Trinity Pioneer ACO, Fort Dodge, Iowa

Uploaded by CMSHHSgov on 26.09.2012


My name is John Ernest Scharf.
I've lived in Fort Dodge all my life.
We are geographically very diverse, so we have a large eight county area and we’re very rural as a Pioneer.
Often times our communities can be as small as a thousand people in the community
to our largest community, Fort Dodge, which is right around twenty-five thousand.
It's a small, quiet, nice community.
I've got shortness of breath and just didn't feel right,
so I called my daughter and she took me out to the emergency room
and that’s when I found out I had that congestive heart failure.
Well when I got released, of course, the hospital talks to you and all,
but then somebody come up and said that somebody would be
calling me to check on me, you know, and then Tammy was the one that called.
I will contact the person after discharge and within forty-eight hours I do a home visit.
When we do post-discharge visits, it allows us to determine
whether or not there are any barriers in the way for the patient to be successful at home
and to implement strategies immediately to help them stay at home
and be successful and self-managed.
She's asked me if I've needed help sorting out my medication,
keep up with my appointments.
And he's now discharged but he also has my cell phone number for work
and I do see him in the community and I call him at least once a week,
just to make sure he's doing OK.
She told me if I ever needed anything, you know, to give her a call,
she'd be there. And that's always good to know.
Previously, when people would try to handle their own healthcare, it becomes so complex
The ACO gives us the opportunity to apply resources to those people,
keep them healthier, to keep them out of the hospital and that's where they want to be.
We began to see these wonderful possibilities of doing better for patients,
doing better for our communities, and providing a level of care that was
unsurpassed as compared to how we had been operating as independent agencies.
Most of what the anxiety is out there, that we're just trying to
cut costs by cutting access, and that's not the case with an ACO.
We've been able to add services that we would not have, likely, without the ACO platform.
Post-care coordinators like Tammy are out there doing the critical work of an ACO
in terms of trying to make sure we catch people while their showing early signs of symptoms
before they get to the point where they're going to have to go back in the hospital to get taken care of.
So far, out of seventeen patients we have not had one readmit or
anybody that has been seen in the emergency room.
We've seen that all of our readmissions in all of our categories
have been driving steadily downward, so we're very pleased about that.
We took this on early because it was a unique opportunity for us to
be on the front-line, the cutting edge of developing the model
and we think we have a unique opportunity with our rural situation, with our aligned providers
to coordinate care in a very meaningful and positive way.
And I think we're making good progress in that area.
We just didn't look back. Once we had the momentum,
we knew this was the right thing to do.
We are proof that it does work.