Learning Systems for Accountable Care Organizations
Prepared for:
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation
Keystone ACO's Health Navigator Program to Identify and Close Care Gaps (Case Study)
Learning Systems for Accountable Care Organizations
Associated Project
Key Findings
Keystone grew the number of CHA-led interventions by 29 percent between 2017 and 2018. Keystone has received positive feedback from clinicians and beneficiaries about the health navigator program.
Keystone Accountable Care Organization’s health navigator program uses community health assistants (CHAs) to identify and resolve beneficiary care gaps. The CHAs collaborate with beneficiaries’ care teams to conduct home visits and determine whether beneficiaries have unmet health and social needs. The CHAs then help resolve these needs by reporting potential clinical issues to the care team and connecting beneficiaries with community organizations to address nonclinical concerns. In 2017and 2018, Keystone’s CHAs supported more than 23,750 interventions to identify and resolve potential care gaps, including conducting home visits, follow-up calls, and email-based outreach to beneficiaries.
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