uncontrolled hypertension were offered an intensive program with telehealth pharmacist visits and coaching from health care navigators to encourage healthy behaviors. The ACO launched a separate effort for patients with hypertension and no recent blood pressure reading. Health navigators mailed home blood pressure monitors, taught patients to use them via the phone and video conferencing, and collected remote blood pressure readings. Patients with out-of-range readings were scheduled for primary care appointments. A year after implementation, the gap in blood pressure control narrowed significantly across the ACO, with 73.1 percent of Black/African American patients attaining blood pressure control compared with 74.3 percent of the overall population.

NAACOS congratulates these ACOs for their outstanding work to improve the quality of care provided to the patients they serve!

More about the award

The following criteria were used to evaluate submissions:

• Innovation—in processes or technology used to improve performance.
• Improvement— in quality as a result of the intervention or innovative strategies used.
• Scalability and long-term contributions—how can the project’s work can be continued, is it scalable, sustainable, transferrable and what was the return on investment.