Our mission through the USMM Accountable Care Partners is to unite Home-Based Primary Care providers in providing high-quality, compassionate, and cost-effective care to the high-risk, frail elderly population across the United States.
Who We Are:
USMM Accountable Care Partners is organized to focus specifically on a subset of Medicare patients who have multiple chronic illnesses (upwards of eight, on average), require multiple medications (average greater than ten), and demonstrate multiple functional impairments. In addition, a large percentage of these patients can be categorized as advanced elderly, with an average patient age of 79 years.
What We Do:
- Help patients live longer, with less emergency room visits and less hospitalizations
- Sharing of clinical and claims data to improve coordination of care
- Improve integration of post-acute resources in the home - including laboratory, mobile diagnostics/radiology, skilled home health, personal care services, palliative care, hospice, DME and pharmacy
- Resources to measure and develop new programs for the high-risk, frail elderly population
- More efficient allocation of healthcare resources through development of advanced care coordination programs to get the right level of care to patients in the most appropriate cost setting
- Better communication and development care plans with patients through more complete understanding of patients' chronic conditions and prognosis
- Benchmarking care delivery to national standards
- Identify and filling gaps in care
- Enhanced provider performance through alignment of incentives and tying performance to outcomes