From medical home to ACO: a physician group's journey

The Medical Clinic of North Texas (MCNT) launched a population health initiative in 2010 that has involved working with self-insured companies to manage the health of their employee populations. To achieve the goals of providing high-quality care at a low cost, MCNT uses historical electronic health record and claims data to calculate state-of-health (SOH) scores for a company's individual employees and for the entire employee population. SOH scores reflect risks related to chronic conditions for each patient, thereby providing clinical teams and care coordinators with the information they need to design and execute patient-specific care plans.