services inside or outside of the Scott
& White Healthcare system, just as in
the past. Patients enrolled in the program
can still go to any doctor they choose
who accepts Medicare. Care from Scott
& White clinicians doesn’t change
if patients choose to opt out of the
ACO program.
By choosing to opt in to the program,
Scott & White patients are allowing
CMS to share information about their
visits outside the healthcare system with
their physicians at Scott & White. Many
patients prefer that their physicians have
access to all this information because
it results in more coordinated care.
CMS provides Scott & White with
information about the steps patients
have taken at a Walgreens location, such
as a vaccination or an in-store health
clinic visit. Dr. Reis says, “Patients don’t
need to do anything differently. The
bottom line is we really just want to
improve care for our patients, and offer
them a better quality of life.”
Delivering quality care to our patients
is Scott & White’s most important
goal. According to Dr. Reis, “Medicare
chose Scott & White for partnership in
the ACO because of our demonstrated
success with quality, and our strong
network of primary care physicians.
But our relationship with our patients
doesn’t stop when they leave the hospital
or physician office. With the ACO we
can take it to the next level.” ACOs by
definition must meet standards under 33
quality measures established by CMS,
which Scott & White consistently
meets or exceeds. These include care
coordination, patient safety, appropriate
use of preventive health services,
improved care for at-risk populations,
and patient and caregiver experience.
Dr. Reis explains that for the last 100
years, healthcare delivery in the United
States has been focused on taking care of
patients with acute care needs, with some
management of chronic conditions.
“This approach has had some good
impact on people’s health, but we need
to be better at helping people manage
their health,” he says. “If we proactively
identify at-risk patient populations, we
can help improve their outcomes and
decrease healthcare costs.”
Areas of focus
Scott & White and Walgreens are
working with Medicare patients with
congestive heart failure, chronic obstructive
pulmonary disease, and hypertension.
Other areas of focus are smoking cessation
and mammography compliance.
Priorities include identifying ways
to improve transitional care for patients
discharged from the hospital, to help
avoid re-hospitalization. Specific action
items might include having a point
person from Scott & White who guides
patients from the admissions process
to home care, making sure they have
what they need at home, and answering
questions about medications. They’ll
address gaps in care, too, by proactively
reaching out to patients who are due
for blood pressure screenings, flu shots,
and other preventive care measures.
Analyzing patient data helps
caregivers at Scott & White in their
efforts. “With predictive modeling, we
can identify patients who are at risk for
re-hospitalization or an acute episode
of illness, and reach out to them first to
avoid disease complications and avoid
having duplicate tests,” says Maureen
Halligan, vice president of strategic
planning at Scott & White Healthcare.
For example, Scott & White caregivers
won’t ask a patient about getting a flu
shot if we know that person already
received one at the pharmacy.
“Every person wants to be healthy,”
says Dr. Reis. “We value our patient
relationships and would only enter into
partnerships that help our patients.” n
Access to additional healthcare information,
like immunizations received or sick visits at an
in-store clinic, can enhance physicians’ overall
efforts to keep patients as healthy as possible.
sw.org | November 13 The Catalyst
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