A new CMS toolkit, released through the CMS ACO learning system, shows five innovative care coordination strategies that have helped Medicare ACOs find success through shared savings.
The toolkit summarizes findings from focus groups and individual interviews with representatives from 21 ACOs that participate in the Shared Savings Program, the Next Generation ACO Model, and the Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model. While many of the ACOs contributing to this toolkit discussed strategies with positive results, others discussed programs that were less successful than expected or that had not yet been in place long enough to show results. CMS believes that this toolkit offers ACOs “a holistic sense of available options and possible implementation challenges.”
The 5 types of care coordination strategies found in the toolkit explain how ACOs support and coordinate care for beneficiaries who:
Receive emergent care in the ED
The toolkit explains that often, when an ACO-attributed beneficiary uses ED services, information about the visit is not communicated to the ACO or to key care team members, such as the PCP or care manager. ACOs shared their strategies to address this by encouraging the presence of hospital leadership, encouraging communication with ED clinicians through in-person meetings, and in some cases embedding staff in the ED.
Require treatment in a skilled nursing facility (SNF)
ACOs expressed that coordinating with SNFs is an important step in providing ACO-attributed beneficiaries with effective and appropriate post-acute care. Many ACOs reported that they developed networks of high-performing SNF facilities, and came up with communication resources, such as brochures and scorecards, to highlight these high-performing facilities for beneficiaries and clinicians. ACOs also discussed meeting regularly with SNF administrative and clinical staff and establishing workgroups and collaboratives, and identifying dedicated staff to oversee the post-acute care plan and coordinate care with SNF clinicians during the SNF admission and discharge process, as well as throughout the SNF stay.
Have recently been discharged home after a hospital or ED visit
One care transition management intervention found successful by ACOs was engaging beneficiaries who received inpatient care no more than five days post discharge by scheduling home visits to conduct functional, social, and environmental assessments. ACOs reported that these visits also provide an opportunity to review discharge instructions with the beneficiary and caregivers. ACOs also found success with post-discharge medication management, which includes both medication reconciliation and beneficiary education.
Have been diagnosed with a chronic condition
When not properly managed, chronic conditions can lead to excessive costs and poor patient outcomes. Many ACOs that found success in this area did so by developing care management strategies, including home visits and hands-on coaching, to target needs related to the chronic conditions. ACOs also used team-based medication reconciliation strategies to help beneficiaries adhere to complicated medication regimens, and used all members of the care team to educate beneficiaries, promote effective self-care strategies, and highlight resources available to the beneficiaries.
Have conditions affected by the social determinants of health
Social determinants of health, such as limited access to transportation, social isolation, housing instability, food insecurity, and an inability to access or afford medications, force clinicians to adjust their care decisions and create obstacles to success in a clinical setting. To successfully combat these obstacles, ACOs embedded tools to assess social risk within EHRs and make these assessments part of the standard workflows for clinician office visits. ACOs also built digital tools that help identify community partners that address social determinants of health and make direct referrals. Many ACOs developed partnerships with community organizations, and some used innovative partnerships, such as with a ride sharing company, to address beneficiaries’ transportation challenges.
CMS provides these toolkits as a way to educate current and prospective ACOs about how to begin or improve operations, with a focus on shifting to a two-sided risk model. CMS writes that “[t]his is the first toolkit in a broader series of resources that will explore different aspects of how ACOs operate to provide value-based care. The toolkits will bring together insights gathered during CMS sponsored learning system events and through focus groups with the ACOs.”
You can find more detailed information about this CMS toolkit here.
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