Coordinated Care

Welcome to Houston Methodist Coordinated Care (HMCC), an Accountable Care Organization

Houston Methodist Coordinated Care (HMCC) is an Accountable Care Organization (ACO) led by doctors affiliated with Houston Methodist, as well as members of the community. Houston Methodist Coordinated Care will work to improve health of the communities we serve by providing high-quality, coordinated care. Our goal is to lower the cost of healthcare, provide a better beneficiary experience and improve beneficiary outcomes.

Coordinated Care Services

Houston Methodist Coordinated Care (HMCC) is pleased to offer a new service called Coordinated Care, which enables a dedicated team of medical professionals to support our participating providers and the Medicare beneficiaries they serve.

To find out more about Coordinated Care services, please call 844-349-4271, M-F from 8 a.m.-5 p.m. CT. Messages received will be returned the next business day.


Personalized Support for Beneficiaries

Beneficiaries who are identified as appropriate for Coordinated Care services are given the opportunity to work one-on-one with a registered nurse coordinated care advisor, who works closely with HMCC’s primary care providers. Care advisors may help beneficiaries on their path to a healthier life by creating an action plan around their personal health goals, answering medication questions, helping schedule doctor appointments, and more.

Access to care advisor support is available at no additional cost to qualifying beneficiaries, as one of the many advantages of their physician’s affiliation with Houston Methodist Coordinated Care. However, beneficiaries are responsible for paying copayments, deductibles and other costs outlined by their benefits plan for office visits or services that may be recommended.


Our Standards of Care

  • HMCC calls beneficiaries to follow-up after each visit to the Emergency Department
  • HMCC facilitates easy access to primary care physicians
  • HMCC collaborates with primary care physicians, specialists and skilled nursing facilities to coordinate care plans

Our Care Programs

  • Coordinated Care—HMCC empowers beneficiaries who may need assistance understanding and managing chronic, complex illnesses.
  • Transition Care—HMCC helps beneficiaries safely transition from an inpatient care setting to home and avoid complications that could cause a readmission.
  • Advanced Illness Care—HMCC offers additional support and specialized care coordination for beneficiaries living with serious or advancing illness and their loved ones.

Dedicated Resources for Providers

One of the most effective ways to improve the quality of care is to offer extra support to beneficiaries outside of the office. HMCC’s registered nurse coordinated care advisors work with identified beneficiaries to ensure they get the support and resources necessary to improve their health and well-being.

In addition to care advisor support, HMCC’s participating providers will have a population health advisor dedicated to their practice, who can provide resources to help assess population needs and ensure identified beneficiaries are receiving the appropriate Coordinated Care services based on geography, health status, resource utilization, and demographics. Population health advisors will assist HMCC’s affiliated physicians and practices with the distribution of timely, accurate and trusted reports to drive effective quality and care management processes and results.

Frequently Asked Questions


Who may be selected for Coordinated Care services?

Beneficiaries may be identified as appropriate for Coordinated Care services based on claims submitted by their doctor and other health care providers. Generally, beneficiaries will only be contacted to participate in Coordinated Care if their doctor believes they may benefit from having additional, dedicated resources to address their health concerns and help them achieve their personal health goals. Participation in Coordinated Care is voluntary, and beneficiaries who are contacted to participate may choose not to do so for any reason.


Who are coordinated care advisors and what do they do?

Coordinated care advisors are registered nurses who work with Houston Methodist. They complement the services already provided by primary care providers and the hospital. Under the leadership of the primary care physician, coordinated care advisors may work with an extended care team including a dietitian, pharmacist, and social worker. Coordinated care advisors may support primary care providers in a variety of ways, including:

  • Contacting  beneficiaries by phone to complete a current health assessment
  • Identifying attainable health goals as a part of an overall plan of care
  • Creating actionable steps to help beneficiaries reach their health goals
  • Connecting beneficiaries with dieticians, pharmacists, and social workers
  • Ensuring beneficiaries have the resources needed to improve their health and well-being


Can beneficiaries who chose to participate in Coordinated Care services still make regular appointments with their doctor?

Yes. Working with a coordinated care advisor does not replace any visits beneficiaries’ may need to schedule their doctor. Anytime non-urgent medical care is needed, beneficiaries are encouraged to call their doctor’s office to schedule an appointment. Beneficiaries who may be experiencing a medical emergency should always call 911.

Medicare beneficiaries have the right to choose any hospital or doctor that accepts Medicare, at any time, even if that hospital or doctor isn’t a part of HMCC.


Is personal health information kept private?

Yes. Federal law protects the privacy and security of beneficiaries’ medical information. Beneficiaries’ medical record may be read by the group of doctors, hospitals, and other health care providers in Houston Methodist Coordinated Care (HMCC) and office staff authorized to help coordinate care. By sharing information with other health care providers, our doctors will not only know about the health issues they’ve treated, they’ll have a more complete picture of each beneficiary’s health. Over time, beneficiaries may notice that:

  • They don’t have to fill out as many medical forms that ask for the same information.
  • The health care providers that they see all know what’s going on with their health because the providers communicate with each other.
  • They don’t need to repeat medical tests because their results are shared among their health care team.
  • The providers participating in HMCC will work with beneficiaries to make sure their health care decisions reflect individual preferences.

Beneficiaries have the option not to share their health care information. Beneficiaries must call 1-800-MEDICARE (1-800-633-4227) to tell Medicare not to share information about their care with their doctor’s Accountable Care Organization (ACO) or any other ACO. TTY users should call 1-877-486-2048. Unless this step is taken, beneficiaries’ medical information will be shared with their doctors’ ACO for purposes of care coordination and quality improvement.



What is an ACO? 

An Accountable Care Organization (ACO) is a group of doctors and other healthcare providers who agree to work together with Medicare to give you the best possible care. ACOs may take different approaches to giving you coordinated care. Some ACOs may have special nurses that help you set up appointments or make sure your medications are in order when you enter or leave a hospital. Other ACOs may help your doctors get you equipment for monitoring your medical conditions better at home, if you need it. Most ACOs use advanced systems that let them more carefully coordinate your care, and make sure your doctor has the most up-to-date information about your health. 

The goal of the ACO is to support your doctor in caring for you by making sure they have the most up-to-date information about your health and your care. For you, this means your doctors communicate better with each other, and you avoid having duplicate tests or answering the same questions over and over. Working together, your doctors can do more to follow your health, make sure you get the best possible care, and may hire additional staff to help meet your unique care needs, depending on what works best for you. 

Doctors and other healthcare providers choose to participate in an ACO because they’re committed to providing you with a better care experience. They may also be financially rewarded for offering you better, more coordinated care. If your doctor chooses to participate in an ACO, you’ll see a poster with information displayed in the office or hospital. 

An ACO isn’t a Medicare Advantage Plan or Health Maintenance Organization (HMO). You’re still in Original Medicare, and your Medicare benefits, services, rights and protections won’t change. And you still have the right to use any doctor or hospital that accepts Medicare at any time, the same way you do now.

ACO Name and Location 
Houston Methodist Coordinated Care
6565 Fannin Street
Suite D200
Houston, TX 77030

ACO Primary Contact 
Dr. Julia D. Andrieni
Phone: 713.441.7638
Email:  jdandrieni@houstonmethodist.org


Organizational Information

ACO Participants
Clear Creek Clinic, P.A.
Hema Patel, MD, P.A.
Jacinto Medical Group, P.A.
Priti Jadav
St. Michael Medical Clinic, PA
TMH Physician Associates, PLLC
TMH Physician Organization

No participants are involved in a joint venture between ACO professionals and hospitals.

ACO Governing Body 
  1. Julia Andrieni, MD; Voting Board Member and Chair / President; President & CEO, Houston Methodist Physicians' Alliance for Quality
  2. Brian Aquino, MD; Voting Board Member; ACO Participant; Clear Creek Clinic, PA
  3. Tom Baxter, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  4. Rachel Bishop, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  5. Tiffany Burns, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  6. Natalie Dryden, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  7. Mahendra Jain, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  8. Seva Papageorge, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  9. Tom‐Thuan Nguyen, MD; Voting Board Member; ACO Participant; St. Michael Medical Clinic, PA
  10. Chris Robben, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  11. Greg Terry, MD; Voting Board Member; ACO Participant; TMH Physician Associates, PLLC
  12. Rafael Pardo, MD; Voting Board Member; ACO Participant; Jacinto Medical Group, PA
  13. Carl Baucum; Voting Board Member; Medicare Beneficiary Representative
  14. JaniceFinder, RN, MSN; Voting Board Member; Community Stakeholder Representative
  15. Mick Cantu, JD; Non‐Voting Board Member;  EVP, Chief Legal officer and Strategic and Business Development Officer, Houston Methodist Hospital System
  16. Jeff Carr, MBA, MHA; Non-Voting Board Member and Secretary / Treasurer; VP of Finance, Houston Methodist Primary Care Group
  17. Dale Clark, PhD; Non‐Voting Board Member; Director of Business Development, Houston Methodist Physicians' Alliance for Quality
  18. Mark Easterly, JD; Non‐Voting Board Member; VP, Legal Services, Houston Methodist Hospital System
  19. Siraj Jiwani; Non‐Voting Board Member; CEO, Jacinto Medical Group
  20. Zachary Menn, MD; Non‐Voting Board Member; Program Manager, Houston Methodist Coordinated Care
  21. Robert Phillips, MD, PhD;  Non‐Voting Board Member; Chief Medical Officer, President, Houston Methodist Specialty Physician Group
  22. Stephen Spielman, MBA, MHA; Non‐Voting Board Member; President, Houston Methodist Primary Care Group

Key ACO Clinical and Administrative Leadership
  1. ACO Executive: Julia Andrieni, MD
  2. Medical Director: Chris Robben, MD
  3. Compliance Official: Catherine V. Meents
  4. Quality Assurance/Improvement Officer: Chris Robben, MD

Associated Committees and Committee Leadership
  1. Quality Improvement Committee: Dr. Chris Robben, Chair
  2. Finance & Operations Committee: Jeff Carr, MBA, MHA, Chair
  3. Physician Advisory Council: Dr. Mahendra Jain, Chair
  4. Management Committee: 
    • Dr. Julia Andrieni, President
    • Jeff Carr, MBA, MHA, Secretary/Treasurer
    • Dr. Chris Robben, Medical Director

Types of ACO participants, or combinations of participants, that formed the ACO
ACO professionals in a group practice arrangement
Networks of individual practices of ACO professionals
Hospital employing ACO professionals

Shared Savings and Losses

Amount of Share Savings/Losses
  • Agreement period beginning 2017, Performance Year 2017: $0

Shared Savings are Distributed
  • Agreement period beginning 2017, Performance Year 2017
    • Proportion invested in infrastructure: To be completed after the conclusion of the performance year. 
    • Proportion invested in redesigned care processes/resources: To be completed after the conclusion of the performance year.
    • Proportion of distribution to ACO participants: To be completed after the conclusion of the performance year.
Payment Rule Waivers
Yes, our ACO uses the SNF 3-Day Rule Waiver.
  1. Allenbrook Healthcare Center
  2. Bayou Manor
  3. Baywind Village Inc
  4. Clarewood House Extended Care Center
  5. Diversicare Humble Llc
  6. Garden Terrace Alzheimers Center of Excellence
  7. Grace Care Center at Northpointe
  8. Holly Hall
  9. North Houston Mc, Llc
  10. Royal Oaks Residence and Rehabilitation Center 
  11. San Jacinto Methodist Hospital
  12. Sharpview Residence and Rehabilitation Center
  13. The Buckingham
  14. The Forum at Memorial Woods Healthcare Center
  15. The Medical Resort at Bay Area
  16. The Medical Resort at Sugar Land
  17. Houston Methodist HospitalSNIF
  18. Tuscany Village
  19. Webster Residence and Rehabilitation Center
  20. Willowbrook Residence and Rehabilitation Center


Quality Performance Results for 2017 Reporting Period


Measure Number

Measure Name

Performance Rate

Mean performance rate (SSP- ACOs)

ACO-1

CAHPS: Getting Timely Care, Appointments, and Information

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-2

CAHPS: How Well Your Providers Communicate

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-3

CAHPS: Patients’ Rating of Provider

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-4

CAHPS: Access to Specialists

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-5

CAHPS: Health Promotion and Education

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-6

CAHPS: Shared Decision Making

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-7

CAHPS: Health Status/Functional Status

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-34

CAHPS: Stewardship of Patient Resources*

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-8

Risk Standardized, All Condition Readmission

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-35

Skilled Nursing Facility 30-Day All-Cause
Readmission Measure (SNFRM)* Readmission

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-36

All-Cause Unplanned Admissions for Patients with Diabetes*

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-37

All-Cause Unplanned Admissions for Patients with Heart Failure*

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-38

All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-9

Ambulatory Sensitive Condition Admissions: Chronic Obstructive Pulmonary
Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-10

Ambulatory Sensitive Conditions Admissions:
Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8)

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-11

Percent of Primary Care Physicians who Successfully
Meet Meaningful Use Requirements

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-39

Documentation of Current Medications in the Medical Record*

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-13

Falls: Screening for Future Fall Risk

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-14

Preventive Care and Screening: Influenza Immunization

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-15

Pneumonia

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-16

Preventive Care and Screening: Body Mass Index (BMI) Screening

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-17

Preventive Care and Screening: Tobacco Use: Screening Intervention

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-18

Preventive Care and Screening: Screening for Clinical Depression Plan

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-19

Colorectal Cancer

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-20

Breast Cancer

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-21

Preventive Care and Screening: Screening for High
Blood Pressure and Follow-Up Documented

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-40

Depression Remission at Twelve Months*

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-27

Diabetes Mellitus: Hemoglobin A1c Poor Control

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-41

Diabetes: Eye Exam*

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-28

Hypertension: Controlling High Blood Pressure

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-30

Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-31

Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic (LVSD)

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year

ACO-33

Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Therapy - for patients with CAD and Diabetes or Left Ventricular Systolic (LVEF<40%)

To be completed after the conclusion of the performance year

To be completed after the conclusion of the performance year



CAHPS = Consumer Assessment of Healthcare Providers and Systems, PQI = Prevention Quality Indicator, LVSD = left ventricular systolic dysfunction, ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker, CAD = coronary artery disease
*= Measure required beginning Reporting Year 2015.
N/A= Reporting on the depression remission measure is not required for 2015, as indicated by N/A

For general questions or additional information about Accountable Care Organizations, please visit www.medicare.gov/acos.html or call 1-800 MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048.