About the Adirondacks ACO
The Adirondacks Accountable Care Organization (ACO) was established in 2013 to carry on the transformational work of the Adirondack Medical Home Pilot (AMHP), which was created with the support of Adirondack Health Institute. This foundational work transformed the way that primary care is delivered in the Adirondack region of the New York State. With a growing focus on rewarding providers based on the generation of “value” versus rewarding primarily based on volume, the region’s five key hospitals partnered with the region’s primary care providers including the region’s largest FQHC to build a physician-led, physician-governed clinically integrated network. The foundation of this partnership positioned the region to focus on performance-based contracts with commercial health plans, Managed Medicaid Organizations, and Medicare Innovative Programs. This clinically integrated network has a quality focus at its foundation and can also be referred to as an “accountable care organization”.
The Adirondacks Accountable Care Organization (ACO) works with 16 healthcare entities who provide acute care, primary care and pediatric care in Warren, Washington, Hamilton, Essex, Clinton and Franklin counties. Each of these participating physician groups are recognized by the National Committee for Quality Assurance (NCQA) as a New York State Patient-Centered Medical Home, a recognition which is renewed annually. Practices that earn NCQA Recognition have demonstrated a commitment to continuous quality improvement and a patient-centered approach to care, by establishing procedures for team-based care, 24/7 access to care and transitional care programs, with practice investments in technology and enhanced care coordination. Patients can be confident that the practice from which they receive care have been vetted based on industry-leading best practices. Many payers utilize NCQA Recognition as a gold star to select providers for quality-based incentive payments.
The Adirondacks ACO has focused our efforts on continuous improvement activities targeted at improving the patient experience of care, reducing per capita costs and improving the health of the populations we serve.
Adirondacks ACO Model
The Adirondacks ACO model is made up of four essential priorities that we refer to as the “Quadruple Aim” of the ACO.
Improve the quality of care in our communities
At the Adirondacks ACO, we continually look for improvement opportunities that may not be obvious for our network. We identify these opportunities by utilizing data from our network and our federal and commercial health plan partners. With the findings of this information, we analyze and develop the best practices for improvement. This information is then shared via interactive reports and implemented among our hospitals, independent medical practices, and community providers to help support providers as they work toward common goals for the region, a healthier community.
Increase patient satisfaction
We love our communities, and we want them to thrive and be happy and healthy. We continue to work vigorously to ensure that patients are getting the right care at the right time, in the right location. We understand that access to health care is challenging in rural areas such as northern New York and Adirondack’s region, so we have created partnerships to offer patients more accessible and integrated community-based resources. We strive to understand patients’ needs and help providers improve their care. We look at not just patient health but the person’s overall wellbeing. We know that when patients are well cared for, and when we focus on prevention and disease management in addition to treatment for illness and injury, patients live happier, more fulfilling lives.
Increase provider satisfaction
Providers, clinicians, and other health care professionals want to help and heal people, and we want them to have the time to give the best quality of care and not be overwhelmed with administrative bourdons. The goal of Adirondacks ACO is to support our provider teams by giving them the tools they need so they can spend more time with patients, delivering care. In a traditional fee-for-service payment system, the focus is on sickness care rather than wellness and health care. Providers generally are paid by the appointment and not for the outcome. We feel that partnering with insurance companies like Medicaid, and commercial payers under a value-based payment (VBP) model helps change the incentive to keep our community healthy. The network is then rewarded with shared savings. Positioning the focus on value, not simply volume.
AHI has been catalytic in the transformation of the health care system. As health care delivery, payment, reform, and policy continues to unfold in complexity, we are working to lead the charge to ensure our stakeholders are informed and engaged in the ever-changing process.
Make healthcare more efficient and cost-effective
Adirondacks ACO understands that when the cost of health care increases, families feel it. This means that it can ultimately deter some from seeking treatment when they need it most, leading to poor health. We want all individuals in our network to get the care they need and not have to worry. By working together with insurance companies like Medicaid and commercial payers, we look to make the system more efficient and cost-effective by paying for results instead of just medical transactions. We do this by helping our participating providers create a patient-centered environment focused on health outcomes rather than procedure volume. This approach is called value-based care, a model that ties quality measures to payments to promote excellent care for our network. In the long run, this will help reduce the cost of healthcare over time in our communities.
What is Value-Based Care?
Our main focus is moving our network from a volume-based to a value-based system. This volume-based model, commonly called fee-for-service that we commonly see in the health care industry, rewards the providers for seeing as many people as possible and ordering as many tests as possible. This ultimately drives up the total cost for health which impacts society as a whole. We achieve this by focusing on quality and intervention, ultimately lowering costs while delivering better health care.
Adirondacks ACO: Our Data
A Data-Driven Approach to High-Quality, Value-Based Care
At the Adirondacks ACO, our model centers on collaboration, transparency, and the strategic use of data to improve outcomes and reduce costs. We bring together 16 regional organizations to align care around patients, support providers with actionable insights, and create a system of accountability that leads to measurable results.
How We Use Data for Quality Improvement
Our model relies on a secure, centralized Client Data Warehouse (CDW) that integrates claims and clinical data from participating payors, providers, and the regional health information exchange (Hixny). This allows us to generate meaningful reporting that powers decision-making across our network.
We turn this data into action through:
- Interactive Dashboards: Real-time access to quality, utilization, and financial trends via our AHI Reporting Portal.
- Pre-Visit Planning Tools: Gaps-in-care reporting that supports point-of-care decision-making.
- Daily ED & Inpatient Alerts: Enabling timely follow-up and care coordination.
- Attribution & Performance Reports: Clear visibility into patient attribution and provider performance.
Driving Improvement Through Analytics & Collaboration
Our data and quality improvement infrastructure supports ACO performance in several ways:
- Quality Measurement & Reporting
We abstract, analyze, and report quality metrics across all ACO contracts including Medicaid and commercial payors. - Opportunity Identification
Utilization and clinical trends are continuously reviewed to uncover gaps, variation, and improvement targets. - Population Health Analytics
Insights are shared across the network to support care management, community health initiatives, and chronic disease interventions. - Education & Peer Learning
We host workgroups that foster a culture of continuous improvement. - Performance Monitoring & Accountability
Each participating organization is supported with custom reports and dashboards, and all are held to transparent expectations through our citizenship criteria, aligning financial incentives with measurable progress.
Case in Point: Diabetes Dashboard
In 2023, the Adirondacks ACO launched a Diabetes Dashboard to monitor performance across diabetic, prediabetic, and non-diabetic populations. This tool tracks KPIs such as HbA1c control, ED and inpatient utilization, and identifies actionable trends by provider or region, guiding population health strategies and interventions.
Proven Results
This model has contributed to consistently strong performance in state and national benchmarks, including:
Over 90th percentile performance in QARR and HEDIS quality measures across the region and demonstrated reductions in avoidable utilization and improved coordination of care.
Looking Ahead
As data capabilities evolve, so does our approach. The Adirondacks ACO is committed to ongoing innovation in analytics, care delivery, and stakeholder engagement, ensuring we continue to improve outcomes for the patients and communities we serve.