BJC Accountable Care Organization

While they only talk by phone, an ACO patient knows she has a friend at the end of the line when she talks to Scotty Duranceau, BSN, RN. 

“We have absolutely formed a friendship,” says Connie, a BJC Accountable Care Organization (ACO) patient about her care partner.  “I just love Scotty to death. He is so professional yet personal. He makes me feel so much better.” 

Connie, who worked in health care in the past, has been dealing with multiple health issues and has been helped by Duranceau for about nine months. 

The feeling between the two is mutual. When asked about his patient, Duranceau replies enthusiastically. “She is great. We have absolutely formed a friendship and sometimes talk every other day. We discuss diet and exercise, and all kinds of things. She is limited on what she can do because of breathing issues, so I’m a support for her when she is having difficulties. She does what she needs to do but if it’s not working, I encourage her to ask for help.” 

The Care Management program is a part of BJC ACO. The program is delivered by a team of dedicated nurses, social workers and care coaches who provide outreach to patients by phone.  

Duranceau helps Connie with planning, understanding her health issues and he serves as the go-between with she and her doctor. Care partners work with providers to help individuals with chronic medical conditions overcome barriers to achieving improved health by promoting self-management with patients. 

“When I talk to him, I just feel better,” Connie says. “I’m sick, trying to do things to help myself, and Scotty helps. I am so happy to have this service that I tell everyone about it.” 

More on the Care Management program 

The Care Management Program is a voluntary service provided to Medicare patients of BJC ACO participants. Patients who don’t wish to participate in the program can opt out at any time. Eligible patients are identified by chronic conditions, risk levels using historical claims data and hospital discharge information. 

Providers may also refer patients into care management by contacting (314) 996-7020 or toll-free (844) 996-7020 or by submitting an ambulatory referral to ACO care management in Epic. 

Kathleen, 57, was a frequent user of Christian Hospital’s emergency room, always arriving by ambulance. She was a smoker with swallowing issues and breathing problems–and was unable to leave her home for very long. 

How Kathleen's nurse care manager helped: 

• Working jointly with the Community Health Access Program (CHAP) at Christian Hospital that uses a paramedic to visit patients in their homes, the nurse care manager identified key issues for improvement 

• Issues such as trash build-up, which was due to Kathleen’s inability to walk to the dumpster, and other medical and psychiatric issues were addressed to improve her quality of life 

Kathleen's patient testimony:  

• Kathleen has gone from only eating ice cream to eating healthy meals and has decreased her smoking 

• She has a cleaner home with better air quality and is now able to walk to the drug store to pick up her prescriptions 

• Her calls to 911 have dropped from five times in a week to no calls over four weeks 

• She is keeping her doctor appointments and has not been to the ER for three months 

Sandra had been a frequent user of emergency services for symptoms she believed were urinary infections. The nurse care manager contacted Sandra following one of these ER visits and developed a rapport.

How Sandra's nurse care manager helped: 

• With comfort and trust, Sandra began calling her nurse with questions rather than just going to the ER

• They found her symptoms were from a variety of causes, including medication side effects; Sandra is now seeing her primary care physician regularly and being treated for chronic back pain 

Sandra's patient testimony: 

• She has also given up smoking and the medication side effects are better-controlled with a few changes 

• She has not been back to the emergency department for a year 

When Dee was discharged from a rehabilitation facility after having her leg amputated, a nurse care manager reached out to her to help her adjust to the changes in her life. 

How Dee's nurse care manager helped: 

• She was able to move Dee’s follow-up appointment with her primary care physician to three weeks sooner than originally scheduled 

• She was able to arrange transportation so Dee could keep her appointment 

• Within the week of her discharge, the nurse set up BJC Home Care Services to provide visits and rehabilitation in her home 

Dee's patient testimony: 

• Dee was very happy with the help she received transitioning into new routines 

• She was able to find a new place to live with improved accessibility 

Don, 36, had been hospitalized six times in under a year for congestive heart failure (CHF). After his last hospitalization in January 2014, a nurse care manager contacted him and followed him for the next five months. 

How Don's nurse care manager helped: 

• She taught him about his disease, following a proper diet, and how to take his medication correctly 

• When she discovered that he was not keeping his doctor appointments with his primary care physician because he did not feel comfortable with the doctor, she found a new one he was comfortable with 

• She helped him quickly see the doctor, and he has continued to take his medication and keep all of his follow up appointments 

Don's patient testimony: 

• He loves how he now feels 

• He has not had any more issues or hospitalizations to date