Enable Community Health

A Southeastern hospital saw a 2-3% drop in environmentally related childhood diseases across all zip codes

Drive Prevention and Health for Individuals in the Community

Deliver the individualized interventions that will keep people healthy while they are still at home and in the community

It feels like community health solutions are everywhere, but we don't have a clear idea of what they should deliver or what to expect. So when we set out to address the complicated issue of community health, we took a different approach.

Because Jvion delivers a Cognitive Clinical Success Machine, we can target individuals at risk of illness and deterioration while a person is in the outpatient setting.

This means that we can stop unnecessary ED visits, keep rising risk patients from deteriorating, better allocate resources and care settings, and help providers avoid high dollar losses.

Using Jvion's machine, providers can do more with less to enable better care coordination, more effective interventions, and the better targeting of high-risk individuals.

Going beyond simple community health indicators to deliver clinical insights driven by a patient phenotype approach that stratifies risk more accurately across a population

We call this approach "community health" because it is about applying preventative measures while the individual is still in the community. It is more proactive, smarter, faster, and better able to deliver value because we can:

  • Identify the individuals who are going to get sick,
  • Determine which interventions will be most effective,
  • Tell you if an individual will engage with an intervention.

This means that we can target specific illnesses, diseases, and conditions with more accuracy and granular insights that drive improved outcomes for your patients and your organization. These results ultimately translate into more effective policy making, education, care coordination, and interventions that improve the health of communities and the quality of care delivered.

Predicting Community Health Risks


Accountable Care Organizations – Topic Deep Dive

Accountable Care Organizations (ACOs) represent a group of doctors, hospitals, and other providers who have come together to provide appropriate, high quality and coordinated care for Medicare patients. The idea is to reduce duplicative efforts and drive quality improvements by enabling better communication and care coordination across all of the providers with which an individual interacts. Provider participation in an ACO is completely voluntary and part of a larger push by the Centers for Medicare & Medicaid (CMS) to encourage coordinated care models.

Did you know? There are more than 600 ACOs across the US?

ACO Goals

The goals of an ACO are known as the "the triple aim," which include:

  1. improving the experience of care,
  2. improving the health of populations and
  3. reducing per capita costs of healthcare.

This aim was first articulated by Donald Berwick, MD, a former acting CMS administrator.

ACO Models

There are a number of different ACO models incorporated within the program including:

  • Medicare Shared Savings Program: that provides incentives for fee-for-service beneficiaries
  • ACO Investment Model: that leverages the Medicare Shared Savings Program ACOs to test pre-paid savings in rural and underserved areas
  • Advance Payment ACO Model: that is available to providers already in or interested in the Medicare Shared Savings Program
  • Comprehensive ESRD Care Initiative: that delivers incentives for beneficiaries receiving dialysis
  • Next Generation ACO Model: that includes ACOs experienced in coordinating care across patient populations
  • Pioneer ACO Model: that includes healthcare organizations and providers experienced in coordinating care across patient populations and care settings

One of the biggest challenges faced by ACOs is what is known as "stickiness" - ensuring that patients covered by the ACO choose providers that are within the group. Stickiness is complicated by the fact that Medicare beneficiaries have unrestricted choice in providers. They can easily go outside the established ACO for care. But ACOs are incentivized based on utilization oversight. When a patient goes outside of the group, the system and its goals are undermined.

Despite the challenges, there is evidence that the ACO model does drive improvements in patient satisfaction. According to a recent report in the New England Journal of Medicine, patients who participated in an ACO reported faster access to care and better coordination between providers. These factors led to greater levels of patient satisfaction with some aspects of care.

ACOs by the numbers
(as of November 2014)

  • There are more than 600 ACOs across the U.S.
  • 20.5M lives are currently covered under an ACO
  • By patients, ACOs served between 46 and 52M as of 4/2014


Accountable Care Organizations (ACO): http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/

ACO manifesto: 75 things to know about accountable care organizations; Shannon Barnet, Tamara Rosin and Heather Punke | October 09, 2014: http://www.beckershospitalreview.com/accountable-care-organizations/aco-manifesto-75-things-to-know-about-accountable-care-organizations.html

ACOs show progress in improving patient satisfaction, study finds; Emily Rappleye: http://www.beckershospitalreview.com/accountable-care-organizations/acos-show-progress-in-improving-patient-satisfaction-study-finds.html

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