46 Population Health Management NHAccountable CarePartners As a partner in New Hampshire Accountable Care Partners (NHACP), Concord Hospital continues its work with eight other New Hampshire healthcare organizations to provide Medicare patients more coordinated, higher quality care, while managing costs. NHACP members include: Concord Hospital, Catholic Medical Center, Concord RegionalVisiting Nurse Association (CRVNA), Exeter Health Resources, Mid-State Health Center, Southern New Hampshire Health System, Elliot Health System, Riverbend Community Mental Health andWentworth-Douglass Hospital. Fifty-five thousand Medicare beneficiaries are assigned to the Accountable Care Organization (ACO) based on an existing relationship with a participating provider. Final performance results for NHACP shared savings program in 2016 show 94.5 percent quality performance, which is approximately five points higher than the previous year. NHACP continues to focus on enhanced care coordination for high-risk patients, working closely on transitions of care with post-acute care partners such as CRVNA and skilled nursing and rehabilitation facilities, improving processes by standardizing best care practices and engaging patients in prevention and self-management. Under the Medicare Shared Savings Program (MSSP), NHACP partners have the opportunity to share in any savings realized by the Medicare program.The savings are calculated by looking at the difference between an ACO’s annual benchmark costs and its actual patient care costs for services provided under strict performance requirements.The ACO also realized more than $6 million in savings for Medicare in the last year, which brings the ACO closer to achieving its shared savings goal. ConcordHospitalcontinuestoutilize datatobetterunderstandtheneedsof ourpatientsanddevelopprogramsand servicestopromotelifestylechanges andinterventionsaimedatlowering individualriskandimprovinglifequality. CapitalRegionHealth CareEnterpriseCare CoordinationSteeringGroup One of the top two illnesses that lead to patient readmission to Concord Hospital is chronic obstructive pulmonary disease (COPD). As a result, the newly formed Capital Region Health Care Enterprise Care Coordination Steering Group has created a COPD Collaborative to develop a comprehensive system’s approach to complex care management for patients with COPD. The Collaborative includes Concord Hospital, Concord Hospital Medical Group (CHMG), Genesis Healthcare, CRVNA and Riverbend Community Mental Health. Additional community partners will be added as needed to enhance services offered to this patient population. The Collaborative has completed a complex patient‘care asset’mapping exercise that highlighted the wealth of resources available from all partners. Partners also shared preliminary data on the current state of the COPD population. Based on our collective findings, it was determined that the initial target would be the current top five percent of the 1,900 CHMG patients diagnosed with COPD.The highest- risk patients have many other chronic conditions, including heart failure and diabetes, which also increase their risk of readmission to the Hospital. Our goal is to ensure that working together, each patient is provided with a personalized care plan, consistent education to improve their self-management skills and connections to supportive services and programs that exist in our community and health system. More effective disease management and care coordination will improve outcomes of COPD patients, reduce Emergency Department and Hospital readmissions and support our transition, over time, to a value- based payment model.