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HNHC Project

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Participate in a new Cutting-Edge Delivery System Initiative for ACOs

Delivering Effective Care to High-Need, High-Cost Individuals:
A Cornerstone of ACO Success


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Who: High-need, high-cost (HNHC) individuals make up five percent of the population but incur nearly 50 percent of health care spending. These patients may have multiple chronic conditions, functional limitations, or behavioral health problems and are more likely than other patients to receive avoidable health care services. They are also more likely to be affected by quality and safety problems, given their frequent contact with the system. Identifying and serving these patients effectively is a key measure of ACO success.

What: Although promising models to care for these patients have been established, few have spread beyond the demonstration stage to become common practice throughout the country. Five major health foundations recently joined together and made a historical commitment to work towards clarifying the needs of HNHC individuals, identifying the best ways of caring for them, and assisting with the spread of proven approaches.

The Institute for Accountable Care is seeking ACO partners interested in deploying:

  1. Home visit programs using community health workers, paramedics, RNs or nurse practitioners; or
  2. Extensivist programs based in clinics or established virtually.
When: The Institute is planning a project to Implement HNHC Patient Initiatives in ACOs beginning in early 2019 with support from The SCAN Foundation, Robert Wood Johnson Foundation, and Commonwealth Fund. The Institute will solicit participation from ACOs that wish to deploy new programs or expand existing initiatives that target HNHC individuals later this fall.

Benefits of Participation
Implementation support and technical assistance. ACO’s will receive grant-supported services that include help with identifying HNHC patients, recruiting and training personnel, patient needs assessment, and integrating data collected from the home into the medical record.

Learning community. ACO’s will participate in a learning community with regular webinars and in-person meetings led by faculty that have successfully implemented these initiatives in their own organizations.

Measuring impact
ACO participants will be part of an independent evaluation that examines the projects to better understand what works, what doesn’t work and why. The project will offer tools and access to technical expertise to help individual ACOs conduct credible accurate return on investment analysis.

How Do I Get Involved?
Contact Teresa Litton to indicate interest and receive more information.

For an up-to-date, curated source on the best research and resources on high-need, high-cost individuals, please visit www.bettercareplaybook.org.

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