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
[SNF 3-Day Rule Waiver](/docs/JUNE 2019 DRAFT SNF 3-Day Rule Waiver Notice.pdf)