Guide Manual Blueprint for Success: Implementing
Accountable
Care Organization
in Our Communities
The Covenant Health Network Senior Care in Motion program’s mission is to seamlessly support senior wellness through a clinically integrated care model and collaborative partnerships, employing best practices to enable seniors to age in place.
Strategic Direction
Aim: Increase the number of beneficiaries in a care relationship with accountability for quality and total cost of care.
Accountable care reduces fragmentation in patient care and cost by giving providers the incentives and tools to deliver high-quality, coordinated, team-based care. Models should increase the number of beneficiaries in accountable care relationships with providers, such as advanced primary care providers and ACOs. Quality of care and outcome measures should be meaningful and include patient values and perspectives.
By 2030, ALL MEDICARE FEE-FOR-SERVICE BENEFICIARIES will be in a caring relationship with accountability for quality and total cost of care.
THE VAST MAJORITY OF MEDICAID BENEFICIARIES will be in a caring relationship with accountability for quality and total cost of care by 2030.
By 2030, an estimated 67 million Americans aged 65 or older will be enrolled in Medicare—an increase of more than 27 million elderly beneficiaries from 2010. The most significant growth will occur among 65-to 74-year-olds.1
1 https://www.cms.gov/priorities/innovation/about/strategic-direction
Collaboratively Committed to Provide
This Manual is the property of Covenant Health Network. It was produced exclusively for Covenant Health Network’s members. Portions of this guide manual cannot be reproduced without written permission from Covenant Health Network, 20860 North Tatum Blvd. Suite #300, Phoenix, Arizona 85050
Table of Contents
Introduction
Covenant Health Network
CURANA Health
Best Practices
1.) Launching CURANA Health in the Community
Pre-Implementation Required Task
Engaging Key Stakeholders
Navigating ACO Partnerships
2.) Utilizing a High-Quality Network of Preferred Providers
Purpose of a High-Quality Network of Preferred Providers
Referring to the High-Quality Network of Preferred Providers
3.) Establishing Successful Collaborative Communications Between CURANA Health and Community
Community CURANA Champion
CURANA Care Concierge Role
Key Communication Workflows:
• New Admission Workflow
• Scheduling CURANA Health Appointments
• Workflow of Provider Visit
4.) The Covenant Senior Care in Motion Program’s Standard of Practice: To Achieve Community and CURANA Health Collaboration in Accountable Operations
Purpose Statement
Increasing awareness of CURANA Health’s MSSP Quality Metrics
Increasing awareness of the Community’s Quality Performance Metrics
Commitment to Quality Assessment and Assurance Standards
5.) Creating a Community and Curana Health Engaged Culture
The Staff and Resident Ambassador Program
6.) Definitions
Population Health
Physician-Led Accountable Care Organization
Medicare Shared Savings Program
Appendix
A. Guides: Best Practices, Processes, Resources, and Tools
B. Alliance Purchasing Network
Covenant ealth et or C ill o timi e re o rce rovi e to it mem er hi , ort mi ion riven enior erving rovi er an net or an create artner hi e igne to enhance alit an inancial e iciencie
CURANA Health a clinically integrated delivery system and Accountable Care Organization plays a key role in bringing the ‘Senior Care in Motion Program’ to life as part of this innovative approach. By leveraging its network and resources, CURANA ensures that high-quality care is seamlessly delivered within its communities
Campus Communities, CURANA Health Accountable Care Organization (ACO), and a Network of High-quality preferred providers share common goals:
• To achieve improved clinical outcomes
• Increased patient and family satisfaction
• Reduced total cost through implementing best practices.
• Consistent metrics and comparison against benchmarks
• Utilize evidence-based processes and innovative technology to maintain resident wellness and health, and
• Implement a process of continuous improvement.
“Being in the Right Place, at the Right Time, to Receive the Right Care”
1) Launching CURANA Health in the Community
Pre-Implementation
Overview
To become an authorized CURANA Health Provider, each community must complete specific documentation initiated by CURANA Health, which will be sent via email.
Required Agreements
1. Joinder Agreement: Establishes the foundational partnership.
2. Facility Staffing Agreement: Outlines the terms of on-site clinical care services (Skilled, Personal Care, and Independent Living)
3. Resident Services Agreement: Details services provided to residents. (Independent and Personal Care or Medical Director in Skilled)
4. Medical Director Agreement: Outlines responsibilities of the Medical Director (if applicable).
5. Clinic Agreement: Specifies terms for operating an on-site clinic (if applicable).
Documentation Workflow
1. Initiation: CURANA Health prepares and sends the necessary documents.
2. Review and Approval: Recipients review and communicate any modifications.
3. Execution: Documents are signed electronically via DocuSign.
4. Finalization: Fully executed documents are stored securely and provided to the community.
Key Contacts
• CURANA Health Implementation Coordinator
• Community Designated Signatory
Engaging Key Stakeholders
Overview
A successful Accountable Care Organization (ACO) implementation relies on a well-structured communication program and the right stakeholders. Engaging the correct individuals ensures smooth adoption, enhances provider participation, and improves patient outcomes. This guide outlines the essential roles involved in a successful Accountable Care Organization (ACO) rollout, as well as the responsibilities that accompany them
Key Players in ACO Implementation
1. Administrators & Executive Directors
• Provide organizational oversight and strategic alignment.
• Secure necessary resources and promote program adoption.
• Ensure ACO initiatives align with broader healthcare objectives.
2. Directors of Nursing (DONs) & Clinical Leaders
• Lead patient care efforts and oversee clinical teams.
• Maintain high standards for care coordination and quality.
• Promote real-time utilization of ACO communication tools among staff.
3. Frontline Staff: Nurses, Care Coordinators & Medical Assistants (MAs)
• Serve as primary users of ACO communication systems.
• Foster patient engagement and continuity of care.
• Offer direct feedback for refining implementation strategies.
4. Provider Liaisons & Referral Coordinators
• Facilitate seamless care transitions between providers.
• Ensure alignment within the ACO network and external healthcare entities.
• Strengthen collaborative relationships between internal staff and partner providers.
5. Community Curana Champions
• Act as local program advocates and technical coaches.
• Support staff in navigating communication systems and workflows.
• Inspire engagement and drive adoption through education and motivation.
Building a Successful Implementation Strategy
1. Engage Stakeholders Early
Involve key individuals from the beginning to establish a foundation of collaboration and trust. By engaging stakeholders early, organizations can foster a sense of shared ownership and alignment toward mutual goals. This involvement ensures diverse perspectives are considered, paving the way for a smoother implementation process.
2. Set Clear Expectations
Define roles, responsibilities, and measurable goals to maintain focus and accountability. Clear expectations help eliminate confusion, streamline workflows, and empower teams to work cohesively. Setting tangible milestones ensures progress is tracked effectively and equips the team to address challenges proactively.
3. Encourage Continuous Feedback
Create an open feedback loop to refine processes and optimize communication tools. Continuous feedback enables teams to pinpoint areas for improvement and make necessary adjustments in real-time. It fosters a culture of transparency and collaboration, ensuring solutions remain relevant and impactful.
4. Monitor & Adapt Strategies
Track performance metrics and adjust strategies to enhance efficiency and improve patient outcomes. Regular monitoring provides insights into what works and what doesn’t, enabling organizations to remain agile and responsive. By adapting strategies while consistently meeting evolving needs, organizations can sustain long-term success.
1. Acknowledge and Validate the Relationships
• Recognize the history and importance of the existing provider relationships.
2. Explain the ACO’s Mission and Benefits
• The ACO aims to deliver the highest quality care while creating efficiencies that benefit everyone—patients, facilities, and providers.
• By working within the ACO’s network, we can maximize attributed lives and ensure the facility fully benefits from the shared savings program.
3. Highlight the Impact of Non-Network Providers
• Explain how maintaining relationships with non-network providers could affect outcomes:
• Using outside providers can reduce attribution, which directly impacts the program’s ability to succeed and diminishes the shared savings available for your facility.
• We need to optimize the attributed lives within the ACO to realize its benefits fully.
4. Focus on Collaborative Solutions
• Finding a path forward together. If there are specific providers you feel strongly about, explore ways to engage them in the network.
• The goal is to ensure continuity of care while aligning with the program’s objectives.
5. Provide Reassurance
• Reassure providers that the decision is not about severing ties but about advancing the collective mission:
o This is not about turning our backs on providers who have supported us, but rather about adapting to a system that ensures long-term success for our facility and residents.
• Value input and navigate this transition as smoothly as possible.
6. Offer Ongoing Support
• Emphasize a willingness to assist in this challenging transition.
• Whether discussing how to approach providers or addressing concerns about the ACO’s network.
Resources:
1. CURANA Health Launch Checklist (page 11)
https://cvhn.box.com/s/ja0exn7aeg0006nlqzmlp8r5pwgzneei
2. Standard of Practice: CURANA Health Engagement
https://cvhn.box.com/s/p1jod7tjgwrj87fje1bhdwisx2tfzwk5
3. Community Orientation Checklist for CURANA Health Personnel (pages 12 & 13)
https://cvhn.box.com/s/hqsct0gvd5563dwrft40dzar7jex8ioh
4. “Redefining Senior Care” Training Slides
https://cvhn.box.com/s/s72nprirc365309606i1d3y1hogaj9ot
TASK
IMPLEMENTATION PHASE
Initial Executive meeting Introduction to the Implementation Team Contract Signatory
The Community Executive identifies the CURANA Clinic space.
CURANA Health Launch
The CURANA Implementation team provides projections & schedules for clinic completion.
Lead Community Staff receive an orientation to CURANA Health
• In-depth overview
• ACO, Pop Health, VBP
• Engagement Activities
• Marketing
CURANA and Community Lead staff will establish a schedule for weekly implementation check-in meetings. CURANA initiates the recruitment of a CURANA care team for the site.
30 days before the Resident meet and greet, the CURANA Care team is introduced to the Community Executive & Lead Staff Physician, Physician Assistant, and Nurse Practitioner Credentialing Completion CURANA Staff orientation to the community is scheduled and completed. The CURANA Practitioner & Community Executive identifies high-quality, preferred providers and service vendors to consider for engagement.
Selected service vendors and high-quality providers will receive an orientation to CURANA Health and Community’s mission for pop health, VBP, and marketing.
Meet-and-greet, Town Hall, and Resident Introduction events are scheduled. The Community can consider including the selected service vendors and high-quality providers in these events.
Community Orientation for CURANA Health Personnel
• Orientation will be specific to the CURANA Health Staff Position and the site of service: Skilled Nursing, Nursing Home Long-Term, Assisted Living and/ or Independent Living Communities
ORGANIZATION
Organization’s Mission, Vision, Purpose
COMMENTS
All
All Administrative Structure
Leadership: Name, Position, Contact, Service Provided
Designated Facility Care Coordinator: Name, Contact, and Location
Clinical Supervisors for Care Areas
Campus Grounds Map: Identifying Key Locations, Buildings, Apartments/Rooms
Designated Parking
Parking Sticker
Facility Entry Systems, Access Codes or Entry Keys
Resident Services Provided on Campus
Facility Resident Programs, Events
Facility Wellness Program
Facility Abuse Prevention Plan and Reporting Policy
Facility Emergency/ Disaster Plan
Facility Fire and Life Safety
Alarms, Exits, Extinguishers, Fire Pull Stations
Infection Control Program
HIPAA Requirements/ Corporate Compliance
Quality Assurance Plan and Meeting Schedule, and Location
COLLABORATIVE WORKFLOW
Meaningful Use EMR Requirements*
Ensure completion of the EMR Authorization Form
Training of Use
Internet/ Shared Drives
Request Triage Policy and Process
Request CURANA Health Contact List
Request Call Rotation/ Responsibilities
All
All
Listing provided
Facility Care Coordinator(s) Introduction *Key Facility ↔ CURANA communicator
All Key Unit/ Site Supervisor 24/7. Listing provided
All Map provided
MD/ NP The campus has the option to designate space
All If utilized.
All An entry device, if utilized, is provided & to be returned at time of exit.
All Campus Service Offered. Listing provided
All Annual Calendar and schedules provided
All Introduction to Wellness Program Manager
All
All
All
All Facility grounds toured
All
All
MD/ NP/OCC Schedule provided
COMMENTS
MD/ NP/OCC CURANA
MD/ NP/OCC
MD/ NP/OCC
Practitioners, CCM Team
Train the CURANA Trainer
MD/ NP/OCC As per Facility Protocol
Received: CURANA notification tree
Received: CURANA Contact List
Received CURANA Provider schedule
Request Coverage Schedule & Modification Notification
Received coverage schedule: Provider, Medical Assistant, Care Concierge Physician, Physician Assistant, and Nurse Practitioner Credentialing
Provide CHN/ Facility Standard of Practice:
High-Quality Preferred Provider Protocol CURANA Referral
Provide Care/ Plan Meetings (location/ frequency)
Provide Schedule for QA &A, Risk Meetings (location and frequency)
Daily Census report distribution
Chronic Disease Management- High Risk
Acute Care, Adverse Event
CURANA Personnel Name:
MD/ NP/OCC
MD/ NP/OCC
Received all required credentialing for assigned Medical Practitioners
MD/ NP/OCC
MD/ NP/OCC
MD/ NP/OCC
SNF/ NH/ AL specific schedules
COMMENTS
Key CURANA Personnel to receiveOCC/ MA
The process to alert a CURANA Practitioner
The process to alert a CURANA Practitioner
Position: ________________________________________________________________________________
Signature:
Orientation provided by:
Community Personnel Name:
Position:
Signature:
Date:
2)Utilizing a High-Quality Network of Preferred Providers
Purpose of Utilizing a High-Quality Network of Preferred Providers
To engage preferred providers who abide by the organization’s mission, vision, and values. CURANA Health ACO and CHN’s High-Quality Network of Preferred Providers will share resources, services, and expertise to enhance patient care and improve health outcomes. Key Requirements to include, but not limited to:
1. Meet specific performance quality benchmarks.
2. Board-certified, when applicable, and active licensure.
3. Strong patient safety records.
4. The specialty must align with ACO gaps and the needs of the patient population.
5. Compliance with reporting requirements for quality metrics and cost performance.
6. Engage in population health management and educational programs.
7. High patient satisfaction scores.
8. Adherence to state and federal regulations (e.g., HIPAA, Medicare, and Medicaid).
9. Participate in Resident, Staff, and family educational and facility-specific scheduled meetings.
To support the development of a high-quality network of preferred providers, communities will begin by completing a Provider Survey. This tool allows each facility to conduct an inventory of its current service providers across key areas. Once submitted, the survey data will be returned in the form of a provider matrix, showing up to three providers per service line. This matrix, in combination with the vetting guide, preferred provider agreement, and preferred provider protocol, can be used to evaluate whether current partners meet the standards for inclusion in the high-quality network. This process is designed to help facilities make informed decisions and align their provider network
Resources:
1. Provider Survey
https://covenantnetwork.qualtrics.com/jfe/form/SV_aacMhJyScGWHInY
2. High-Quality Network Provider Vetting Guide for ALF and SNF Sample
https://cvhn.box.com/s/v0v5uzvexx160cbql7brma1b1znkjase
3. High-Quality Network Preferred Provider Agreement
https://cvhn.box.com/s/n4ylipn7p19l3xdhyyz40000zehevu56
4. High-Quality Network Preferred Provider Protocol
https://cvhn.box.com/s/nhwbcyyftdsnos6qijfpotsp1q9v4ke2
Referring to CURANA Health ACO and High-Quality Network of Preferred Providers
Purpose:
CURANA Health ACO and its established network of high-quality service providers must demonstrate several key benefits that positively contribute to resident care and facility operations. These benefits contribute to a higher quality of life for the residents and a more efficient and effective system within the senior living community. Several key benefits include:
1. Improved Care Coordination: This ensures seamless transitions between various levels of care and services, reducing the risk of care fragmentation.
2. Enhance Quality of Care
3. Cost Efficiency: Coordinated care can help reduce unnecessary medical tests, hospitalizations, and other healthcare costs by providing timely and appropriate interventions.
4. Increased Resident Satisfaction
5. Streamlined Communication: Facilitates better communication between healthcare providers, ensuring all parties are informed and aligned on the resident's care plan.
6. Access to CURANA Health’s Comprehensive Services2
7. Extended Services from the High-Quality Network of Preferred Providers: In alignment with CURANA Health’s ACO value-based care program, extended services may include Home Health, Hospice, Rehabilitative Occupational, Physical, and Speech Therapy, Podiatry, Ophthalmology, Dental, and other services tailored to the individual resident's needs.
Measuring the Effectiveness of Referrals in senior living involves tracking several key metrics to ensure the referral process contributes positively to resident care and facility operations. Some crucial metrics and methods:
1. Referral Source Tracking
2. Resident Satisfaction
3. Health Outcomes
4. Cost Savings
5. Engagement and Participation
6. Feedback from Referral Sources 2 Accountable Care and Accountable Care Organizations
3.) Establishing Successful Collaborative Communication Between CURANA Health and Community Partners
Introduction
Effective communication and inclusivity are foundational to successful collaboration with CURANA Health. These principles enable coordinated care delivery and promote a culture of teamwork across all departments within senior living communities.
The Community CURANA Champion
The Community CURANA Champion is a key leadership role responsible for introducing and supporting the CURANA Health care model within the senior living environment. This individual ensures consistent implementation, coordination, and sustainability of new care delivery concepts.
Key Responsibilities:
• Provide leadership and clear direction for implementing CURANA Health programs.
• Foster collaboration and break down interdepartmental silos.
• Advocate for change, addressing staff and resident concerns.
• Monitor progress and adjust based on feedback and outcomes.
• Promote enthusiasm and participation among staff and residents.
• Encourage a spirit of teamwork and inclusivity.
The CURANA Care Concierge
The CURANA Care Concierge serves as a liaison between the community and CURANA Health, facilitating resident engagement, practitioner support, appointment planning, participation in community events, and management of care-related logistics and supplies.
Champion and Concierge
Collaborative Communication
Strong communication between the Community Champion and CURANA Care Concierge is essential for seamless care coordination and inclusive operations. This partnership ensures proactive, responsive care delivery.
Key Communications Include:
• Distribution and updates to patient appointment schedules.
• Notification of resident condition changes or adverse events.
• Coordination of emergency triage and follow-up reporting.
• Distribution of census reports reflecting admissions, discharges, and transfers.
• Sharing practitioner schedules and CURANA team availability.
• Information on community events and wellness programs.
• Coordination of marketing activities and outreach events.
Key Tasks Include:
• Schedule regular debriefing meetings between Champion and Concierge.
• Share collaborative meeting schedules for:
o Resident care planning
o Quality assurance
o Risk and safety
• Designate "Train the Trainer" roles to support ongoing education for CURANA and community staff on:
o EMR system access and documentation
o TigerConnect communication
o Referral processes and service provider coordination
o Access to advanced healthcare directives
o Emergency and life safety preparedness
Key Communication Workflows
1. Collaborative New Patient Admission
a. Referral Received
• Community notifies the CURANA Care Concierge.
• Community shares resident information (name, diagnosis, medication list, etc.) as needed.
b. Admission
• Community completes standard admission procedures.
• Champion informs Care Concierge of resident arrival.
• Care Concierge schedules an initial CURANA visit.
c. Ongoing Engagement
• Admissions, Marketing, and the Care Concierge collaborate to onboard new residents to both the community and CURANA Health services.
2. Scheduling CURANA Practitioner Appointments
a. Independent Living
• The patient, Practitioner, and Concierge Collaborate to create a resident-centered care plan and schedule visits
• Patients contact the Clinic or Concierge to schedule, modify, or cancel visits.
• For acute issues, patients contact the Concierge or the Clinic. In emergencies, patients call 911. Non-urgent changes are triaged for practitioner response within 48 hours.
b. Assisted Living
• AL Champion coordinates new admission visits through the Care Concierge.
• AL Champion receives regular visit updates from the Concierge.
• In acute cases, Champion calls 911. Non-urgent conditions are reported to the Concierge for triage and scheduling with a practitioner
c. Skilled Nursing Facility
• Visits are scheduled per facility policy in collaboration with CURANA protocols.
• Acute issues are directed to 911 by the Charge Nurse. Other problems are reported to the Concierge or CURANA Practitioner for triage within 48 hours.
3. CURANA Practitioner Visits
Practitioners conduct visits including:
• Preventive care to manage chronic conditions
• Annual wellness exams
• Medication management
• Palliative and acute care
• Coordination with external providers (e.g., home health, hospice, podiatry)
Following visits, practitioners provide a debrief to the Community Champion or Director, including:
• Medical, functional, or psychosocial risks
• Notable changes in condition
• Updates to the care plan aimed at preventing hospitalization
Conclusion
By designating clear roles, establishing communication workflows, and maintaining consistent collaboration between CURANA Health and community partners, senior living environments can deliver high-quality, resident-centered care that is proactive, coordinated, and sustainable.
4.) The Covenant Health Network Senior Care in Motion Program
Standard of Practice for Collaborative Accountable Care with CURANA Health
Purpose
The Covenant Health Network and CURANA Health are committed to providing care and services that are timely, safe, effective, person-centered, efficient, and equitable. A mutual understanding of value-based care programs within a clinically integrated senior living partnership is essential.
Why Understanding Value-Based Programs Matters
1. Improved Care Coordination – Enhances continuity across ACOs, SNFs, and Home and Community-Based Services (HCBS), ensuring consistent, high-quality care tailored to residents’ needs.
2. Enhanced Quality of Care – Shifts focus from volume to value, helping reduce readmissions and improve outcomes.
3. Financial Incentives – Enables partners to meet quality benchmarks and maximize shared financial rewards.
4. Regulatory Compliance – Aligns with Medicare and Medicaid requirements, supporting ongoing funding and avoiding penalties.
5. Holistic Patient Care – Promotes an integrated approach that addresses medical, behavioral, and social needs, particularly within Assisted Living and Home and Community-Based Services (HCBS) settings.
Collaborative transparency in performance metrics helps elevate care, achieve financial goals, and improve outcomes.
CURANA Health’s Medicare Shared Savings Program (MSSP)
CURANA Health ACO participates in the Medicare Shared Savings Program to provide highquality, coordinated care while reducing unnecessary costs, adding measurable value to both the community and the CURANA partnership.
Success Criteria - Meet or exceed Medicare-defined cost savings thresholds. - Perform well in the following shared savings quality metrics: - Patient Experience - Care CoordinationPreventive Health - Chronic Disease Management
Attribution Process - Beneficiaries assigned to CURANA Health - CURANA delivers the majority of their care - Communities may receive shared savings allocations based on aligned performance
Community Quality Performance Metrics
Skilled Nursing Facilities (SNFs): - CMS Care Compare 5-Star Ratings, including: - Health Inspections - Short- and Long-Stay Quality Measures - Staffing - Rehospitalization RatesState-specific Medicaid Value-Based Quality Metrics
Assisted Living / HCBS: - State-specific Medicaid Value-Based Quality Performance Metrics (Currently under review or development in some regions)
Commitment to Quality Assessment & Assurance Standards
To sustain high performance and continuous improvement, Community and CURANA Health agree to:
1. Establish and track key performance benchmarks.
2. Conduct operational and clinical KPI reviews quarterly (at minimum) and annually.
3. Analyze results to identify strengths, weaknesses, and improvement opportunities.
4. Collaborate on targeted improvement plans.
5. Implement changes that may include:
o Updates to clinical and operational standards of practice.
o Educational programming aligned to Key Quality Indicators (KQIs), including:
▪ Onboarding for new hires
▪ Ongoing staff training and in-services
o Resident education calendars and wellness events centered on KQIs.
5) Creating a Community and Curana Health Engaged Culture
The Staff and Resident Ambassador Program
Purpose:
To engage staff and resident ambassadors in promoting awareness and participation in the facility’s Physician-led CURANA HEALTH, supporting growth in the patient panel through peer influence, education, and trust-building.
Program Goals
• Educate residents and families about the benefits of participating in CURANA HEALTH.
• Increase resident engagement with the campus’s healthcare services.
• Improve care coordination and outcomes through higher resident participation.
• Foster a sense of ownership and trust between residents, staff, and CURANA HEALTH physicians.
1. Ambassador Roles and Responsibilities of an Ambassador
Resident Ambassadors
• Serve as peer influencers and trusted voices.
• Share their personal positive experiences with the CURANA HEALTH care model.
• Help new and current residents understand CURANA HEALTH benefits (e.g., coordinated care, wellness visits, continuity of care).
• Participate in CURANA HEALTH awareness events, town halls, or orientation sessions.
• Encourage residents to discuss joining with staff or CURANA HEALTH representatives
Staff Ambassadors
• Reinforce CURANA HEALTH messaging in daily interactions.
• Identify residents who may benefit from or be interested in CURANA HEALTH participation.
• Serve as liaisons between residents and CURANA HEALTH physicians.
• Assist with coordinating informational sessions or distributing materials.
• Celebrate and share success stories internally.
2. Selection Criteria
Resident Ambassadors Should Be:
• Well-respected, socially active residents
• Comfortable speaking with peers
• Participants in the CURANA HEALTH (preferred but not mandatory)
• Willing to attend training and informational meetings
Staff Ambassadors Should Be:
• Engaged frontline team members (e.g., activities coordinators, nurses, concierge staff)
• Knowledgeable about the CURANA HEALTH structure and benefits
• Positive communicators with rapport across departments
3. Training and Support
• Provide orientation sessions covering:
o What is CURANA HEALTH?
o Specifics about the facility’s physician-led CURANA HEALTH
o Communication skills (active listening, answering FAQs
o HIPAA/privacy considerations
• Ongoing monthly or quarterly check-ins to update materials, discuss resident feedback, and celebrate successes.
• Provide talking points, flyers, FAQ sheets, and referral forms.
4. Engagement Activities
• “Ask a CURANA HEALTH Doc” Q&A Events: Casual events with CURANA HEALTH physicians.
• New Resident Orientation Involvement: Include ambassadors in welcome sessions.
• Resident-Led Small Groups: Informal coffee chats to discuss healthcare experiences.
• Wellness Fair Participation: Ambassadors host a booth or lead tours.
5. Incentives and Recognition
• Recognition at resident meetings and staff huddles.
• Certificates, ambassador pins, or a feature in newsletters.
• For staff: Nomination for quarterly excellence awards or small stipends (if feasible).
• For residents: Tokens of appreciation (gift cards, wellness kits, reserved dining privileges).
6. Evaluation and Feedback
• Track new resident CURANA HEALTH enrollments and correlate with ambassador activity.
• Collect ambassador feedback: What's working? What’s challenging?
• Use brief resident surveys to assess awareness and satisfaction.
• Adjust training, messaging, or engagement tactics based on data.
8. Messaging Framework (for Ambassadors)
Core Message Points:
• “The CURANA HEALTH Team helps ensure you’re getting the right care at the right time.”
• “Our doctors communicate and collaborate for your benefit.”
• “Joining the CURANA HEALTH doesn’t cost you anything extra, but it offers more coordinated care.”
• “Many of us have already joined it’s made things simpler and more personalized.”
Resources:
Ambassador Program Training Guide https://cvhn.box.com/s/c5jhybkvvyksbqcpjxvt08xo10oral5z
DEFINITIONS
Population Health
Population health in senior living refers to a comprehensive approach to managing and improving the overall health and well-being of older adults within a senior living community. It involves addressing the population's collective health outcomes while considering the social, environmental, and individual factors influencing well-being. Below are the key components of population health in senior living:
1. Focus on Preventive Care
2. Chronic Disease Management
3. Holistic Wellness
4. Data-driven Decision Making
5. Social Determinants of Health
6. Collaborative Care Models
7. Resident-Centered Approach
Physician-Led Accountable Care Organization
A Physician-Led Accountable Care Organization (ACO) is a healthcare delivery model designed to improve care quality, enhance resident outcomes, and reduce costs by incentivizing coordinated, value-based care.
Key Characteristics of Physician-Led ACOs:
1. Primary Care Focus is led by CURANA health practitioners, coordinating residents' care. They prioritize preventative care, chronic disease management, and early interventions.
2. Value-Based Care Model
a. Incentives are tied to meeting quality benchmarks and achieving cost savings, b. Providers share in savings if CURANA HEALTH ACO meets cost and quality targets.
3. Collaborative Care
a. Encourages integration and communication, b. Reduces fragmentation of care.
4. Relies on analytics to track resident outcomes.
5. Facilitates initiative-taking care management.
Medicare Shared Savings Program (MSSP)
The Medicare Shared Savings Program (MSSP) is a federal initiative aimed at enhancing the quality of care for Medicare beneficiaries while reducing unnecessary healthcare costs.
CURANA Health is responsible for meeting quality standards and reducing healthcare spending below a set benchmark, enabling them to share the savings with the Provider.
In the context of the Medicare Shared Savings Program (MSSP), attribution refers to assigning Medicare beneficiaries to CURANA Health ACO. CURANA Health ACO is
responsible for care coordination, quality outcomes, and associated costs. This is the foundational concept for measuring performance in achieving cost savings and quality improvements.
Attribution Criteria:
Attribution is based on where beneficiaries receive most of their primary care services:
• Primary Care Providers (PCPs): Beneficiaries are attributed to CURANA HEALTH ACO if they receive most of their primary care services from PCPs within the ACO, including:
o Physicians
o Nurse practitioners, physician assistants, and clinical nurse specialists.
• Excluded beneficiaries from attribution:
o Those enrolled in Medicare Advantage plans or other Medicare-managed care programs.
o Those that are aligned with other ACOs or value-based models.
Challenges of Attribution:
• Attribution rules can be difficult to navigate, especially in cases where beneficiaries see multiple providers.
• Residents may change providers, affecting attribution stability.
• Communicate and ensure beneficiaries understand their alignment with CURANA Health ACO without limiting their freedom to choose providers.3
3 Overview of MSSP with CURANA’s Partners https://cvhn.box.com/s/f5y5p49le8g7iyf7z88pw0qce7gclwql
A. Guides: Programs, Processes, Resources, and Tools
1) Community Patient Transfer for Skilled Services
a. CURANA Health Direct to SNF Admission Program
https://cvhn.box.com/s/q1zj0d74yz13rbstttn0da8qx0zfioxh
b. CMS SNF Waiver Guidance
https://cvhn.box.com/s/055f5ti46rn5uyqtf96z4vo7h77skeix
c. Transfer Agreement Sample for Community-to-Community Resident Transfer https://cvhn.box.com/s/3jl2afxvlftl5wrukvwzf6qmba368853
2) Tiger Connect HIPAA Secured Messaging
https://tigerconnect-p.allego.com/9R-gTbVGIy0aJ59
Schedule time with TigerConnect
3) Remote Resident Monitoring (RPM)
a. Covenant Health System: Helpany https://helpany.com/chn/
b. CURANA Health System: RPM https://cvhn.box.com/s/tzr00b1vri1d3nr5np77dkaqe3hsoxu2
4) Transitional Care
a. CURANA Health
Transitional Care Model (TCM)
https://cvhn.box.com/s/k1gbj25ma8tu3pmp7s1pjegj177a2e1y
b. Covenant Health Network: Transitions in Care Tool Kit
https://cvhn.box.com/s/9ia2w3rs9tfubovr467z2kcous4mn3h0
5) INTERACT Best Practice Tools: Create an account at the site below to receive FREE tools & resources
a. Assisted Living: https://pathway-interact.com/interact-tools/interact-version-2-0-tools-for-assisted-living/
b. Skilled Nursing Home: https://pathway-interact.com/interact-tools/interact-tools-library/interact-version-4-5-tools-forsnfs-nursing-homes/
c. Home Health: https://pathway-interact.com/interact-tools/interact-version-1-0-tools-for-home-health-care/
6) CURANA Health Behavioral Health Program
7) CURANA G.U.I.D.E. Program: Guiding an Improved Dementia Experience Model Implementation
Based on CURANA/ CHN’s evidence-based best practices, additional resources will be added.
Best Practice Manual 2025
B. Alliance Purchasing Network
The Alliance Purchasing Network (APN) is a partnership of successful State and regional Senior Care Service Provider groups and Alliances designed to establish national purchasing agreements that benefit mission-driven senior care facilities. Beyond being your purchasing partner, APN strives to give our member facilities a strategic advantage in providing quality care.
➢ APN is dedicated to giving member senior care facilities control over their purchasing costs
➢ APN is designed to maximize the return of incentives, rebates, and lower prices to participating member organizations
➢ APN is an opportunity for member organizations to create a new revenue stream by expanding services to member facilities
➢ APN is a transparent, low-overhead organization
➢ APN provides a network of Vendors who do more than “deliver a product”; they are a part of the provider's team
Alliance Purchasing Network Vendor Guide