Enabling ACO Patient Engagement: Solutions for Outreach

We’ve talked before about using data and reporting to help drive ACO patient engagement. For this post, we’re going to talk about enabling patient engagement through outreach. In this article, we’ll discuss why you should segment your patient population prior to conducting outreach, how to segment your population, and how to deliver appropriate engagement solutions to each segment.

Why is Segmentation Important?

The primary reason you should delineate patient populations is that different processes are required for each segment in order for ACOs to perform final reconciliation with the information that CMS provides. Also, the data sources and technical solutions available to handle gaps in care can vary depending on the segment you are trying to reach.

Prevention and population health is one of the main objectives for ACO Quality Measures, and ACOs must perform patient outreach to achieve these goals.

In order to perform proper patient outreach, two populations must be identified: • Disengaged patients • Engaged patients

Disengaged Patients

If a patient isn’t coming in for office visits, it would be easy to assume that he/she is healthy and isn’t in need of services. In most cases that might be true. However, the patient might have risk factors that could be identified and/or prevented with more regular screenings. Failure to act on these risk factors could lead to more severe outcomes for the patient and more costly channels of care. Prevention and population health is one of the main objectives for ACO Quality Measures, and ACOs must perform patient outreach to achieve these goals. There can be a lot of IT integration that needs to happen in order to properly identify the disengaged patients. This is especially the case for ACOs that have patients who visit external private clinics. Once the integration is complete, you’ll have a clear picture of the entire patient population being served by the ACO The process for isolating disengaged patients begins by utilizing claims data from internal and external providers in the ACO. We can then categorize claims by patients that have specific characteristics. For example, for the MSSP measure (NQF #0031): Preventive Care and Screening: Breast Cancer Screening we must find patients that are ages 40-69 as one criteria and also fall into the exclusions specified in the CMS’s ACO measures documentation. If the patient is a part of this population and has no record of a screening, she can be flagged and outreach can be performed.

Identifying and Addressing the Engaged Patient

Patients that are visiting the doctor regularly have different methods of engagement and thus, providers have more control over the solutions with which to engage them. When a doctor sees a patient regularly there are more opportunities for performing outreach since the patient is already doing the bulk of the work. While a patient is visiting the office, doctors have the ability to advise them on how to alter their behavior via their EMR solution. Epic offers a health maintenance solution, and AllScripts also has a Clinical Quality solution that shows physicians any potential gaps in patient care. Beyond the individual visit, the central administration of the ACO must still keep track of the patients coming in to the office and whether providers are conducting analysis via their EMR systems. The ACO will likely need another layer of analytics on top of their EMR to monitor its utilization.


We’ve looked at ways to perform outreach to both engaged and disengaged patients. We’ve also looked at some ways to identify both groups. ACO technology departments should provide ways to help administrators and providers make outreach more efficient. An integrated reporting solution is recommended where possible to help reach disengaged patients, while engaged patients are addressed at point of care via EMR solutions.