Rural ACO — Colorado & Utah
Community Care Alliance
A collaboration of small, rural, critical access hospitals and affiliated primary care clinics serving over 20,000 attributed Medicare patients across Colorado and Utah. CCA is the convener for Western ACO (WACO), a Medicare shared-savings program.
The Challenge
CCA’s goal was to keep patients healthier while reducing ED visits and hospital admissions — but providers had limited information on which patients to target for preventive interventions. With over 700 patients per care manager and charts spread across rural facilities, finding the right patients was cumbersome and often reactive.
Many high-risk patients had fallen off the radar entirely — a “ghost population” not coming to appointments, living in remote areas, and quietly deteriorating without clinical oversight.
A Patient Success Story
A patient with congestive heart failure and kidney disease who lives alone, 60 miles over a mountain pass, had stopped coming to appointments and dropped off the clinic’s radar. An ambulance frequently brought him to the ED because of falls. He was taking medications sporadically.
Care manager Andrea Christie, RN, was alerted to this patient by HDAI’s rank-ordered list of future high-risk patients. She reached out, discovered he needed help coordinating follow-ups, and set him up for weekly blood pressure checks, frequent labs, and physical and occupational therapy.
He hasn’t been back to the ED since.
How CCA Uses HealthVision
Pre-Filtered Patient Cohorts
HDAI sends pre-filtered lists of high-risk and rising-risk patients, making it easy for care managers to prioritize outreach without manual chart review.
Predictive vs. Retrospective
Targeting based on predicted future risk rather than past utilization — catching patients before their health deteriorates, not after the ED visit.
Regular Platform Use
Care managers log into HealthVision every two weeks on average, usually to inform care planning for complex patients and review risk trajectories.
I can look at HDAI’s HealthVision data, see which patients are at higher risk, and reach out to them. Then we can get their chronic conditions to a more manageable level.
— Amber Christie, RN, Chronic Care Manager, Gunnison Valley Health
With HDAI’s predictive analytics tools, we can intervene with patients who are potential frequent fliers, then start coordinating their care. That can slow their pace of moving into the high-risk category.
— Marnell Bradfield, Administrative Director, Community Care Alliance
Reach Your Ghost Population
See how predictive analytics can help your care managers find and support high-risk patients before they end up in the ED.
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