Truehelm portfolio company CareConnectMD is a leader in value-based care for long-term care. The company is an integrated primary care focused medical group and value-based care enablement platform focused on providing better care to high needs, long-term care populations. The company has provided direct care to patients for 30 years and has developed a proven value-based care model designed to support skilled nursing facility and long-term care operators and providers. This article by CareConnectMD CEO and Founder Kim Phan provides insights into how better care can be delivered at a lower cost through intentional innovation.
The U.S. healthcare system is full of paradoxes. Take the label itself: What we refer to as a single “system” is actually a highly fragmented and complex marketplace. Healthcare outcomes are worsening, even while healthcare spending is skyrocketing (The Commonwealth Fund). And for a system that devotes so much time and energy to extending life, it often fails to adequately address what end of life should look like or how to meaningfully support patients and their families on that journey.
Addressing that particular paradox – and bringing dignity to fragility – is the mission of CareConnectMD. We specialize in serving a high-needs population approaching the end of life, an often overlooked and underserved population. We do so in a way that also supports other important goals of our healthcare system, such as improving the quality of care, reducing overall costs, and enhancing the experience of both patients and providers.
This high-needs population includes frail, immobile patients with multiple complex chronic conditions in the last years of their lives. Most of these patients receive care primarily through hospital systems or skilled nursing facilities (SNFs). Their care is often highly uncoordinated, contributing to not only high costs and poor outcomes, but also reduced quality of life and undue stress on their families. This population comprises the majority of the 5% of the U.S. population that accounts for around 50% of total healthcare spending (Agency for Healthcare Research and Quality).
The Potential for Value-Based Care
Given the complex medical needs of this high-needs population and the fragmented nature of their care, they are ideally suited for value-based care (VBC) models. This model shifts the focus from volume of services delivered to quality of patient outcomes, encouraging providers and operators to coordinate care, improve outcomes, and enhance overall patient health. The Centers for Medicare & Medicaid Services (CMS) has committed to transitioning all Original Medicare patients into value-based programs by 2030. As part of this effort, CMS introduced the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model, specifically designed to improve VBC access to this high-needs population and other underserved communities. CareConnectMD is proud to be one of only 14 participants nationwide selected to lead this initiative.
However, despite the clear potential for VBC with this high-needs population, transitioning to a value-based model is challenging for many healthcare providers because it requires significant changes in care delivery, data management and financial models. Individual providers and groups often lack the resources and expertise to navigate this complex transition successfully.
CareConnectMD’s Success as a VBC Facilitator
That’s where CareConnectMD delivers unique value to both providers and their patients. We support the transition to VBC, aligning all parties around common goals and providing critical expertise and resources that allow physician groups and operators working with high-needs patients to successfully make the transition to a value-based model.
We’ve developed a highly effective accountable care model that enables the type of proactive, team-based care that is critical for high-needs patients but difficult to deliver in a fee-for-service system. We offer clinical support and care coordination, operational guidance, technology-enabled care and insights, and financial support to providers and operators.
Our approach has consistently reduced care costs and improved patient outcomes. In fact, CareConnectMD was the top-performing High-Needs ACO REACH for the most recent finalized performance year (2023), with a gross savings rate of 29.5%. We also earned top scores in key care quality measures, ranking in the 90th percentile in avoiding unnecessary hospitalizations, and ranking in the 98th percentile in avoiding re-hospitalizations.
A Track Record of Enhancing Care and Outcomes
Those strong results showcase the effectiveness of our patient-centered approach in the ACO REACH program. But it’s not a new strategy for us; CareConnectMD has been delivering compassionate, outcome-driven care for high-needs patients for decades.
My personal passion for caring for high-needs patients took root early in my life, when I supported my father during his late-stage cancer treatment. I witnessed firsthand the challenges high-needs patients face in navigating a fragmented healthcare system. That experience inspired me to focus my career on bringing compassionate care to sick and vulnerable populations.
Nearly 30 years ago, I founded CareConnectMD to deliver direct, compassionate care to medically complex patients in Southern California. Over time, based on our deep understanding of the unique needs of these patients and their families, we developed a highly successful and scalable value-based model. Our approach offers proactive patient care; provides support for clinicians; and aligns payers, providers and patients around shared goals.
As a leader in the industry’s transition to value-based care, CareConnectMD was an early first–mover in CMS’s ACO programs, long-term care Medicare Shared Savings Program (MSSP) ACO and High-Needs ACO REACH.
Today, in addition to providing direct care to patients in California, we are bringing our successful model to entities that provide long-term care nationwide. As a leading VBC facilitator, and consistently one of the top-performing ACO REACH groups, CareConnectMD offers a unique combination of clinical support and care coordination, technology-enabled care and insights, and expert operational services to physician groups and SNFs, enabling their successful transition to a value-based model.
The Path Forward
While the landscape has evolved since CareConnectMD was founded in 1996, our goal—revolutionizing healthcare for vulnerable populations—has not. What has changed is our approach to achieving that goal, especially for high-needs populations.
CareConnectMD is dedicated to redefining long-term care for high-needs patients by fostering stronger connections and collaboration among healthcare providers and facilities. Our approach centers on delivering personalized, value-based care that addresses each individual’s unique needs and driving better outcomes and improved quality of life. The idea is to align care strategies so providers and payers can work cohesively toward shared goals and ultimately, reduce unnecessary costs while improving clinical outcomes and enhancing the lives of patients.
As the healthcare industry evolves, CareConnectMD isn’t merely adapting to change—we are driving it. We take pride in our success over the decades and remain determined to advance care for this important high-needs population.
1) The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.