ACO saves $600,000 and improves patient outcomes with pop health platform

Since first becoming an accountable care organization, Texas’ Amarillo Legacy Medical ACO noticed that its home healthcare costs, at their highest point, were double the national ACO costs.


When Mary Jo Zallar, RN, joined as COO, she began asking home health agencies (HHAs) to send the ACO weekly reports that included information such as which patients they served, the conditions of those patients, the details of their visits and the types of therapies being provided.

What the ACO quickly noticed was that some of the HHAs were quite generous with the rules. The ACO even found some patients who had been on home healthcare for several years, which is not what home healthcare is designed for. It is designed for episodic acute care.

So ACO staff knew from some of the documentation and discussions that a lot of waste and abuse was out there, and they needed a mechanism to get their arms around the problem.

“We initially developed our own Microsoft Access database to track who was ordering home health, to which agency; how long patients had been receiving home healthcare; and when the episode of care started,” Zallar explained. “While the internal database allowed us to track these things, there were some limitations. We needed a way to dig through the muck and identify root causes and facilitate change.”


That way came through their choice of technology, a population health management platform from vendor Lightbeam.

“Lightbeam offers the exact mechanism we needed,” Zallar stated. “The platform provides an option to build a custom cohort to better track [and] evaluate patterns and trends for patients using home health, and collaborate between healthcare providers. It also offers an easier way to report on and follow up with companies that had the most significant opportunities to improve home health utilization and cost.”

The ACO needed specific cohorts that would enable it to create and track home health cases, associated reviews for appropriateness, and recommendations made to healthcare providers. The ACO team was searching for a seamless way to review home health orders and track whether there were any indications for the need for that skilled care. The Lightbeam platform provided an automated process for getting information to physicians and tracking their responses and recommendations.

“In addition to needing an easy way to pull a home healthcare document, print it, and send it to the physician for recommendations and signature as indicated, we needed to be able to track and analyze the data,” Zallar added. “The platform was selected so that we could input home health cases and final decisions into a database to track them. In short, we needed a platform that put all the data about our patients at our fingertips.”


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Part of the ACO’s need for this platform stemmed from the fact that it had disparate electronic health record systems. That was an additional challenge. Lightbeam gives EHR diagnostics outside of the EHR system, so everyone who needs to review these diagnostics has access, Zallar noted.

“In addition to the care managers on our internal team, we provide security-limited access to our Lightbeam system to our skilled nursing facility affiliates and HHAs,” she said. “Two years ago, we were approved to use the three-day SNF waiver, which means our patients are no longer required to be hospitalized three days before admission to an SNF.”

By providing access to the platform, the SNF affiliates’ caseworker or intake coordinator can look up the patient in Lightbeam and leverage the tool to quickly and easily determine whether that patient is one of the ACO’s patients, she added. It also allows the ACO’s team to accurately track the patient who qualifies for the SNF three-day rule waiver, she said.

“Giving our SNF and HHA affiliates limited access to the platform also allows us to proactively close gaps in care,” she said. “Both entities can administer vaccines under their service. Using Lightbeam, they can access and review a patient’s vaccine record to determine if a vaccine is required and when it was last administered. This access helps to close those gaps in care without requiring a doctor’s office visit.”

Additionally, ACO physicians have access to Lightbeam data through face sheets. Before a visit, physicians for the ACO’s contracted patients are given a face sheet with pertinent information about that patient. These face sheets, printed directly from Lightbeam, inform the provider which preventive care and diagnostic services may be needed based on a snapshot of the patient’s history.

“The physician can also see, at a glance, any gaps in care which need to be resolved,” Zallar explained. “Along with the face sheet, an HCC coding sheet is printed pre-visit as well. This tool helps facilitate annual, up-to-date coding that accurately reflects the acuity of the patients being cared for by the healthcare provider. This data is essential when calculating risk-adjusted metrics.”


Amarillo Legacy Medical ACO was accustomed to seeing high costs in SNFs and HHAs, but when its advisory group from Lightbeam started calculating the results of its intervention accomplishments, the ACO realized it had in excess of $600,000 in savings in the first-quarter data results. If that trend continues, that increases the ACO’s potential for bonus.

“We became an at-risk ACO last year, and, had we not had this technology, we would most likely have been required to repay at-risk money back to CMS,” Zallar said. “What helped to keep us within the neutral risk corridor during the first six months that we were at-risk was the fact that by using Lightbeam we were capturing the actual acuity of our ACO patients.”

Through the use of the platform to track and evaluate cost and quality of care during 2020’s public health emergency and CMS’ declaration of not holding ACOs accountable for unpredictable risk during COVID-19, the ACO is in a good position to demonstrate shared savings this year, she added.

“Additionally, we have commercial contracts,” she noted. “At the end of each commercial contract year, we can use the platform to identify all the patients in the denominator for specific quality measures. We can then take that list, look up patients in Lightbeam, and verify the clinical information. We have found a lot of information that wasn’t picked up in patient claims and were able to validate needed patient information.”

That data is validated and uploaded to the appropriate secure SFTP sites and included in the calculations for earned gain shares in those contracts, she said.

“To date for 2020, this has resulted in an excess of $450,000 gain-share,” she said. “Those dollars are then risk- and quality-adjusted and sent to providers in the ACO, which helps keep them engaged in the ACO to improve quality and utilization and, ultimately, patient outcomes.”


“Make sure to think about the big picture and look at the type of information you need to capture,” Zallar advised her peers. “You want to choose a vendor that will support your existing workflows, not make you change your workflows to adapt to their product. Additionally, pick a technology that is easy to use, and pick a company that is very responsive in support and follow-up.

“When you are selecting a platform, you want to have all your stakeholders involved in the selection,” she continued. “If you expect your care managers to do a lot of the data collection and you leave them out of the loop until you’ve decided on what platform you are going to use, they might find that it’s too time-consuming or not user-friendly.”

One must get that buy-in from everybody upfront and make sure it is going to work for all stakeholders, she said.

“Ultimately,” she concluded, “you want to find a vendor that is a good partner: one that listens, is proactive and is responsive, not just somebody that wants to sell you their product.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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