Risk stratification that drives shared savings
Predictive analytics across 125K+ beneficiaries driving $4.2M in shared savings for an ACO.
Reactive care management guarantees missed savings and missed patients.
The Challenge
An ACO managing 125,000 Medicare beneficiaries struggled to identify high-risk patients across multiple EHR platforms (Epic, Cerner, Allscripts). Care management teams allocated resources reactively—after hospitalizations—rather than proactively. Quality scores lagged peers, shared savings targets were missed for two consecutive years, and care managers spent more time assembling patient profiles than intervening.
The Innovoco Solution
We built a predictive analytics platform that integrates data from multiple EHRs, claims feeds, pharmacy records, and social determinant proxies. Chronic disease risk scoring, gap-in-care identification, and automated outreach workflows give care managers prioritized action lists grounded in clinical evidence.
Phase 1 — Data unification and risk model
Harmonized patient records across three EHR platforms using FHIR and custom ETL. Trained risk models on 36 months of claims and clinical data, validated against actual utilization with clinician review of top-decile predictions.
Phase 2 — Care management integration
Embedded risk scores and care gap alerts into existing care management workflows. Automated outreach for preventive services (annual wellness visits, A1C screening, medication adherence) with attribution tracking to measure intervention effectiveness.
Key implementations
Multi-EHR data harmonization
FHIR-based integration layer normalizes patient records across Epic, Cerner, and Allscripts without requiring EHR customization.
Chronic disease risk scoring
Ensemble models predict 12-month hospitalization risk for CHF, COPD, diabetes, and CKD—updated weekly as new clinical data arrives.
Gap-in-care engine
Rules and ML surface overdue screenings, missed medications, and incomplete care plans against HEDIS and ACO quality measures.
Attribution and impact tracking
Every outreach and intervention is logged with downstream utilization outcomes, enabling cost-per-avoided-event calculations for shared savings reporting.
Clinician-facing dashboards
Care managers see prioritized patient lists with risk drivers, recommended actions, and contact history—not raw model scores.
Technical Innovation
The platform queries across EHR systems without centralizing all patient data in one place—reducing compliance scope while enabling cross-system risk scoring. Models update incrementally on weekly data rather than requiring expensive full rebuilds.
Impact
- 30% reduction in care management costs through better targeting of high-risk patients.
- 22% increase in preventive care completion rates across the beneficiary population.
- $4.2M in shared savings generated in the first full performance year.
- Quality scores improved from below-median to top-quartile on five of eight ACO measures.
The ACO shifted from reactive to proactive care management—interventions reach the right patients before acute events, and shared savings fund further program expansion.
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