ACOs

WHO WE SERVE: ACOs

The patients driving your cost and quality performance need more than the system currently offers them.

ACO performance depends on managing the attributed patients with the highest complexity and the highest cost. These patients are almost universally managing multiple chronic conditions at once, and the fragmented point-solution model that created their situation is not equipped to reverse it.

Nudj gives ACOs a scalable, physician-led whole-person care program that starts with each patient as an individual, addresses the root causes of their conditions, improves the clinical markers that determine your quality performance, and reduces total cost of care where it is most concentrated.

What Nudj Delivers For ACOs

ACOs are accountable for populations no single-condition program has effectively reached. Your highest-complexity attributed patients are managing cardiometabolic disease, behavioral health conditions, and chronic pain simultaneously, and your current programs are treating each one separately, if at all. Nudj is one model, one care team, and one whole-person approach that addresses all of it, built to run alongside the primary care relationships in your network without disrupting them.

1. Scalable lifestyle medicine for your highest-risk attributed patients

Nudj is not a point solution for one condition. It is a foundational whole-person care model that addresses the behavioral, lifestyle, and clinical drivers of chronic disease across any condition. For ACOs managing patients with cardiometabolic disease, behavioral health comorbidities, and chronic pain simultaneously, Nudj addresses all of it with one program and one care team, starting from each patient’s individual circumstances and building the clinical intervention around who they are.

2. Outcomes that move your quality measures

HbA1c reduction. Blood pressure control. Medication adherence improvement. Medication de-escalation. Behavioral health integration. These are the clinical markers that determine ACO quality performance under MSSP, REACH, and value-based contracts, and they are the outcomes Nudj is built and documented to produce. Every result is attributed, reported in real time, and formatted for quality reporting and performance review.

3. Lower utilization where it costs you most

The patients Nudj enrolls are those who should not be in your specialists’ offices, urgent care centers, or emergency departments for conditions that whole-person lifestyle medicine can address. Surrounding them with coordinated care between visits reduces avoidable utilization and frees your specialists to see the patients who belong in their offices, at the right margin, for the right procedures. Fewer ER visits. Fewer avoidable re-referrals. Every remaining appointment is appropriate, reimbursable, and high-value.

$3,230

Average annual savings per enrolled patient, documented at scale

 42%

Average HbA1c reduction

4. Runs alongside your attributed providers

Nudj does not disrupt existing care relationships in your network. It extends them. Our team works alongside the primary care physicians in your attributed network, communicating at key clinical milestones, supporting their care plans, and keeping them informed. Patients stay with their existing provider. Their outcomes improve. Your ACO performance metrics improve with them, and the providers in your network gain a lifestyle medicine capability without adding staff or changing their practice.

Already Aligned With Where Value-Based Care Is Heading

Nudj is an accepted participant in the CMS ACCESS Model, the federal program designed to advance equitable access to whole-person care and accountable care for Medicare and Medicaid beneficiaries. These are exactly the populations ACOs are accountable for.

The ACCESS Model requires whole-person care delivery, care team integration, and outcomes accountability. Nudj meets all three, and the alignment work is already done. ACOs exploring ACCESS participation, or already operating within the model, can deploy Nudj without adapting our approach to meet ACCESS requirements. We are already there.

If you are in conversation with CMS about ACCESS participation, or your ACO is looking for a scalable whole-person care model that fits within the ACCESS framework, Nudj is the program to bring to that conversation.

The Data Nobody Else Has

ACOs have EHR data. They have claims data. They have revenue data. What they don’t have is data on what is actually happening between the doctor and the patient, in the gap where care disappears and costs accumulate.
Nudj has been collecting that data for five years: call transcripts, engagement patterns by time of day, day of week, and point in the care journey, referral patterns, barriers, what drives engagement and what drives drop-off, and patterns of purpose across thousands of patients and hundreds of providers.

 

5 years

Of continuous whole-person care delivery data

 120

Health data points per patient

 5.8M

Data transmissions captured

 

For ACOs, this data has a specific application: hyperlocal population intelligence. What is happening in a specific neighborhood, a specific practice, a specific patient demographic. Which providers generate the best referral outcomes. Which patient populations face the highest barriers. Where your attributed members go when the system can’t reach them. This is the intelligence that lets your ACO design programs that work for your market, not a one-size-fits-all protocol built for someone else’s population.

No EHR captures it. No claims system models it. Nudj has it, and we are building the infrastructure to surface it for our ACO and health system partners.

The Data Nobody Else Has.

ACOs have EHR data. They have claims data. They have revenue data. What they don’t have is the data of what is actually happening between the doctor and the patient, in the gap where care disappears and costs accumulate.
Nudj has been collecting that data for five years. 120 health data points per patient. 5.8 million transmissions. Call transcripts. Engagement patterns by time of day, day of week, and point in the care journey. Referral patterns. Barriers. What drives engagement and what drives drop-off. Patterns of purpose across thousands of patients and hundreds of providers.

For ACOs, this data has a specific application: hyperlocal population intelligence. What is happening in a specific neighborhood, a specific practice, a specific patient demographic. Which providers generate the best referral outcomes. Which patient populations face the highest barriers. Where your attributed members are going when the system can’t reach them. This is the kind of intelligence that lets your ACO design programs that actually work for your market, not a one-size-fits-all protocol designed for someone else’s population.

No EHR captures it. No claims system models it. Nudj has it, and we are building the infrastructure to surface it for our ACO and health system partners.

Ready to move the performance metrics that matter?

Our team works with ACOs to identify the right attributed patient population, model what clinical and financial outcomes look like for your specific risk arrangement, and design an implementation that runs alongside the provider relationships already in your network. You don’t need to build new infrastructure. You need the whole-person care model that makes your existing infrastructure perform.