PROVEN EXCELLENCE
Metrics of Success
Primary Care Engagement
- Increased Annual Wellness Visit completion by 30% in 1 year
- Increased Risk Score Capture 2% points year over year
- Quality Performance greater than 97%; ranked in top 10 for best quality performance for Texas ACOs
High Performing Post-Acute Care Network
- Created a high performing post-acute care network with improved outcomes
- 25% reduction in home health expenditures
- 37% reduction in inpatient rehab expenditures
- 50% reduction in SNF expenditures
Cost and Utilization Reduction
- 32% reduction in emergency room visits
- Greater than 20% cost reduction; turned performance around in a hospital-based ACO from 14% over benchmark to greater than 8% under benchmark in less than 3 years.
- Self-insured commercial plan with 12% total cost reduction and improved quality rating
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Health Equity and Community Health
- Strategic plan and design for an Accountable Community Health Model, the ACH model is bringing key stakeholders and community members together with the goal of transforming systems to improve community health and achieve greater equity on a sustainable basis bridging SDOH and health barriers to improve overall outcomes.
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- Designed and implemented a Medicaid and Uninsured Patient Navigation Program. Creation of a navigation program for the most vulnerable populations in the community to educate and assist patients navigating the health care continuum. The navigation program assists patients with establishing a medical home and assessing patients for social determinants of health and overcoming barriers thus reducing avoidable and preventable emergency room visits.
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