Advanced Management USA, LLC manages a network of five large ACOs across the country, including California Clinical Partners ACO (CCPACO), an Advanced Track ACO formed in 2019, that spans from Kern County to San Diego County in California. Approximately 18,000 lives are assigned to the ACO, and their providers serve 36,000 Medicare patients each year.
Advanced Management wanted to improve CCPACO’s patient outcomes and provide better value by reducing readmissions and improving care coordination. The organization identified a 30 percent greater risk of readmissions when Medicare Transitional Care Management (TCM) services are not completed. Because effective TCM services depend on real-time notification of a patient discharge, Advanced Management looked for ways to notify CCPACO providers of admissions of their attributed patients so that the appropriate interventions and TCM services could be coordinated.