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BJC Accountable Care Organization, five years later

Author: ROBERT S./Tuesday, September 05, 2017

by Karen Gallagher

BJC | The BJC HealthCare Accountable Care Organization (ACO) had important successes in its first four years. It achieved a quality score of 97.66 percent from Medicare’s 33 ACO quality measures and saved Medicare $3.5 million. The BJC ACO has the lowest per-beneficiary cost in the St. Louis area.

Greatest successes include:

  • complex care management and readmission avoidance programs
  • involving private providers in addition to BJC Medical Group
  • quality improvement and reduction in cost

What is BJC Accountable Care Organization?

Dr. Nathan Moore

On July 1, 2012, BJC became the first health care provider in the St. Louis area to take on the challenge of forming an accountable care organization to take better care of seniors. 

“Our ACO is focused on providing exceptional and high-value health care to our patients,” says Nathan Moore, MD, ACO medical director. “We have a team of nurses, social workers and care coaches who work one-on-one with our patients and assist them with chronic care management, socioeconomic barriers to care and disease education. Our ACO team works closely with our partners in primary care, specialty care, hospitals and skilled nursing facilities to ensure that care is coordinated and well-managed across all sites.”

BJC ACO includes all BJC Medical Group, BJC hospitals, BJC Home Care Services and selected private providers.


Patients are given the opportunity to become a part of BJC ACO when their physician joins. To date, almost 43,000 seniors are covered by the program. 

At least once a year patients meet with their physicians and go over every aspect of their care. This results in a care plan that the patient and physician develop together. It addresses the needs of the patient related to his or her health status and starts a flow of information that goes to every doctor and clinician involved with the patient to ensure continuity of care.

There are benefits for specialists as well. When patients come into a specialist’s office, there is a care plan from the primary care physician that shows not only who is involved in the patient’s care, but exactly what’s been done for the patient. It allows the specialist to know his or her role in the care and to whom to communicate the results.

Dr. Moore notes that BJC is the only ACO in St. Louis that has qualified as a CMS Advanced Alternative Payment Model ACO under the new physician prospective payment system.

Care partners bring a personal touch to BJC ACO patients

Natalie Barone

Many patients might have been headed for an emergency department visit, if not for the help of care partners assigned to them through BJC Accountable Care Organization (ACO).

ACO beneficiaries can choose to participate in this free service. Care partners call and work with patients after they’re discharged from the hospital, or when they’ve been identified as being at high risk for a hospital admission due to chronic disease.

The nine nurses, four health coaches and two social workers who are part of the program keep the patient’s physician updated through the patient’s electronic medical record. They assist with coordinating discharges from the hospital, provide information to patients to help manage their conditions, go over instructions and answer questions. They help the patient coordinate care with other health care providers and avoid duplicate or unnecessary tests.

Natalie Barone, RN, BSN, started following patient Roger Brainerd after he had back surgery at Barnes-Jewish Hospital. She made sure home health contacted him and set up his first home care appointment. 

“I was able to speak with the patient’s significant other and educate her on red flags to watch for after his surgery,” Barone says. “She was performing dressing changes, so we focused on signs of infection that should be reported immediately. Roger did have questions for his doctor when he got home, so I also got those answered for him.”

Care partners also discuss discharge instructions with their patients who have been in the hospital to make sure they have a follow-up appointment with their provider. They help patients communicate with their provider so their questions and concerns can be addressed in a timely manner, and help educate patients and their caregivers on their diagnosis and how to identify when they should call their doctor to catch issues early. 

“Natalie calls now every couple of weeks to see how I’m doing and if there have been any challenges,” says Brainerd. “She shows genuine concern. It’s nice to have someone like her as a resource. I’m doing well and doing my physical therapy.”

Social workers on the team consider all aspects of a patient’s life and how that impacts their health and health care decisions. They also connect with patients by phone to provide information and resources to help them meet their health care goals. 

LeTicia, a patient working with Bethany Goff, MSW, LCSW, found the information she was provided about mental health therapists useful. 

“Bethany has been extremely helpful and I talk to her every other week,” LeTicia says. “I feel more in control now and can also call her when I need her.” 

ACO patients can check in by phone for peace of mind

Tinika Bunch

Tinika Bunch, LPN, listened carefully to her new BJC Accountable Care Organization (ACO) patient as she took the patient’s medical history by phone. The patient suffered with chronic obstructive pulmonary disease (COPD), and was always short of breath and often home alone. Bunch, an ACO care partner, immediately thought of a new program offered at no cost to patients through BJC ACO. 

The program, called Epharmix, is a phone check-in service for those with COPD and congestive heart failure. Signing up for the service is optional, but it’s a way a patient’s primary care physician team can stay up-to-date with the patient’s  lung and heart health.

“I explained the program to the patient and that I thought it would be perfect for her. She was very excited about getting started,” Bunch says. “The patient said she felt better knowing she would be called twice a week, and a care partner would call her if she indicated that she was in distress. It’s a great benefit to have a program that will assist patients, especially patients who may not have family or friends who can check up on them on a regular basis.”

Patients receive computerized phone calls or text messages asking about their breathing, swelling in their legs, weight gain and their quality of life. Answering is fast and easy and keeps their primary care physician team informed of their lung and heart health.

If patients call the service, it connects them to their BJC ACO care partner. Calls begin two times per week soon after they enroll, and patients can opt out at any time. 

“This product is not intended to replace the communication that patients have with their provider,” Bunch says. “Instead, it provides them and their families with a little extra peace of mind.”

Visit www.bjcaco.org for more information.

Karen Gallagher, karen.stewart@bjc.org

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