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NAACOS Names 2023 Leaders in Quality Excellence Award Winners


Three accountable care organizations (ACOs) received recognition for their efforts by the National Association of ACOs (NAACOS), which named them this year’s Leaders in Quality Excellence.

To recognize the achievements of select accountable care organizations (ACOs) this past year, the National Association of ACOs (NAACOS) named Delaware Valley ACO, the University of Texas Southwestern (UTSW) ACO, and University of California San Francisco (UCSF) Health as 2023 Leaders in Quality Excellence, according to an announcement on the NAACOS website.

NAACOS established the Leaders in Quality Excellence Awards in 2021 to “recognize ACOs working to improve the quality and safety of patient care and advance population health goals.” NAACOS explained that it chose these winners specifically because they exemplify how ACOs across the country are closing gaps in care and improving care coordination for complex patients.

Delaware Valley ACO received this award for creating a home-based palliative care strategy that helped improve care for patients facing serious illnesses or nearing the end of life. According to NAACOS, Delaware Valley ACO developed this strategy after a collaborative team of clinicians and analysts built clinically relevant claims-based views of end-of-life care among their Medicare patients and national benchmarks. One of their findings was that 47% of their patients received hospice care for a week or less before death, compared with 28% nationally.

They then used their findings to show stakeholders that they should implement palliative care earlier. After implementing this strategy, the proportion of patients who received hospice care for 1 week or less before end of life improved from 47% to 32%. This strategy also allowed Delaware Valley ACO to provide more positive end-of-life experiences for patients and families. Overall, they found that patients who received home-based palliative care had cost savings of approximately $9000 in the last 90 days of life.

UTSW ACO, also known as Southwestern Health Resources, received this award by helping patients prevent avoidable hospitalizations and emergency department visits. They achieved this by developing a novel risk stratification algorithm, using artificial intelligence machine learning techniques, that matches high-risk patients with complex care management services. NAACOS explained that UTSW ACO completed this by building predictive models integrating claims and electronic health record data with information from publicly available health data sets to identify individual-level socioeconomic care barriers.

UTSW ACO then encouraged patients to enroll in a long-term complex care management program that provided personalized support and care coordination for clinical, social, pharmaceutical, and behavioral health needs. Six months later, they found 2 unplanned hospital admissions among the 25 patients who received complex care management and 31 unplanned hospital admissions among 91 patients who did not. Because of the program’s success, UTSW ACO said it plans to enroll 1800 individuals in complex care management in 2023.

Lastly, UCSF Health was named a Leader in Quality Excellence as it reduced discrepancies in hypertension control among its patients. NAACOS explained that this became a health equity goal for UCSF Health in 2020 after identifying a 10-point gap in high blood pressure control between Black patients (67.6%) and White patients (77.8%).

UCSF Health worked with health disparity researchers to interview Black patients and better understand their preferences, barriers, and competing priorities. Based on their answers, UCSF Health designed interventions, including culturally tailored hypertension education materials, to help reduce discrepancies. They also designed a team-based intervention involving the primary care, pharmacy, and population health departments to help patients manage their hypertension. For those with uncontrolled hypertension, they offered an intensive program with telehealth pharmacist visits and coaching from health care navigators to encourage healthy behaviors.

To help patients with hypertension who had no recent blood pressure readings, UCSF Health navigators mailed home blood pressure monitors. They taught patients how to use the monitors through phone calls and video conferencing, and they collected blood pressure readings remotely. One year after implementation, UCSF Health found that the gap in blood pressure control narrowed significantly as 73.1% of Black patients attained it.

Overall, NAACOS noted that its Quality Committee chose these 3 organizations out of all nominees because of their efforts aligning with the criteria of innovation, improvement, scalability, and long-term contributions.

“NAACOS congratulates these ACOs for their outstanding work to improve the quality of care provided to the patients they serve,” they concluded.


NAACOS Leaders in Quality Excellence Awards. National Association of ACOs. Accessed June 26, 2023. https://www.naacos.com/2023-naacos-leaders-in-quality-excellence-awards

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