The San Juan ACO utilizes the CCA Population Health and Care Coordination program to manage all population health management work. The CCA Population Health and Care Coordination program takes a systematic, collaborative approach to the transformation of healthcare delivery and quality improvement. The Program is centered on a learning model that promotes continually improvement through alternating learning and action periods. The model places our ACO participants into cohorts in order to better learn from one another how to move their practices towards patient-centered medical home-type settings. The ACOs uses this collaborative approach to achieve more connected care teams, bi-directional communication channels, and increased data analytics capabilities. This program assists ACO participants in understanding the needs of their patient populations – through the use of robust data analytics – and developing evidence-based care practices to meet those needs and improve the health outcomes of their patient populations.
The program aims to improve the health of communities by improving patient outcomes through:
- Training and support of care coordinators;
- Providing patient-centered interventions and engagement strategies;
- Providing a population health and care coordination platform for
- Patient registries
- Predictive risk modeling and stratification
- Centralized, coordinated, multi-disciplinary care plan.