How a pop health platform helped one ACO prevent 98 strokes and 39 heart attacks in less than a year

Arizona Care Network’s IT-infused approach to population health has helped the accountable care organization better coordinate on annual wellness visits, boosting compliance.
By Bill Siwicki
02:11 PM
How a pop health platform helped one ACO prevent 98 strokes and 39 heart attacks in less than a year

The Arizona Care Network serves hundreds of thousands of patients throughout the state.

Arizona Care Network, an accountable care organization based in Phoenix, is quite focused on care coordination – so much so that it has a division focused entirely on the practice. The division is called N Compass, which provides comprehensive care coordination to patients based on their personal needs.


The ACO especially wanted to lend support to its nearly 6,000 caregivers and ensure the most efficient and appropriate use of resources needed to achieve the desired clinical outcomes.

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“While our providers are eager to manage care for their patients, we learned that they don’t always have the targeted and actionable insights they need to deliver the right care to the right patients at the right times,” said Dr. Mark Schippits, chief medical informatics officer at the Arizona Care Network.

“The network has access to a plethora of patient data from a variety of sources – from internal records, ADT feeds, VBA portals and Arizona’s Health Information Exchange – but we needed to distill all that data and information into meaningful insights,” Schippits explained.

Although the network’s care coordination model was strong to begin with, he added, staff also knew that some of the network’s 310,000 patients were being overlooked because of the sheer volume of people the network serves.


Data and analytics are the operative words in healthcare, Schippits said. The challenge is not about getting information, but rather, what to do with it. With this in mind, the network devised a three-pronged strategy to drive its N Compass program.

“First, using the athenahealth population health platform, we created and applied a proprietary algorithm to stratify patients according to their health status,” he explained.

“Using a five-tiered pyramid, we prioritize patients based on their condition, utilization and risk, and then share this information with providers to coordinate care at their office or with help from our team,” he added. “Importantly, the pyramid uses all of the data we collect, but synthesizes the data into a single, manageable operational source.”

The ACO also employs biometrics to identify and monitor patients’ conditions and creates a care summary rich with information that providers may not otherwise know. The summary includes a profile with demographics, and the health status and/or risk for each patient. There also is a detailed report of the patient’s hospital and emergency department utilization, along with other events that could influence their care.

Finally, the summary tracks the patient’s medications, including compliance in taking and refilling prescriptions. The ACO includes a recommended care plan based on network guidelines that the provider can update or customize for each patient.

“These three elements – stratification, biometrics and a care summary – give providers an in-depth look at their patient to help them manage identified health risks and achieve the best possible clinical outcomes,” Schippits said.


There is a variety of population health systems on the health IT market today, from vendors including Allscripts, CareEvolution, Cerner, Cota Healthcare, eClinicalWorks, Epic, Geneia, GSI Health, Health Catalyst, HealthEC, Innovaccer, MAP Health Management, Medicity, NextGen Healthcare, Optum, Orion Health, Philips, Varian Medical Systems, Vivify Health and ZeOmega.


Informatics is the engine that drives Arizona Care Network’s population health program. The network uses predictive modeling to identify patients according to their health histories, risk of inpatient hospital and emergency department utilization, medication use, and level of disease control. Such information is noted in the detailed care summary to help providers create a comprehensive plan for addressing their rising health risks, quality measures, HCC management and other issues.

“After synthesizing the data, the network uses a semi-custom referral platform built on the par8o principle to share insights with providers and offer assistance in managing patient care,” Schippits explained.

"These three elements – stratification, biometrics and a care summary – give providers an in-depth look at their patient to help them manage identified health risks and achieve the best possible clinical outcomes."

Dr. Mark Schippits, Arizona Care Network

“This could include notifying patients of annual wellness checks and screenings and advising providers of patients who are at risk of moving into a more complex state of health,” he said. “Because the technology platform is secure, the network can share consistent feedback and updates on patients for whom it coordinates care.”

A case in point: Arizona Care Network can arm providers with a list of “rising risk” patients recently diagnosed with diabetes or work directly with a patient on ways to proactively manage their health, get reminders to get appropriate screenings, and receive periodic calls to check on their condition. Similarly, higher acuity health issues could get a personal house call by a network provider within 48 hours of discharge from the hospital or a skilled nursing facility.

“The network also uses informatics, including 14 General Practice Reporting Option (GPRO) measures to evaluate the N Compass program’s effectiveness — including if the outreach is working, patients are taking more control of chronic conditions, hospital utilization is down, and more,” Schippits said.


Arizona Care Network’s use of data and analytics to refine its care coordination model is delivering promising results.

“We’ve seen greater collaboration between the network and its providers, along with better coordination on annual wellness visit compliance,” said Schippits. “During the past three quarters, the network also exceeded its overall performance on 13 of 14 designated GPRO measures on its entire patient population. Best of all, our care coordination model was instrumental in preventing 98 strokes and 39 heart attacks during that time.”


Accountable care organizations are designed to harness the power of data to enhance knowledge, make smart decisions and deliver big results. Taking a data-driven approach to population health is the right thing to do, but there are some key considerations for getting such a program like Arizona Care Network’s under way, including, Schippits said:

  • The first step is getting one’s informatics house in order. That means making an investment not only in technology but also in experts with a deep understanding of healthcare IT.
  • Data for data’s sake will not move the needle on care coordination and clinical outcomes. Think strategically about the information one wants to capture and be sure that it is actionable at the physician level.
  • Engage providers in the process. Get an understanding of the information they need, and then deliver it to them in an easily digestible format.
  • Insights about one’s patient population are only part of the equation. In addition to focusing on analytics, invest in a diverse and talented care coordination team. Arizona Care Network’s includes navigators, RNs, MAs, social workers, behavioral health coaches and a population health pharmacist.
  • Every population health program is different. Consider what one needs, then create the tools and secure the resources to bring the program to life.

Twitter: @SiwickiHealthIT
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