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Innovative Model of Care Delivery: ACO

Added on: 09/30/13 by Meryl Moss, MPA, EMHL

Coastal is an ACO and like the other organizations highlighted in the Commonwealth Fund series, has had a history of moving toward a patient centric model. Our Medicare ACO started in July of 2012 and Coastal’s United ACO arrangement began in April of 2013.  We have a longer history of doing business in an alternative payment model with Blue Cross/Blue Shield of Rhode Island. In 2009 Blue Cross provided infrastructure for PCMH development and payment for NCQA III recognition. In 2011 we received capitated payments for specific enhancements to care and in 2012 entered into a shared savings agreement.

Physicians felt an imperative to have all payers participate in our ACOs. They didn’t want to treat any patient differently because of insurance. If we were going to provide patient-centric care, it would be for all patients. In fact, if any one payer had refused to allow us to become an ACO, we made the very difficult decision to not participate with that carrier. As it turned out, all insurers agreed to contract with us at the level we felt was appropriate.

There are three essential elements/best practices to supporting the ACO model; two we have developed over time, but the third is new to us.  The first is the establishment of a powerful and versatile clinical HIT platform. Coastal implemented an eClinical Works electronic health record system in 2006.  We added clinical registry reporting in 2008 and by 2011 were able to correctly report on a myriad of quality measures. We became NCQA level III in 2009, which required enhanced registry and clinical reporting and in 2011 rolled out our patient portal. This past year we have focused on a data analytics and care management platform. This will enable us to combine the clinical information from the electronic health record with claims data from Blue Cross, United and Medicare. Physicians will be able to view a dashboard of clinical quality measures as well as cost information for each of their patients regardless of where the costs are incurred; the hospital, nursing home, primary care office or specialty practice.

Individual providers will also be able to benchmark their cost and quality metrics against other physicians within the group as well as those nationally. The idea is to improve quality while reducing variation.

The second essential element is the creation of the right clinical infrastructure to support the PCMH model.  We were helped along because of our long-standing history of having Ph.D. pharmacists imbedded in our practices. CSI, Rhode Island’s Chronic Sustainability Initiative, allowed us to experiment with adding nurse care managers to the care team.  Improved clinical outcomes and high patient satisfaction rates from the CSI pilots, gave us the confidence and the momentum to include nurse care managers as a part of every Coastal office.  The need for tighter care coordination extended the nurse care managers into the main referring hospitals and nursing homes.

The right clinical infrastructure didn't stop with the hiring of qualified clinical staff. We had to develop a higher level of clinical leadership and invested in a Chief Medical Office, who began full-time this past January and a highly skilled Clinical Director, who started in the spring.  Staff education and training became crucial, because every member of the team needed to learn how to function in this new patient centered environment. Managers needed to learn how to reengineer their offices so that tasks and processes supported transformed care instead of the traditional care provided in physician offices.

The third essential element is new to us: engaging patients in their care. Coastal's marketing department has had to reinvent itself in order to focus on the education of patients. We are just beginning to roll out a patient communication plan. The first part of the plan is to install flat screen televisions in the waiting room of every office. Patients can learn about the basics of the patient centered medical home and the role of each member of their clinical team. In addition, information concerning all Coastal's clinical programs and how to access them are available. We are sending out blasts through our portal to all portal enabled patients; approximately 45% of Coastal patients at last count, to learn about new services and avoid unnecessary emergency room and urgent care visits.  The mantra is “call us first”.

New patient participation on Coastal committees and the ACO advisory board will help us to develop programs that serve the needs of our patients and their families.  The voice of the patient has never really been heard, but now we are listening.


This is a time of experimentation and we are on a journey.  Even though we have had good patient satisfaction scores, are meeting all quality targets and have had a reduction in the overall cost of care for our Medicare population, I am far from satisfied.  My CCP is about changing the culture in the physician offices so that every member of the team; including the medical assistants and the office secretarial staff, embrace and embody these new concepts of "patient first" care. We are calling this "Coastal Care".  Without truly institutionalizing the Mayo model, we are just working around the edges.

When we are successful, every internal stakeholder including patients, staff and physicians will be able to clearly articulate our values and goals. They will also feel very proud of being part of either delivering or receiving Coastal’s outstanding patient care.