CUSTOMER: Accountable Care Organizations

Improve Patient Outcomes and Quality Measures


Transform Patient Care and Collaboratively Improve Outcomes

As an ACO, you've come together voluntarily to give coordinated high-quality care to Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.

Orb Health helps ACO's implement scalable and effective Chronic Care Management and additional Medicare services that result in meeting the majority of the Medicare requirements placed on ACO's. Our Collaborative Virtual Care solution not only coordinates care, but meets the spirit of the ACO by enabling collaboration across PCP, specialists, and surgeons and reflects that interaction in the EMR. Our solution measures and documents the interactions as well as sets proper patient coding so value-based care bonuses can be realized annually.

Services that Match ACO Requirements

Orb Health Collaborative Virtual Care enables ACO’s to implement a wide range of Medicare reimbursed services such as Chronic Care Management, Transition Care Management, Remote Patient Monitoring, Behavioral Health and much more that aid in meeting the care requirements of the ACO.

Care is delivered by licensed and certified medical practitioners that handle all aspects of the patient’s needs between office visits.  Appointment scheduling, specialist discovery, Rx management and ordering, deciphering lab results, condition education, and much more including being there just as someone who listens to their concerns.

Our Virtual Care Hub ensures the EMR remains the “patient record of truth”, increasing the effectiveness of existing portals, ensuring billing readiness, and code compliance.  Our remote care delivery services are broken down into smaller pods that maintain an industry low patient-to-nurse ratio, enabling meaningful relationships that drives a more engaged and compliant patient while delivering your Best Practices.

Each of these CMS services has a profound downstream effect on ACO’s abilities to meet value-based care requirements.  For example, CCM increases medication adherence, provides connections to social services, and increases appointment compliance.

Streamline Coding and Scoring

Orb Health’s workflows, policies, and procedures ensure that all interactions with the patient are documented and synchronized with the EMR record including all required coding and scoring.  Each year, our Virtual Care Hub helps re-score your patient-base based on the annual HCC scoring requirements.

Orb also helps you discover additional scoring that you may have missed, ensuring you accurately reflect your patient populations score average and meet the value-based care requirements to attain your ACO care bonuses.

Audit-Ready Compliance

Our compliance teams check every interaction note and document to ensure all guidelines and requirements are met before we sync the data back to the EMR. This level of review ensures you are always ready for an audit and we stand with you in the event one occurs.

This review includes all coding inside of the Orb health interaction so your own compliance, coding, and billing systems are presented with properly formatted information so they can efficiently perform their roles.

Measured Outcomes

Orb Health has proven outcomes that help multiple scoring areas for ACOs.  In the Orb Health 2019 Patient Outcomes Study, Orb Health saved a Florida based FQHC $6.22mm dollars with a 54% reduction in Emergency Department utilization and subsequent hospital readmissions.

Orb Health also maintains a 4.8/5 star patient satisfaction rating and 98% retention rate as a virtual extension of your ACO.   These examples and other measurable results directly tie to ACO requirements and help your ACO achieve your value-based care bonus.

Supported ACO Quality Measures (Partial List)

Care Coordination / Patient Safety
  • ACO-43 - Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91) ╪‡
  • ACO-13 - Falls: Screening for Future Fall Risk
Patient / Care Giver Experience
  • ACO-1 - CAHPS: Getting Timely Care, Appointments, and Information
  • ACO-2 - CAHPS: How Well Your Providers Communicate
  • ACO-3 - CAHPS: Patients’ Rating of Provider
  • ACO-4 - CAHPS: Access to Specialists
  • ACO-5 - CAHPS: Health Promotion and Education
  • ACO-6 - CAHPS: Shared Decision Making
  • ACO-7 - CAHPS: Health Status/Functional Status*
  • ACO-34 - CAHPS: Stewardship of Patient Resources
  • ACO-45 - CAHPS: Courteous and Helpful Office Staff
  • ACO-46 - CAHPS: Care Coordination
At-Risk Population
  • ACO-27 - Diabetes Mellitus: Hemoglobin A1c Poor Control‡
  • ACO-28 - 8 Hypertension (HTN): Controlling High Blood Pressure
  • Requires 5 Advancing Care Info, 6 Quality Measures, 4 med / 2 high Improvement Activities
  • Orb Health Supports 6 Advancing Care Info, 19 Quality Measures, 28 med / 2 high Improvement Activities