Sheela for ACOs
Drive quality, manage costs, and coordinate care across your ACO network
Accountable Care Organizations succeed by coordinating care, closing quality gaps, and managing total cost of care. Sheela empowers ACOs to proactively engage patients, ensure care plan adherence, and prevent costly complications - all at scale! From preventive care outreach to post-discharge follow-up, Sheela helps you maximize shared savings while improving patient outcomes.
Key Use Cases for ACOs
Care Gap Closure
Automated outreach to patients with open quality measures (mammograms, A1C tests, etc.)
Transitions of Care
Post-discharge calls within 24-48 hours to reduce readmissions and ensure follow-up
Medication Adherence
Regular check-ins with chronic disease patients to ensure medication compliance
High-Risk Patient Monitoring
Proactive monitoring and outreach to patients at risk for hospitalization
Annual Wellness Visits
Schedule and remind Medicare patients about AWV completion
Chronic Disease Management
Regular touchpoints for diabetic, CHF, COPD, and other chronic disease patients
PCP Attribution Management
Help patients select and maintain relationships with primary care providers
Care Coordination
Coordinate care between PCPs, specialists, and other care team members
Social Determinants Screening
Identify social needs and connect patients with community resources
Benefits
Maximize Shared Savings
Improve quality scores and reduce costs to earn maximum shared savings payments
Reduce Readmissions
Post-discharge follow-up reduces 30-day readmissions by 15-25%
Improve Quality Scores
Automated gap closure drives MIPS, MSSP, and ACO REACH quality measure improvement
Lower Total Cost of Care
Preventive outreach and care coordination reduce ER visits and hospitalizations
Scale Care Management
Extend care management reach without proportional increases in staff
Patient Engagement
Higher patient activation leads to better adherence and outcomes
Quality Measure Focus Areas
Preventive Care Measures
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Cancer Screenings - Breast, colorectal, and cervical cancer screening outreach​​
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Immunizations - Flu shots, pneumonia vaccines, and COVID-19 vaccinations​​
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Annual Wellness Visits - Medicare AWV scheduling and completion​​
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Depression Screening - PHQ-9 administration and follow-up
Chronic Disease Management
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Diabetes - A1C testing, eye exams, kidney function monitoring
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Hypertension - Blood pressure control and medication adherence
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Heart Failure - Daily weight monitoring, symptom tracking, medication compliance
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COPD - Pulmonary rehabilitation participation, medication adherence
Care Coordination Measures
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Post-Discharge Follow-up - Ensure timely PCP visits after hospitalization and avoiding readminssions
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Medication Reconciliation - Post-discharge medication review
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Specialist Coordination - Ensure communication between specialists and PCPs
