Raleigh-based Community Care of North Carolina (CCNC) recently partnered with Wilmington-based Medicare ACO Physicians Quality Partners (PQP), a clinically integrated network developed by New Hanover Regional Medical Center, to improve care delivered to complex patients enrolled in the hospital system’s Medicare Shared Savings Program.

CCNC’s goal is “to help build a sustainable, cost-effective model for accountable care,” spokeswoman Elizabeth Lubben said in an email response to questions.

Locally, CCNC’s Community Care of the Lower Cape Fear (CCLCF) provides on-the-ground care management services to targeted PQP patients.

Community Care of the Lower Cape Fear serves the urban center of Wilmington and surrounding rural communities in New Hanover, Brunswick, Pender, Bladen, Columbus and Onslow counties.

CCLCF’s network works in collaboration with doctors, hospitals, county health departments and departments of social services to improve health outcomes for nearly 98,000 eligible patients, Lubben said.

CCNC provides its proprietary analytical tools, known as CareTRIAGE and CareIMPACT, to help PQP identify patients who are most “impactable,” or those whose care can be significantly impacted through targeted interventions at the right time, Lubben said.

CareTRIAGE uses pharmacy data to determine risk scores for adverse events, medication problems and risk of hospital admissions and readmissions. CareIMPACT is a data visualization tool that helps organizations understand disease burden, demographics, costs, utilization patterns and care opportunities in a population.

“CCNC has analyzed our Medicare data, applied predictive risk modeling and depicted our data in an actionable dashboard that helps us to deploy targeted interventions to change the trajectory for high-risk patients,” Philip Brown, chief physician executive of New Hanover Regional, said in an email.

"We are hopeful that this will move us a long way in reducing readmissions, improving patient safety and boosting quality of life for our patients,” Brown added.

CCNC’s analytics help to identify optimal opportunities and methods of intervention, allocate resources efficiently and drive down costs.

“As reimbursements move toward ‘pay for value’ approaches, population health efforts of this sort are essential to a hospital’s financial success,” Lubben said.

CCNC is also tapping into its primary care and care management infrastructure to provide additional care resources to the Lower Cape Fear community by bringing targeted services to the right patients at the right time and place.

“This increases outreach to Medicare patients in need of specialized guidance or services to avoid worsening of their conditions, readmissions and repeated trips to the emergency department,” said Angela Ives, executive director of CCLCF.

The newly implemented care management system “increases quality of care and thwarts worsening conditions and hospital readmissions and is showing great promise at New Hanover Regional Medical Center,” Lubben said.

According to the Centers for Medicare & Medicaid Care Services, accountable care organizations, or ACOs, are groups of doctors, hospitals and other health care providers, that come together voluntarily to give coordinated high-quality care to their Medicare patients.

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.