Palm Beach ACO

PBACO Holding supports provider organizations in value-based care across its affiliated network. For transitional care management, CMS expects an interactive contact with the patient within 2 business days of discharge and a visit within 7 or 14 days. Coordinators were calling patients one at a time, and annual wellness visit outreach competed with everything else on their lists.

The first phase of the partnership covers outreach for transitional and preventive care. For post-discharge follow-up, the agent calls or texts the patient after a discharge, confirms the follow-up plan and books the visit, while nurses and care managers make the TCM interactive contact and answer every clinical question the agent routes to them. For annual wellness visits, the agent works the list of patients due by phone and text and books the visit, and practice staff take the patients who ask for a person.

Every discharge gets an outreach attempt by phone or text, with exceptions routed to the care team. Follow-up visits are booked by the agent during the call, and patients due for a wellness visit are worked from one list by phone and text. The announcement describes room to expand into documentation, care coordination and other workflows over time.