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HNHC Project

Overview  ♦   Program Details  ♦   How to Participate  ♦   Resources


Participate in a 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 adversely affected by quality and safety failures, given their frequent contact with the system.

What: Although proven models to care for these patients have been implemented successfully, they have not entered the mainstream of American medicine. 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.

Project Objective: Help ACOs identify high-need, high-cost individuals and introduce programs that effectively address their unmet medical and non-medical needs in order to meaningfully reduce avoidable medical spending and generate a strong return on investment.

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 that seek to address unmet medical and non-medical needs; and

  2. A learning collaborative of ACOs developing or implementing extensivist programs based in clinics or organized virtually. We expect that the extensivist model learning collaborative will expand to become a demonstration program 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 technical assistance to help them launch their programs efficiently and effectively. This includes helping your ACO effectively identify and enroll HNHC patients; training your management and frontline staff; providing libraries of relevant documents including workflows, patient assessment forms and model policies and procedures; and offering data analytic support.

  • Learning community. Your organization will be invited to join a ACO learning community where you will work with a group of your peers supported by experienced facilitators and expert faculty from ACOs that have already launched successful programs. We will offer both group and individual consultation on strategic and operational issues.

  • 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 use the NAACOS Medicare data warehouse to conduct a rigorous evaluation of the impact of your program on utilization and spending. We will also provide support to help you measure your ACO’s 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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