Medicare ACO — 54,000 Attributed Lives
Houston Methodist Coordinated Care
The largest Medicare ACO in Houston, with 300+ primary care physicians, using HealthVision to power advanced illness identification, complex care management, transitions in care, physician network optimization, and SNF performance analysis.
AI-Powered Care Programs
Advanced Illness Care
Predictive models identify patients likely to need hospice within 90 days, stratified by actionability. AI-generated chart summaries reduce clinician burden and accelerate referrals to palliative and hospice care.
- Earlier hospice referrals with appropriate enrollment
- Lower per-beneficiary costs and admission rates vs. non-participants
- Higher patient and family satisfaction with end-of-life care
- Reduced clinician EHR time through targeted AI summaries
Complex Care Management
Patients in the top 25th percentile of unplanned admission risk are enrolled in intensive care management with monthly physician visits, case review, and workflow triggers into transitional care and chronic care programs.
- 31% reduction in cost per patient
- 4% lower admission rate for program completers
- Monthly case review with risk-based prioritization
- Workflow triggers into TCM, CCM, and RPM programs
Transitions in Care
Post-discharge patients are risk-stratified and those identified as highest risk are placed in enhanced follow-up programs with additional clinical support to prevent readmissions.
- 12.5% readmission rate vs. 13.0% expected (risk-matched digital twins)
- Risk-targeted post-discharge follow-up scheduling
- Getting patients to the right level of post-acute care
- Continuous measurement against digital twin benchmarks
Beyond Care Programs
HMCC also uses HealthVision data for strategic network decisions that go beyond direct patient care.
Physician Recruitment
Identified and signed five new physician groups serving 2,500+ Medicare beneficiaries by analyzing clinical and cost performance of providers in the market.
SNF Performance
Identified post-acute skilled nursing facilities with the lowest readmission rates, enabling smarter referral patterns and better post-discharge outcomes.
Nurse Performance
Measuring individual nurse effectiveness in preventing avoidable ED visits and admissions, using data for education and performance improvement.
We’ve always achieved shared savings in our ACO program, but this will probably be our best year. HDAI is part of that. They help us improve care for our patients, and if you provide better care, return on investment follows.
— Dr. Julia Andrieni, CEO and President, Houston Methodist Coordinated Care
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