Keys to ACO Success | June 2023 | Clinical Corner

June 1, 2023

Keys to Successful Participation in the McLaren ACO


CMS is requiring Physician Accountability for Cost, Quality, and Patient Satisfaction. The goal of our ACO is to support our providers with the people, processes and technology to effectively and efficiently improve patient outcomes and quality care in our communities.

Building an effective ambulatory population health management strategy is a requirement to continue to provide services to our patients and payors.  Providers need to focus on the health of our patients (HEDIS metrics) and the management of chronic illnesses from the patients’ home setting.

Keys to being successful in the McLaren ACO:

  • Adoption of PCMH (Patient-Centered Medical Home) capabilities by PCPs and PCMH-N (Patient-Centered Medical Home – Neighbor) principles by specialists.
  • MPP staff to assist with practice workflow, quality gap closure, managing patient transitions of care and chronic illness.
  • Utilization of our Population Health software, Persivia – offers HCC coding, care coordination, patient disease registry, payor quality data.
  • Utilization of McLaren Healthcare System and McLaren Physician Partners (MPP) Providers
  • Attention to Hierarchical Condition Categories (HCC) – Utilize Persivia software to integrate HCC coding into Electronic Medical Records.
  • Electronic submission of quality data to payors, improving all HEDIS and key performance metrics above the 90th percentile.
  • Enhance McLaren and independent Provider care coordination revenue streams.
  • Care Coordination access and programs across multiple payors, assists our providers in management of our complex patients:
    • Managing over 17,000 patients in our Care Coordination programs.
    • Implemented Chronic Care Management billing program.
    • Reduction of Skilled Nursing Facility (SNF) utilization.
    • Utilizing a preferred SNF network.
    • After hours and weekend access to Care Coordination
    • Remote patient monitoring
    • ESRD (end stage renal disease) care management program
    • Medication review of complex patients by a pharmacist or pharmacy tech
    • Transitional Care Management with Medication reconciliation

CMS and CMMI’s objectives are to transition all Medicare and Medicaid beneficiaries into accountable care relationships by 2030. Accountable care requires access to and coordination of primary care and specialty care to meet the full range of patient needs. The services listed above are intended to improve patient satisfaction, enhance patient outcomes, and address fragmented, costly care.