1. wain IOR mtoicut A MILIKAID 51.1MICIS
re Learning Systems
IN for Accountable Care Organizations
Brown and Toland Physicians' Approach
to Serving High-Risk, High-Cost Patients
to Improve Outcomes at Lower Costs
This case study describes how Brown and Toland Physicians, an independent practice
association (IPA) in the Pioneer accountable care organization (ACO) program, serves
patients with complex needs and high costs to achieve better health outcomes at lower
costs. Brown and Toland's strategy uses a tiered approach to tailor the provision of
care-managed services to patients' needs:Ihis experience is valuable to all ACOs
seeking to improve health outcomes and costs for a subset of patients with complex
health needs.
BACKGROUND AND SUMMARY
Brown and Toland's care management program
builds on 20 years of experience contracting with
health maintenance organizations to manage
risk and to monitor utilization and quality. Early
utilization analyses indicated that a small num-
ber of Brown and Toland's patients generated a
large portion of health care costs.
Patients with complex health needs, particularly
Medicare patients, had multiple chronic diseases
and behavioral health needs and they struggled
with complex medication regimes. In addition,
these patients often faced significant life stress-
ors and needed assistance with permanent and
accessible housing, extended at-home nursing
care, and transportation to health care providers.
Brown and Toland developed tiered care man-
agement programs to target patients' medical
and social needs in order to obtain better health
outcomes and lower costs.
Brown and Toland customizes the delivery of
care management services to meet the particular
health needs of patients through three core
programs: (1) support through care transitions
for those at risk for hospital readmission; (2)
outpatient care management for patients with
chronic conditions, behavioral health needs, and/
or complex prescription drug treatment; and (3)
home-based medical care for frail patients with
critical and complex health needs.
Brown and Toland applies the following strate-
gies when implementing the care management
program:
• Develop strong partnerships with key care
delivery organizations, such as physician
practices, hospitals, skilled nursing facilities
(SNFs), behavioral health providers, and home
health care and community services agencies
April 2015
1

2. ACO Learning System Case Study
• Use multiple methods to identify a subset of patients for
whom complex care management has the potential to improve
health outcomes and reduce costs
• Integrate the provision of care across delivery sites through
regular communication and exchange of information
• Maintain a system of feedback and monitoring to identify
promising strategies
Brown and Toland joined the Pioneer ACO program in January
2012 and currently has approximately 18,000 aligned benefi-
ciaries. The Pioneer ACO Model is operated by the Center for
Medicare &Medicaid Innovation and designed for health care
organizations and providers that are experienced in cwoordinat-
ing care for patients across care settings. In comparison to the
Medicare Shared Savings Program, the Pioneer program enables
ACOs to move more rapidly from a shared savings payment
model to a population-based payment model.
ORGANIZATION
Brown and Toland Physicians is a San Francisco-based net-
work of independent physicians who came together in 1992
to provide a comprehensive network of physicians for health
maintenance organizations and to create administrative efficien-
cies among the physicians. The physician-owned IPA consists of
550 independent primary care and 1,172 specialty care physi-
cians, many of whom work in small practices with one or two
other providers. Collectively, Brown and Toland physicians serve
300,000 patients, more than half of whom are covered under
some form of risk-sharing agreement.
IDENTIFYING HIGH-RISK, HIGH-COST
PATIENTS
Brown and Toland combines multiple diverse methods to
identify a wide range of patients who will benefit from complex
care management, whether enrolled in Medicare, Medicaid, or
a commercial health plan. The patient identification approaches
incorporate the results of predictive modeling, recent acute care
or emergency department (ED) visits, and physician referrals. In
combination, these approaches identify a subset of patients who
are likely to benefit from complex care management.
Identifying Patients from an Acute Event
Brown and Toland identifies most high-risk, high-cost patients
during an inpatient hospital stay or ED visit. To find these
patients, Brown and Toland's hospital-based care managers
review daily reports of all hospital and ED utilization and
screen patients to identify those who meet a combination of
the following criteria: history of acute admissions in the past
six months, inpatient readmission in the past 30 days, diagnosis
of congestive heart failure or chronic disease (such as diabetes),
treated with complicated medication regimes, and poor social
support. To facilitate this review, Brown and Toland partnered
with hospitals that serve a large portion of their population to
flag Brown and Toland patients in their electronic health record
(EHR) system. "We get notified between 24 and 48 hours at the
latest," said Dr. Marcus Zachary, Brown and Toland's vice presi-
dent of population health, rather than wait two to three months
for claims data to become available. After receiving notification
that the hospital treated a Pioneer patient, the care managers
use read-only access to review the patient's' EHR and discharge
plan. The care managers, located at the hospital, are also well
positioned to coordinate with discharge planners to establish a
successful transition plan.
Identifting Patients Through Physician Referrals
Brown and Toland identifies high-risk, high-cost patients that
are treated in an outpatient setting through physician referrals.
The physician referral method evolved early when Dr. Zach-
ary realized cold-calling high-utilizing patients failed. Instead,
Brown and Toland provides primary care providers with lists of
their patients that have been identified as potential care man-
agement candidates based on predictive modeling. The model
incorporates a variety of data sources, including medical claims,
prescription drug utilization, labs, and diagnosis codes. The pro-
viders review the list to identify patients who can benefit from
complex care management. In describing early conversations
with providers, Dr. Zachary said: "I wasn't in there saying, 'Who
are the people who need to go into complex care management
and who are the people who are homebound?' but rather 'Here's
a list of folks that we identified as being in the Pioneer program.
Can you take a look at this list and see if there is anybody that
you would like us to partner with you to help them with their
care?'"This strategy leverages physicians' personal insight into
patients' health needs, resource availability, and social supports.
"There's no substitute for that," Dr. Zachary said.
Brown and Toland reduced the burden associated with physician
referrals by developing a "no wrong door" policy stating any physi-
cian can refer any patient and the complex care team will provide
services for that patient. Care coordinators then assess the needs
of identified patients, align care management or referral services
(if needed), and communicate the care plan to the physician.
Another strategy to reduce the burden on physicians involved
modifying the EHR system. Physicians can quickly see which
patients are attributed to the Pioneer program and submit refer-
rals for care management services through the click of a button.
Brown and Toland fosters partnerships with physicians, both to
improve the appropriateness of referrals and to provide continu-
ity of care delivery when care management begins. Within a
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3. ACO Learning System Case Study
week of receiving a physician referral, Brown and Toland care
coordinators call the physicians to discuss the patient's plan of
care. Dr. Zachary emphasized that this establishes "a positive
cycle ... it is human nature that if [the physicians] don't hear
from you, they're going to assume that you're not thinking
about their problem; that they wasted their time." Over time,
physicians have become more knowledgeable about the type of
patient who benefits from complex care management. "If we cre-
ate a positive cycle and they see you as the 'that was easy' button,
then you're going to get access to the office in a way that you
haven't before," he said.
DELIVERING COMPLEX CARE MANAGEMENT
Brown and Toland's approach to its care management pro-
gram tailors service provision to patients' particular needs. The
program consists of three approaches, each supported by a care
management team centralized within Brown and Toland. These
three approaches are distinct in service provision, intensity, and
duration (see Table 1).
Brown and Toland designed the three approaches to meet
the patients' different levels of need. Based on their evolving
health status, patients can move from one level of care manage-
ment to another. Most patients first engage in transitional care
management, which meets their needs within four weeks. If the
care transitions team determines a patient would benefit from
additional care management, the team collaborates with the out-
patient complex care management team to smooth the patient's
transition to the next level of care management. Other patients
are engaged in outpatient complex managed care based on
physician referrals. The team enrolls patients in the home visit
program who have difficulty leaving their homes, are frail, have
complex needs that are difficult to manage, or require frequent
visits with a health care provider.
Teams consisting of nurses, care coordinators, and social workers
support all three care management approaches. The team-based
approach builds continuity and trust with patients and primary
care providers, while enabling Brown and Toland to spread
care management resources across multiple provider practices.
The teams generally work virtually, often communicating with
patients and providers by telephone and recording care manage-
ment provision using a shared software platform. The technology
system enables the care management teams to build on informa-
tion collected from the initial patient assessment through each
patient encounter and facilitates ongoing communications with
the patient's providers. In addition, the teams use this informa-
tion when transitioning patients from one care management
track to another as patients' health care needs evolve.
A common patient engagement approach links all three care
management approaches. The team's engagement goals include:
assessing and understanding the patient's unique health, social,
and welfare needs; managing and coordinating needed care; and
addressing patient-level barriers that drive poor outcomes and
Table 1
Three Approaches
to Care
Management
Care
Management
Approach Description Caseload
Transitional care
management
Supports patient through transition
from hospital to SNF or home,
with service duration of one
month or less
Each month, up to five
registered nurses and two
care coordinators make
roughly 1000 calls to
approximately 400 members
Outpatient
complex care
management
Provides care management for
patients with multiple chronic
conditions and complex health and
social needs, with average service
duration of three to six months
Six registered nurses and six
care coordinators together
managed around 1,300
cases in 2014
Home visit
program
Coordinates and delivers care to
patients who are frail and benefit
from home-based medical care
provided; of the three tracks, the
home visit program is the most
intensive and can continue for an
indefinite time
Each of the two nurse
practitioners has a caseload
of about 70 patients.
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4. ACO Learning System Case Study
4
high utilization. Brown and Toland trains staff to develop skills
based on a foundation of motivational interviewing, a goal-
oriented approach to behavior change that focuses on building
intrinsic motivation, understanding each patient's unique needs
and challenges, and helping to remove or mitigate obstacles to
achieving better outcomes in more appropriate care settings.
Additional training includes strategies to have difficult con-
versations with patients, either virtually or in person. Ms. Ann
Marie Molyneaux, director of clinical services, found that with
experience and consistent mentoring by nurse supervisors, care
managers become adept in handling difficult tasks. For example,
they learn the best ways to introduce and lead conversations about
patients' end-of-life wishes, or they know when they have to allow
people to make their own choices, even if that means a mentally
competent elder returns to less than optimal living arrangements.
The care management team also engages with family members
and caregivers that patients have identified as key members of
their support network. This engagement provides a more com-
plete assessment of patients' care needs, financial challenges, and
living environment. In addition, social workers are cognizant of
the demands facing patients' caregivers. Social workers identify
opportunities to support family members and caregivers so that
they may be able to continue caring for patients on an ongoing
basis, for example enabling a caregiver to have an occasional
respite from the daily challenges of caring for a loved one.
In addition to engaging patients directly, the care management
team partners with key providers to affect positive changes in
service delivery and patients' lives. These providers generally
serve a high volume of Brown and Toland's patients and include
primary care practices, hospitals, SNFs, and home health agencies.
The basis of these partnerships is a high degree of communication
throughout care provision, from streamlining the referral process
to integrating care plans. For example, Brown and Toland recog-
nized that one SNF treated many of its patients but had a higher
percentage of hospitalizations after SNF discharge than other
SNFs. Brown and Toland partnered with the SNF to increase
medical support to serve patients and developed clearer commu-
nication methods between the hospital and the SNF.
The partnerships are a mechanism to increase engagement with
patient and caregivers and to enable the care management team
to build on established physician—patient relationships. Brown
and Toland promotes use of a common EHR platform across
partner hospitals and primary care practices, both to facili-
tate communication and enable care team members to access
patients' information in real time.
Transitional Care Management
Transitional care management focuses on supporting a patient
from hospital or ED discharge through the first follow-up
appointment with his or her primary care provider. The primary
care provider appointment usually occurs with seven to fourteen
days of discharge, though the team might provide continued
support for another three to four weeks until the patient's
health stabilizes. The teams, composed of registered nurses and
unlicensed, highly skilled care coordinators, are located within
hospitals treating a large portion of Brown and Toland patients.
After identifying patients appropriate for transitional care
management, the team assigns the patient to a care management
team member with expertise appropriate for the patient's needs,
such as a care coordinator or a registered nurse for medically
complex and high-risk patients. The care management team
then works with hospital discharge planners to review recent
medical records, consider patient needs that might arise after
discharge, and anticipate issues that might increase the risk of
readmission. For example, the care coordinator might discover
that a married man who would typically be discharged home
requires assistance because he has limited family-based support
after his wife's recent stroke.
The care coordinator could determine that the patient would
benefit from review by the registered nurse care manager. For
example, the patient might have been prescribed a complicated
medication regime, either before or during the hospital stay. The
registered nurse would review the medications, perhaps with
a Brown and Toland staff pharmacist or medical director, to
recommend that the prescribing physician simplify or adjust the
medication treatment. In addition, the care coordinator may also
work with the home health care nurse, when involved in patient
care, who also complete medication reconciliations.
After discharge, the care coordinators contact patients, arrange
for office visits with patients' primary care providers, align refer-
rals, and ensure patients have at-home supports to remain in
stable condition. Completing initial outreach soon after an acute
event is most effective because patients are receptive to help
when feeling stressed or overwhelmed by their treatment plans.
In the initial post-discharge telephone call, care coordinators ask
patients open-ended questions about their hospital experiences,
their understanding of their treatment plans, and whether they
have any questions or concerns:The goal of the care coordina-
tor's outreach, notes Ms. Molyneaux, is to complement hospital
staff's discharge education by providing patients with an oppor-
tunity to focus on what is important to them and identify issues
that can affect their ability to heal.
Care coordinators also screen for health needs that would
benefit from involvement by other members of the care manage-
ment team. In the rare instance when a patient's health needs
appear to be too complex to manage through telephone calls,
a registered nurse or social worker makes a home visit. If the
home visit identifies potential prescription medication prob-
4

5. ACO Learning System Case Study
lems, the nurse can complete a medication reconciliation by
comparing the patient's understanding of the prescribed drug
treatment with data recorded in the EHR. The registered nurse
may conclude the care plan requires adjustment and connects
with the patient's primary care physician to consider alternate
treatment strategies.
The care transitions team can continue to provide care man-
agement for the patient for up to one month after discharge,
collaborating with SNFs, home health agencies, and/or primary
care providers to ensure patients have continuity of care. The
ongoing support can address transportation barriers that limit
the patient's ability to get to follow-up appointments, such
as limited access to a car or difficulty maneuvering steep San
Francisco stairways. The care team might discover that crucial
equipment, such as oxygen tanks, are not delivered when sched-
uled or that family caregivers who are present in the first days
after discharge must return to work. The care transitions team
determines if a patient requires ongoing support and refers the
patient to the care management program focused on complex
management in the outpatient setting.
Outpatient Complex Care Management
The outpatient complex care management program serves
patients with multiple chronic conditions and complex health
needs that drive utilization. Care management includes support
and coordination of medical care, identification and mitigation
of barriers to good health outcomes, and connection with social
services. Patients generally receive complex care management for
three to six months, until the care management team determines
the patients no longer requires their services. Occasionally, the
team finds patients are stable within the six month window and
can be supported by the primary care physician with infre-
quent check-ins by the care management team. More complex
patients, such as those in the beginning stages of dementia, may
require ongoing care management.
The complex care management team includes registered nurses,
unlicensed care coordinators, social workers, and a supervisor to
mentor the team and troubleshoot issues. The team is organized
into small groups, called pods, which are associated with specific
physician practices. This structure supports the development of
relationships among the care management staff, the physician
practice, and the patients treated by each physician practice.
To initiate complex care management, a care coordinator calls
the patient as the representative of the primary care physician's
office and relays that the physician believes the patient might
benefit from additional assistance. "This approach has been
vital to gaining patients' trust," says Dr. Zachary, noting that
patients are often skeptical about care management and fear it
is an attempt to limit services. Care coordinators who make the
initial patient contact can be selected based on their proficiency
with foreign languages; Brown and Toland enrollees' primary
languages frequently include Cantonese, Spanish, or Tagalog.
After initial contact, registered nurse care managers connect
with patients to establish an in-depth understanding of their
health care needs and ensure the involvement of all appropriate
providers in the care plan. The nurses develop this understanding
by performing a number of screenings and assessments related
to activities of daily living, family and social support, medica-
tion therapy management, depression, and end-of-life plans (if
appropriate). Depending on the results of these assessments, the
nurses and care coordinators will contact the patient's primary
care physician, specialists, a social worker, a pharmacist, and/or
a home health care agency. In addition, nurses work closely with
care coordinators, who support patients who have billing and
logistical questions.
Over time, the care coordinator remains in contact with patients
through telephone calls to continue to build relationships, assess
evolving medical and social needs, refine the care plan, and con-
nect patients with community services such as Meals on Wheels
or the health insurance advocacy programs. "Providers regard
them as an extension of their office staff," says Ms. Molyneaux,
offering an example of providers requesting care coordina-
tor assistance for patients struggling to manage their insulin
regimens. Throughout these communications, care coordinators
remain alert for indications that the nurse should also connect
with the patient, such as unmanaged pain, medication confu-
sion, or symptom escalation. In those situations, the nurse may
determine that the patient would benefit from a home visit.
The care management team can involve social workers to iden-
tify behavioral challenges that compromise health improvement
or contribute to increased utilization. For example, a patient
with chronic obstructive pulmonary disease requests an ambu-
lance for an ED visit up to five times in a week. In a 45-minute
telephone conversation with the patient, a social worker and
nurse discovered that the trigger for the ED visits was anxiety,
not the patient's medical condition. Over a series of phone calls
the care management team educated the patient about anxiety
and convinced her to use her prescribed anti-anxiety medication,
which halted the frequent ED visits.
Home Visit Program
Brown and Toland provides home-based medical care to frail
patients with complex, critical health needs. The home visit care
team provides highly individualized services, customized to meet
the goals and care preferences of the patients, families, and pri-
mary care providers. Many of the patients enrolled in this care
management track would likely have moved to custodial care if
not for the support of involved caregiving from family members.
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6. ACO Learning System Case Study
In collaboration with a patient's primary care provider, the home
visit care team delivers medical care and services in the patient's
residence to maximize functionality and alleviate suffering.
Some patients will regain functioning and return to receiving
all their primary care from their office-based providers, whereas
others continue to receive treatment from the home visit care
team for the rest of their lives or until the patient transitions to
hospice care.
Brown and Toland has two distinct home visit care teams, each
consisting of a nurse practitioner and a social worker, that travel
to the patients' homes. The teams include care coordinators who
are located within Brown and Toland's central offices, are skilled
in customer service, and serve as a conduit for communication
among the care team, patients, and families. In this role, the care
coordinators act as the glue for the team by managing referrals;
coordinating appointments; serving as a consistent contact for
patients' families to discuss care preferences and health needs;
and aligning care from other providers, such as home health
nurses, physical therapists, and medical equipment suppliers.
For both care teams, Dr. Zachary acts as a medical director and
provides clinical oversight. Should he be unavailable, the care
team contacts a designated back-up physician.
To initiate care, the nurse practitioner and social worker visit
the patient's home together and spend about two hours com-
pleting a full assessment of the patient's needs and supports
and identifying the patient's goals. The social worker identifies
behavioral health issues, considers the adequacy of the patient's
support systems, and considers issues that might negatively
affect health outcomes. The nurse practitioner completes medical
assessments, performs prescription and medication management,
and provides care in the home. Together, the nurse and social
worker identify barriers to better care, which can include a lack
of transportation, inadequate support, and gaps in the patient
and family's knowledge. Newly enrolled patients often require
intensive medical treatment because mobility issues limit their
ability to access office-based medical care. Based on this initial
visit, the nurse practitioner and social worker work with the
patient and family to create a comprehensive care plan.
The home visit care team implements the care plan and man-
ages patients' chronic conditions and treatment on an ongoing
basis within their residences. They coordinate this care with the
patients' primary care providers and other specialist providers by
taking the following actions:
- Coordinate in-home care delivery by other providers, such
as home health agency visits for minor wound care, behav-
ioral health treatment, or physical and occupational therapy
- Order in-home labs, x-rays, and durable medical
equipment
- Explore end-of-life wishes and complete related forms
- Respond to emergent medical issues
- Manage prescription drug treatment
The team also aims to reduce caregiver burden by supporting
and linking caregivers to counseling and other community
resources. For example, one team made a referral to speech
therapy for a patient suffering from multiple sclerosis who had
trouble speaking and swallowing. The team also aligned support
for the patient's husband, who served as the main caregiver and
had difficulty managing the burden.
Throughout care provision, the nurse practitioner remains in
close contact with the patient's primary care provider. Recently,
Brown and Toland implemented information technology
enhancements to enable the nurse practitioners to access and
input into the charts in the patient's EHR, further integrating
the home visits with the patient's broader care team.
MONITORING AND EVALUATION
To continue refining and improving the care management
program, Brown and Toland calculates trend analyses of
utilization, quality, and patient satisfaction measures. The trend
calculations reflect changes in care delivery for all Brown and
Toland patients, including Pioneer-aligned beneficiaries. Taken
together, these early analyses provide an indication that Brown
and Toland's care improvement initiatives, including the care
management program, enable patients to receive higher quality
care in the outpatient and home settings and reduce unnecessary
inpatient and ED treatment.
Between 2012 and 2014, Brown and Toland found the number
of acute care and ED admissions among patients over 64 years
had decreased. The number of acute care admission per thousand
senior patients dropped from 239 to 178 and the number of ED
visits dropped from 325 to 274 (Figure 1). At the same time,
patients' length of stay for acute and rehabilitative care in the
inpatient setting also decreased, from 1,179 to 1,057 days per
thousand senior patients (see Figure 2, on the following page).
Looking beyond the inpatient setting, Brown and Toland also
found that patients' length of stay in skilled nursing facilities
reduced from 1,033 to 881 days per thousand senior patients.
To supplement the utilization analyses, Brown and Toland looks
to survey data of patient experience and quality data from the
HEDIS and STAR Metrics. Between 2012 and 2014, Brown
and Toland found a steady improvement in the mean patient
satisfaction score. In addition, 2013 and 2014 quality data indi-
cate improvement in multiple areas. For example, the percent
of patients receiving colorectal and nephropathy screenings
increased, as did the percent of patients receiving appropriate
6

7. 1,400
>- 1,200
A
U) 1,000
CDC
s. 800
CU
350
300
250
200
150
100
50
0
600
2
Q.
-
400
#AdministrationperThousandsPatients>64yrs.
rzi 200
0
20142014 2012 2013
Inpatient (Acute and Rehabilitative Care)
— Skilled Nursing Facility
2012 2013
Acute Care
Emergency Department
• ACO Learning System Case Study
Figure 1
Number of Admissions for Brown and
Totand's Senior Patients, 2012 — 2014
Figure 2
Length of Stay Measures for Brown and
Toland's Senior Patients, 2012 — 2014
management of hemoglobin Alc and the percent of women
with osteoporosis management following a fracture.
LESSONS LEARNED
Brown and Toland's layered approach to patient identification
and care management has evolved over time, based on feedback
from providers, the experiences of the care management teams,
and insight gleaned from data analysis. Some lessons learned to
date include the following:
• To identify patients appropriate for care management,
provider insight into patients' needs should supplement
predictive modeling results. Early outreach attempts based
on predictive modeling alone resulted in a 10 percent patient
engagement rate in the outpatient care management program.
Brown and Toland made a number of process changes to
increase the recruitment, including increasing collaboration
with patients' primary care physicians to understand which
patients were most appropriate for complex care management.
Likewise, Brown and Toland's hospital-based care managers
work with discharge planners to identify good candidates for
the transitional care program.
• Partnerships with providers improve patient
engagement and enhance the effectiveness of care
management. To increase the patient engagement and the
effectiveness on ongoing care management, care management
teams establish close connections with patients' primary care
providers. Brown and Toland found that when care coor-
dinators call patients as representatives of the primary care
physicians' offices, patients view the team as an extension of
their physician relationships and engagement rates improve.
Once patients begin receiving care management services, care
management teams continue to coordinate with providers, for
example to arrange for office visits, align referrals, or complete
medication reconciliations.
• Harness information technology to facilitate
communication within the care management team
and to increase continuity of care. When beginning the
Pioneer program, Brown and Toland spent months improv-
ing communication networks and building the information
technology tools to better manage care for Pioneer-aligned
patients. "What we did early on, which I think helped us
greatly, was spend a lot of time, and a lot of energy, invest-
ing in connectivity and information technology to get these
patients integrated within our already-existing systems," says
Ms. Stephanie Mamane, vice president for payor contracting
and accountable care. In addition, Brown and Toland created
a shared software platform for the care management team
to document information about patients' needs, note care
provided, and record the results of screenings and assessment.
The teams use these data in communications with providers,
to smooth the transition between care management programs,
and to limit repetition of screenings and assessments.
7

8. ACO Learning System Case Study
SUMMARY
Dr. Zachary summarized Brown and Toland's work for
patients with complex needs and high costs: "We provided care
coordination ... in such a way that we eliminated unneces-
sary transitions. We eliminated medical errors. We improved
communication. We improved access. And we have somebody
who's watching the whole thing, to be captain of the ship for
care coordination. And that is what drives the outcomes and
ultimately the savings."
ABOUT THE ACO LEARNING SYSTEMS PROJECT
Mathematica Policy Research and its partners—the Institute
for Healthcare Improvement, Health Services Advisory Group,
Premier Inc., Telligen, and TransforMED—are conducting this
project for the Center for Medicare & Medicaid Innovation. The
project team creates a structure for peer-to-peer learning to help
Medicare ACOs achieve better care for patients, better health
for populations, and lower health care costs. The team is grateful
to Brown and Toland Physicians for its valuable contributions to
this case study, specifically Marcus Zachary, M.D., vice president
of population health and senior medical director; Ann Marie
Molyneaux, R.N., director for clinical services; and Stephanie
Mamane, vice president for payor contracting and accountable
care. We particularly appreciate their careful review of this brief
and the time they devoted to answering our many questions
during our interviews. Cory Sevin, Catherine Craig, and Sonya
Streeter wrote this case study. The observations in the case study
represent the views of the authors and do not necessarily reflect
the opinions or perspectives of any state or federal agency.
For more information, contact ACO Learning System
at PioneerLearningActivities@mathematica-mpr.com .
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