Compare your ACO's
outcomes
Over a 100 pre-built and
validated predictors

Pinpoint future admissions

that could be avoided

Reduce future adverse events

Improve chronic condition management

Lower hospitalization costs

We built a full suite of predictors

We identify actions

associated with the best outcomes

We turn your data

into predictions
What questions shall we answer better together?

We provide tools to help you succeed in value-based care

Knowing how to allocate scarce patient care resources means pinpointing which patients require which interventions in order to improve outcomes while managing costs.

Rising care complexity

Covid-related health challenges and disruption in care have created an environment where patient care has become inconsistent and patients’ health problems have become more complex.

Provider burnout

Staffing shortages are expected to get worse, leading to attrition and impacting access to care.

Rising expectations

As national quality and cost outcomes improve the bar keeps rising for achieving shared savings.​

Our predictors and analytics help value-based care organizations deliver targeted savings in high value segments​

High-resolution risk cohorts

Performance analytics

Patient-level risk and health profile

Network insights

Identify target populations

Act to prevent adverse outcomes

Measure effectiveness of actions

Improve accuracy and impact

We help you target the patients and actions that will have the greatest impact on reducing costly adverse events

We help you target the patients and actions that will have the greatest impact on reducing costly adverse events

Identify target populations

Act to prevent adverse outcomes

Improve accuracy and impact

Measure effectiveness of actions

Target patients at risk in order to prevent adverse outcomes in the future

Patients are ranked based on precise risk predictions, updated weekly. You can easily save cohorts by provider group or physician or by risk to assist clinicians as they prioritize and plan for patients who will benefit from proactive outreach and interventions.

Cohorts and Patients

Actionable, targeted, risk-ranked cohorts for your care teams

Identify risk-driven patient cohorts with actionable care gaps, for example patients with diabetes at high risk of foot ulcer and no podiatrist visit in last 12 months.

Use the list to gain visibility to activity outside your preferred care network, for example, identify attributable patients. 

Spotlight View

Patient-level insights and Health History

With your permission, we access up to 8 years of claims for your patients directly from CMS in days, not weeks. Updates weekly.

For each patient, focus on high value opportunities with a detailed understanding of how past health history is driving future risk.

Identify opportunities to achieve improved outcomes from your network

To compare “apples to apples” we compare your patients’ outcomes to those of digital twins with the same demographics and baseline risk. See how your network performs on utilization, adverse events, and cost when it is tightly risk-matched to clinically-similar populations.

Performance Analytics​

Physician recruitment

Increasing savings rate and lives under risk through targeted identification of high-opportunity primary care providers

SNF referral optimization

We can enable fine-grained optimization of SNF utilization to match the right patient to the right skilled nursing facility

Performance Analysis

Clinical programs

Advanced Illness Care Planning

Our predictors support clinicians to identify patients who could benefit from advanced care planning but may not yet be on anyone’s radar.

Patient attribution/retention

Our analyses identify “borderline attributables”—patients who with 1-2 visits to an ACO’s provider would be attributed to the organization

Chronic care management

Sophisticated targeting of high-risk patients to reduce high-cost adverse events associated with poor chronic care

Acute episode management

Especially for hospital-based ACOs, improving care transitions and in-hospital outcomes prevents readmissions and poor discharges

The value this brings is that it gives us a more targeted insight into the adverse outcomes that could affect our population. We have general risk indicators that tell us which patients require heightened attention, now this helps us dive deeper to understand the likelihood of specific adverse events, such as hospitalization for CHF.
Sheila Magoon, MD, Executive Director Buena Vida y Salud ACO

How ACOs are using Health Vision

Problem

The care management team was unable to reach out to every ACO patient who became eligible for chronic care management, resulting in preventable adverse events.

CARE MANAGEMENT Prioritizing Outreach

Solution

At this medium-sized, physician-led ACO in Florida, the care management team was looking for a way to prioritize their complex care patients who were at greatest risk of an unplanned hospitalization.  So, they turned to Health Vision. They created a list of patients, updated weekly through the automated claims feed from CMS.

  • Patients with a greater than 70% chance of hospitalization in next 12 months, from high to low risk AND
  • Who have active diagnosis of all of COPD, Heart Failure, and Chronic Kidney Disease, AND
  • Have not seen a primary care provider in last 12 months

 

Now, the rank-ordered list has become an essential component of planning and proactive care management, reducing the burden on care managers and improving outcomes through targeted outreach.

Problem

ACOs are trying to help patients and families select high quality SNFs that are the best fit for their needs. But aside from the 5-star rating system, there is a dearth of detailed, timely, and objective information on SNF performance.

NETWORK BUILDING High-Quality Preferred SNFs

Solution

At this large, hospital-affiliated ACO in the northeast, patients and their families with post-acute short-stay needs mainly choose SNFs by geographic proximity to their home. The ACO Pop Health team turned to Health Vision for comparative performance based on digital twinning methodology. By market, they rank-ordered  SNFs by relative performance on these metrics and reset their preferred network.

  • Mortality rate
  • Length of Stay in the SNF
  • Readmission to an acute facility within 90 days
  • Total Cost, 90 days from SNF admission

 

This information is updated quarterly. It is now being used to inform performance improvement conversations between ACOs and their provider partners.

Contact us and learn how we can help you