COPD Population Health Management: Incidence, Prevalence, and Mortality in a Primary Care Accountable Care Organization

Accountable care organizations (ACOs) have emerged as an effective healthcare delivery model for managing quality and cost at a population level. Within ACOs, pharmacists are critical for the delivery of high-value health care, offering patients and health care providers medication-related training, resources, and guidance that can improve quality of care at lower costs. Partners For Kids (PFK), one of the oldest and largest pediatric ACOs in the country, has successfully leveraged pharmacists to provide population health management and medication management to promote health outcomes for individual patients and the overall population it serves. This review explores how the inclusion of pharmacists in the development and execution of various quality improvement initiatives within PFK has positively impacted outcomes for patients while also lowering overall spend. A catalog of interventions is provided to offer various ways that pharmacists can intersect as providers in the triad of patient/family, payor, and provider. By providing enhanced training and education, on-site guidance, medication management, and population-level data analysis, pharmacists are able to identify and improve inefficiencies in care. Moving forward, ongoing engagement of pharmacists in health care operations will be a necessary feature to maximize health care value.

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Accountable Care: Building Systems for Population Health Management

10.15868/socialsector.25012 ◽

2014 ◽

Author(s):

Sarah Klein Klein ◽

Douglas McCarthy McCarthy ◽

Alexander Cohen Cohen

Keyword(s):

Population Health ◽

Health Management ◽

Accountable Care ◽

Population Health Management ◽

Building Systems

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Accounting for accountable care: Value-based population health management

Social Studies of Science ◽

10.1177/0306312719840429 ◽

2019 ◽

Vol 49 (4) ◽

pp. 556-582 ◽

Cited By ~ 6

Author(s):

Linda F Hogle

Keyword(s):

Health Outcomes ◽

Population Health ◽

Financial Risk ◽

Health Management ◽

Healthcare Providers ◽

Big Data Analytics ◽

Accountable Care ◽

Population Health Management ◽

Data Intensive ◽

Account Giving

Accountable Care Organizations (ACOs) are exemplars of so-called value-based care in the US. In this model, healthcare providers bear the financial risk of their patients’ health outcomes: ACOs are rewarded for meeting specific quality and cost-efficiency benchmarks, or penalized if improvements are not demonstrated. While the aim is to make providers more accountable to payers and patients, this is a sea-change in payment and delivery systems, requiring new infrastructures and practices. To manage risk, ACOs employ data-intensive sourcing and big data analytics to identify individuals within their populations and sort them using novel categories, which are then utilized to tailor interventions. The article uses an STS lens to analyze the assemblage involved in the enactment of population health management through practices of data collection, the creation of new metrics and tools for analysis, and novel ways of sorting individuals within populations. The processes and practices of implementing accountability technologies thus produce particular kinds of knowledge and reshape concepts of accountability and care. In the process, account-giving becomes as much a procedural ritual of verification as an accounting for health outcomes.

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impact of a Pharmacy-Led Transitions of Care Program Within a Primary Care-Based Accountable Care Organization

The Senior Care Pharmacist ◽

10.4140/tcp.n.2021.311 ◽

2021 ◽

Vol 36 (6) ◽

pp. 311-316

Author(s):

Tina Joseph ◽

Genevieve M. Hale ◽

Cynthia Moreau ◽

Stephanie L. Kourtakis ◽

William R. Wolowich

Keyword(s):

Primary Care ◽

Primary Outcome ◽

Care Setting ◽

Primary Care Setting ◽

Care Program ◽

Accountable Care Organization ◽

Transitions Of Care ◽

Care Organization ◽

Pharmacy Services ◽

Accountable Care

OBJECTIVE: To assess the impact of pharmacist-led transitions of care program on 30-day readmission rates in the accountable care organization (ACO) primary care setting. DESIGN: Retrospective cohort study. SETTING: Two primary care provider (PCP) offices with an ACO in South Florida. PATIENTS, PARTICIPANTS: Adult Medicare patients who completed a post-discharge follow-up visit at two primary care offices within an ACO from July to December 2017. INTERVENTIONS: To supplement postdischarge visits with a PCP, the pharmacy services were also provided two days per week with a PCP. The comparator groups were patients who only saw a PCP or those who saw a PCP and pharmacist. MAIN OUTCOME MEASUREMENTS: The primary outcome was hospital readmission or emergency department visit within 30 days. RESULTS: A total of 190 subjects were included. There were 113 patients in the PCP group and 77 patients in the PCP/pharmacist group. There was a reduction in the primary outcome when comparing the PCP-only versus PCP/pharmacist groups (6.2% versus 3.9%; P = 0.74). CONCLUSION: Involving pharmacists in patient transitions of care in the primary care setting may be beneficial as previous studies have demonstrated. Further studies evaluating pharmacy services in emerging health care models are needed in order to most effectively utilize the expertise of the pharmacy team.

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