Community ACO — South Texas & Virginia
Buena Vida Y Salud
A partnership between community physicians and the South Texas Physician Alliance — 96 providers united around coordinated, quality, affordable care. Within six months of deploying HealthVision, BVyS transformed its approach to patient targeting and care management.
The Challenge
Healthcare is witnessing significant strain — soaring costs and increased utilization for an older and sicker population. BVyS needed a strategy that would maintain high-quality care while controlling expenses, specifically by pinpointing sub-populations based on predicted future risk and deploying tailored interventions to reduce the likelihood of adverse events.
Risk-Based Patient Segmentation
1,372 patients were segmented into three cohorts using HDAI’s mortality, hospice, and unplanned admission predictors.
Advanced Illness Care
Top 5th percentile
Mortality or likelihood of entering hospice
Complex Care
Top 25th percentile
Unplanned admission risk
Rising Risk
25th–50th percentile
Unplanned admission risk
How It Worked
PCP Targeted Lists
Rank-ordered by highest risk for unplanned admissions, delivered to physicians with instructions to see patients monthly for six months.
Top Contributing Factors
Surfacing the specific factors driving each patient's risk — guiding conversations around proactively reducing ED visits, falls, and admissions.
Workflow Triggers
Automatic triggers into Transitional Care Management, Chronic Care Management, and Remote Patient Monitoring for patients requiring additional support.
It’s amazing what our physicians and nurses have achieved in just 6 months by focusing on patients that needed our attention the most. This level of predictive targeting allowed us to be true to our goal of keeping patients healthy at home.
— Dr. Sheila M. Magoon, Family Practice
Drive Results for Your ACO
See how predictive targeting can transform care management in your organization.
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