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Our Insights Workbook is a monthly executive-level review of ACO performance with actionable metrics and data visualizations to get to increased savings.

By aggregating and analyzing open data, we empower our members to build strong networks and optimize care plans, improving quality patient care and reducing overall costs for their patients.

Reduce Wasteful Spending

Build & Harness Network

Increase Necessary Care

Reduce Variation in Care

Reduce Patient Churn

Acquire New Patients

Increase necessary care

A core principle of the ACO structure is improving patient safety and quality of care by providing what is necessary in a timely manner. Evaluate provider compliance with measures from literature, as well as your own clinical guidelines, and utilize patient care gap lists for better compliance.

Context

Transitional Care Management compliance is central to good preventive care and can prevent downstream costs.

Objective

The below data visualizations indicates Transitional Care Management compliance and PCP visits post-discharge for all eligible patients. While compliance with TCM visits tends to be lower than Annual Wellness Visits, good proxy for TCM visits are PCP follow-ups that may not have TCM coding.

TCM Eligible Visits by Follow Up Type for TINS with Top TCM Eligible Volume

Next: Reduce Variation in Care

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