Community Care Partnership of Maine Accountable Care Organization
Need: To increase access and quality of care for Medicare, Medicaid, uninsured, and commercial patients in rural Maine.
Intervention: Community hospitals and Federally Qualified Health Centers in Maine formed the Community Care Partnership of Maine Accountable Care Organization (CCPM ACO).
Results: CCPM serves about 100,000 patients in Maine. In addition, it implemented ACO shared savings plans with Maine Medicaid, Medicare, and five commercial health insurance and Medicare Advantage plans in the state.
The Community Care Partnership of Maine Accountable Care
Organization (CCPM ACO) began in August 2015 and became a
Medicare Shared Savings Program ACO in January 2016. The
ACO began when Penobscot Community Health Care (PCHC) and
St. Joseph Healthcare in Bangor partnered together. This
Federally Qualified Health Center (FQHC) and community
hospital, respectively, then invited rural community
health centers and community hospitals to join.
While collaborating with major healthcare facilities in
Bangor and Portland, the rural facilities in this ACO
still maintain independence. Each member organization is
considered a joint owner in CCPM and receives one vote in
decision-making, whatever the organization's size.
CCPM uses a health information exchange (HIE) called
share patient information among the hospitals and FQHCs.
This HIE allows the facilities to provide
better-coordinated care to their patients and to collect
population health data. In addition, the HIE provides
real-time predictive analytics in order to predict (and
work to prevent) readmissions. Through the RWJF grant
resources, CCPM is working to incorporate social
determinants data from two regional community action
CCPM also allows member organizations to share services
in order to reduce costs and duplicated services. Rural
organizations do not have to "reinvent the wheel" when
they can borrow another organization's expertise or
CCPM is a forum for sharing best practices on how to help
patients be as healthy as possible and how to help reduce
unnecessary emergency department visits or
hospitalizations. Rural member organizations particularly
like how monthly sharing with their peers reduces rural
isolation and provides collegial support.
CCPM hosts a Complex Case Review Group. Biweekly meetings
follow a case presentation format in which presenters
outline a patient's background, demographics/social
history, pertinent clinical history, and social
determinants of health and then solicit recommendations
from an interdisciplinary team of experts that includes
pharmacy, psychiatry, care management, and social work.
CCPM also offers a Pharmacy Consult service to prevent
adverse drug events via medication reconciliation.
CCPM also created a Skilled Nursing Facility
Collaborative to partner with skilled nursing facilities
as well as a patient diagnostic code workgroup to educate
billers, coders, and clinicians on the importance of
accurately capturing diagnosis code information.
In 2019, CCPM launched Pharmacy Consults as a benefit of
ACO membership. Any patient of its 17 member
organizations is eligible to receive this service. CCPM
employs a Clinical Pharmacist to support this service
line. Upon referral, the Clinical Pharmacist performs a
comprehensive medication review and issues
recommendations that includes:
Changes in the medication regime
Instructions for monitoring for specific desired (or
Suggestions for management of
potentially inappropriate medication use
In 2019, CCPM began onboarding and training medical
assistants (MAs) to support its member organizations with
pre-visit planning. CCPM's centralized MAs are specially
trained to provide comprehensive pre-visit planning,
reducing administrative burden and freeing up time for
both the provider and MA.
CCPM offers medication-assisted treatment (MAT)
consultation on a contracted basis to interested member
organizations. In addition, CCPM offers a free online
Continuing Medical Education (CME) Series as a benefit of
ACO membership. Any employee of the 17 member
organizations is eligible to access the library of
AMA-accredited CME modules, many of which are tailored to
an FQHC audience.
Over the course of several years, CCPM has implemented a
complex LLC legal structure, compliance program,
organization, and financial structure. CCPM also covers
about 100,000 patients in Maine.
CCPM completed its fifth year of a shared savings
contract with Medicare in December 2021. In addition, it
has implemented shared savings arrangements/contracts
with the health payers Anthem, Anthem Medicare Advantage,
Aetna, Harvard Pilgrim, and Cigna. The ACO anticipates a
similar arrangement with another Medicare Advantage Plan
in the next few months.
In 2016, CCPM had a savings of $4.3 million in the
Medicare Shared Savings Program (MSSP). In 2017, this
savings was over $8.8 million. In 2018, CCPM generated
over $17.2 million in savings under the MSSP, resulting
in about $7.4 million shared savings for CCPM, which was
then distributed back to its participating member
organizations. This success continued in 2019 and 2020.
CCPM is the only ACO in Maine, and one of a handful of
ACOs nationwide, to have achieved shared savings for 5
consecutive years (2016-2020).
The ACO was named a 2016 Case Study in Innovation by the
American Hospital Association and presented its work at
the AHA Rural Health Care Leadership Conference in
While CCPM views its vast geography spread across the
state as a strength, it recognizes that the distance
poses some logistical barriers. To overcome these
barriers, CCPM hosts the majority of its committee
meetings virtually to reduce travel time for attendees, a
practice that allowed it to continue operations during
the ongoing COVID-19 pandemic.
CCPM also contends with the use of multiple electronic
medical records (EMRs) across its 18 member
organizations, which at times poses challenges in
starting new initiatives.
Some member organizations had tried other ACO models but
felt that they didn't "fit" into these work cultures.
CCPM was a better fit because the member organizations
shared similar values, like focusing on their
communities' immediate needs.
CCPM also credits its long-standing success to the
leanness of its organizational structure. All of CCPM's
officers fulfill their role in a part-time capacity while
also serving in a separate role at one of its member
Mary Prybylo, RN, MSN, FACHE, CEO
Community Care Partnership of Maine
Accountable Care Organizations
Federally Qualified Health Centers
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