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HNHC Project

Overview  ♦   Program Details  ♦   How to Participate  ♦   Resources


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 will launch two distinct projects beginning in May 2019 with support from several national health foundations:
  1. A demonstration project to implement home visit programs using community health workers, paramedics, RNs or nurse practitioners and evaluate their impact; and
  2. A learning collaborative of ACOs developing or implementing extensivist programs based in clinics or organized virtually. We expect that the learning collaborative will expand to become a demonstration program beginning in 2020.
We are seeking NAACOS members that are interested in joining one of these projects.

Benefits of Participation
  • Technical assistance. ACO’s will receive grant-supported services that include help with identifying HNHC patients, staff training, patient assessment forms, model policies and procedures, and data support.

  • Learning community. ACO participants will be part of an independent evaluation to understand what works, what doesn’t work and why. We will provide tools and access to technical expertise to help ACOs calculate return on investment.

  • Measuring impact. ACO participants will be part of an independent evaluation of the project to understand what works, what doesn’t work and why. We will provide tools and access to technical expertise to help ACOs measure return on investment.
How Do I Get Involved?

Complete the request for information applications and contact Teresa Litton if you have any questions.

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