Cleveland, Ohio, University Hospitals is on a mission to address and eliminate the most common complaints about healthcare in the United States: that it’s not accessible to everyone because it’s not affordable, and that it’s not navigable because it’s fragmented. Patients slip unnoticed through cracks in the system, while doctors and hospitals are paid based on services and procedures rather than the quality of the care they provide.

UH, along with a growing number of healthcare systems across the country, is addressing these complaints head-on with its thriving accountable care organizations (ACOs)—an increasingly popular healthcare model in which networks of specialists and primary-care physicians collaborate with public-health officials to address the health of communities as well as individuals. Armed with vast pools of data on health risks in a community, such as the incidence of asthma among children or diabetes among immigrants, the ACO can focus its attention on healthcare problems before they become endemic—and costly.

By emphasizing preventive care in the community, ACOs aim to keep people from getting sick and to deal with health issues when they arise as quickly and as close to home as possible, whether at urgent-care facilities, clinics, or even home itself. By focusing on patient outcomes rather than the number of procedures performed, ACOs are showing they can “bend the cost curve” for healthcare in America, and that is integral to their approach: In ACOs, the healthcare providers, including hospitals, are compensated based not only on the quality of their outcomes and their adherence to best practices but also on the savings captured as a result.

Since UH first rolled out ACOs in 2010, before the Affordable Care Act pressed for nationwide adoption of the model, it has grown into one of the largest accountable care organizations in the country. Its collection of ACOs now cares for more than 300,000 people in the region, including Medicare and Medicaid beneficiaries, the self-insured, and those covered by commercial insurers.

But in 2012, UH gave new meaning to the ACO’s focus on preventive care for high-risk populations by establishing an ACO specifically for children and young adults from low-income households. The Rainbow Care Connection (UHRCC) was borne out of a $12.7 million Healthcare Innovations grant from the Center for Medicare & Medicaid Innovation to UH Rainbow Babies & Children’s Hospital, and now delivers care to a Cleveland-based population of 70,000 children who are covered by Medicaid.

Some of those children have complex, chronic conditions that require constant medical attention. Under the Rainbow grant, teams of “comprehensive care” providers surround each patient to deal with the medical, social, and emotional problems faced by the children and their families. “I can’t even begin to explain how hard it was before we had the Comprehensive Care Team…from the paperwork to the meds and everything in between,” wrote one child’s caregiver in their feedback to UH. “You are the answer to a prayer we have been praying for such a long time.”

The UHRCC was one of the first pediatric ACOs in the nation, but UH had enough experience with their existing, established ACOs that they felt confident in reaching out to a newer, more vulnerable population.

“Now it’s about: How are they getting quality care when they’re not in front of your doctors, not in your hospital, and how do you build an infrastructure to engage people?”
–Nathan Hunt, Director of the UHACO

In doing so, they made a great leap forward not only for ACOs but also for community healthcare in general. “The pediatric Medicaid population has the greatest opportunity to make a long-term impact,” said Dr. Andrew Hertz, the medical director of the UHRCC. “They're the neediest people who are going to become tomorrow's adults. So the excitement of this program is just that: We can change the trajectory of a child.”

For University Hospitals, team-based “connected care” is a baseline principle: ongoing, conscientious attention to a community of individuals, wherever they are on the spectrum of healthcare needs. “You know when a patient comes to our health system, they’re going to get excellent care,” said Nathan Hunt, director of the UHACO, which manages each of the health system’s 14 ACOs. “We’ve expanded our focus to: How are they getting quality care when they’re not in front of our doctors, not at one of our medical centers, and how do we leverage our health infrastructure to take the appropriate action?”

Through its ACOs, University Hospitals is building that infrastructure in almost every way imaginable. And while there is no silver bullet for Cleveland, where widespread unemployment and poverty conspire to produce high rates of infant mortality and obesity, they have given the city an arsenal with which to fight back.

Opportunity in Numbers

In a dense, urban environment like Cleveland, the range of health needs is highly diverse, and data on health indicators in different geographic and demographic communities is too often tangled, uncoordinated, or siloed by the organizations that collect it.

As a result, University Hospitals decided that each of its ACOs would have to connect the dots, compiling data from Medicare and Medicaid, private insurance companies, local providers, and patient records. To its partners among independent hospitals and other local providers, who often know the needs of their communities better than anyone, UH provides the specialists, technology, infrastructure, and data-processing capability they need to devise best practices and achieve optimal outcomes for their patient populations.

“We’ve scaled our resources to provide the right level of support to members in the community,” said UHACO director Hunt, “and now we’re using data, our relationships with physicians, our Electronic Medical Records (EMRs) and our analytical tools to identify the populations where we can make the most impact.”

After the opportunity in a population is identified, UH determines how it can best be addressed. Cleveland’s health needs and gaps in care tightly correlate with factors such as lack of transportation, education, or income, according to the region’s Community Health Needs Assessments. Putting together its various sources of data allows the ACO to find places where such problems are most acute and deploy targeted programs to address them—in effect, working to prevent medical issues before they have to be treated.

Among the greatest challenges UH faced was spreading that communications- and data-driven approach to all the members of its ACO network, which now comprises 13 community hospitals, four main campus hospitals, and a vast number of affiliated health centers, emergency rooms, urgent-care clinics, and primary-care providers. The system’s healthcare footprint now spans as many as 15 counties in northeast Ohio, and for the ACO to be as effective as possible, all those providers had to be on the same page.

Establishing Collaborative Care

Dr. Donald Sheldon, regional president of UH community hospitals, was the president of Elyria Medical Center before it joined the UH system. “It became evident that to get into the future of medicine and stay viable, especially with the strong players in the Cleveland market, it was important for us to look at partnering,” he said. UH stood out from other potential partners, Sheldon added, because it recognized the deep institutional knowledge of local hospitals and practitioners about the communities they serve.

“The community hospitals that have joined our system—we’ve had four in the last two years—really have brought tremendous insight about how they deliver care and organize their resources for their local communities,” said Elizabeth Hammack, associate general counsel to the UH health system. “There are opportunities of scale in terms of resource distribution, standardization, and efficiency that are relatively new in healthcare.”

For its part, UH provides an experienced team of specialists in ACO infrastructure development to help local partners upgrade outdated processes and introduce new ways to measure their efficacy of care.

“The experts and the faculty members at UH Case Medical Center, as well as clinical leaders in our community hospitals, help develop protocols that then can be utilized not only at the main campus, but throughout our system and partnering facilities,” said Dr. William Steiner, interim president and medical director of the UHACO.

Instituting the ACO model across the sprawling University Hospitals system has been arduous and vastly complex, but the payoff from all that work is easy to see. One UH outreach coordinator remembers how her engagement with local families became a symbol and sinew of UH’s bond with the community. “I had families come up and tell me that it’s nice to see me and they were glad University Hospitals cared so much,” she reported back to UH. “They are just looking for someone to care and listen.”

So ultimately, the numbers, the initiatives, and the administrative logistics emerge from a simple belief in doing the right thing. “Our executive leaders always approached creating and growing our population health infrastructure and ACOs as the right thing to do from a quality of care perspective,” Hunt said. “We continue to be a leader in that space, but this only makes us better. It helps our community, it helps our patients, and it helps us stay ahead of this new world of healthcare.”

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