5 Care Coordination Strategies for Medicare ACO Success

By Jacqueline LaPointe

April 16, 2019 - Embedding care managers in the emergency department, establishing networks of high-performing skilled nursing facilities, and home visits are strategies accountable care organizations (ACOs) are using to improve care coordination for Medicare ACO success, according to a new CMS toolkit.

Released April 11, the toolkit details innovative strategies top Medicare ACOs in the Shared Savings Program, Next Generation ACO Model, and Comprehensive End-Stage Renal Disease (ESRD) Care Model have used to coordinate care, improve care quality, and earn shared savings.

CMS intends for the toolkit, as well as future publications on Medicare ACO success, to give “actionable ideas to current and prospective ACOs to help them improve or begin operations, particularly as they consider a shift to a two-sided risk model.”

Through discussions with 21 successful Medicare ACOs, the federal agency found that ACOs are employing a variety of methods to coordinate care for diverse patient populations, including system-wide initiatives and targeted interventions that support individuals with specific conditions or needs.

While successful Medicare ACOs are implementing a variety of care coordination strategies, the toolkit showed that most organizations are coordinating care for patients who:

Go to the emergency department (ED)

Require care from a skilled nursing facility (SNF)

Have recently been discharged home after a hospital or ED visit

Have been diagnosed with a chronic condition

Have conditions impacted by social determinants of health

“In exploring how ACOs coordinate care for beneficiaries in these five areas, this toolkit describes ACO strategies to enhance collaboration with post-acute care providers, facilitate the sharing of beneficiary information between clinicians, and leverage community resources for beneficiaries with complex care needs,” CMS stated.

Coordinating care for patients presenting in the ED

The emergency department is one of the most expensive setting, making ED reform a top priority for ACOs. Successful Medicare ACOs are focusing on coordinating care for patients after an ED visit to reduce costs and improve quality, the toolkit explained.

Holding in-person meetings with hospital leadership and administrators is key to opening communication between ACOs, key care team members, and ED providers, the toolkit elaborated. In-person interactions and the presence of hospital leadership establishes common ground between ED and ACO providers, resulting in coordinated care.

Encouraging communication between ED clinicians and primary care providers (PCPs) through e-alert technology also improved care coordination for ACO patients who presented to the ED.

Some successful Medicare ACOs are also embedding staff in the ED to promote care coordination, the toolkit continued. Embedded care managers facilitate communication and collaboration between ED clinicians and PCPs to assist with discharge and transfer and close information gaps.

SNF networks improve care coordination

ACOs are still financially responsible for the care quality and costs of care provided after discharge. To better control post-acute dollars and outcomes, many successful Medicare ACOs are developing networks of high-performing skilled nursing facilities, the toolkit stated.

Medicare ACOs are using publicly available data (i.e. the CMS Five-Star Quality Rating System), claims, and SNF-submitted information to identify SNFs that consistently deliver high-quality, low-cost care. The organizations then establish a network of high-performing SNFs and create brochures for patients to show them preferred facilities. One ACO even created a scorecard based on ACO-developed measures to support patient decision-making.

Once Medicare ACOs establish a preferred SNF network, the organizations promote continuous quality improvement by regularly meeting with SNF administrative and clinical staff or developing collaboratives that allow “peer-to-peer learning” between preferred SNFs.

The initiatives allow ACOs to identify care coordination strategies for post-acute care and collaborate on treatment plans.

For some successful Medicare ACOs, putting a care manager, nurse, or physician in a SNF also supports care coordination, enabling ACOs to provide hands-on support and address potential complications.

ACOs perform at-home follow-ups and medication reconciliation

Getting patients to heal safely at home reduces costs and improves patient outcomes. To ensure patients can transition back to their homes safely, successful Medicare ACOs are sending providers to patient homes.

At-home follow-ups for patients who received inpatient care is a top strategy for Medicare ACOs looking to improve care coordination and reduce instances of avoidable care, like hospital readmissions and ED visits, the toolkit showed.

Successful Medicare ACOs are sending nurses, care coordinators, and other staff to the homes of patients that were in the hospital no more than five days ago. The providers answer patient questions, confirm that patients understand post-discharge plans, ensure patients have the equipment and medication they need for recovery, and determine whether the patient has seen a PCP or needs additional follow-up.

Many ACOs are also performing medication management services in patient homes. Nurses, pharmacists, or pharmacy technicians are going to patient homes to perform medication reconciliation, educate patients on medication dosage and side effects, and outreach to promote adherence.

Focusing on patients with chronic conditions

Poorly managed chronic conditions lead to excessive costs and utilization, as well as poor patient outcomes. Chronic conditions can jeopardize share savings, so successful Medicare ACOs are coordinating care for these patients through home visits or hands-on coaching, the toolkit stated.

Shared Savings Program and Next Generation ACOs target high-risk, high-cost patients with chronic obstructive pulmonary disease (COPD) and diabetes, among other conditions, while ACOs in the ESRD Care Model prioritize patients with additional health-related challenges.

For the target patient population, the ACOs educate patients about their condition, identify care access barriers, and address potential contraindications or medication gaps. The care coordination initiatives also promote self-management and medication adherence.

Using a team-based approach is key to success. Medicare ACOs use pharmacists, specialists, and care coordinators to coach patients, promote effective self-care strategies, and connect patients with additional resources and support.

Addressing social determinants of health

Limited access to transportation, social isolation, housing instability, food insecurity, and other social determinants of health can affect up to 90 percent of an individual’s health, according to highly-cited statistics.

Therefore, successful Medicare ACOs are modifying their care decisions to account for social determinants of health and better coordinate care, the toolkit showed.

Identifying patient challenges with social determinants of health is the foundation of the care coordination strategy. Multiple Medicare ACOs develop and use paper- or EHR-based assessments to pinpoint social determinants of health and communicate the information to clinicians. Providers can use the information at the point of care to develop more appropriate treatment plans and connect patients to community resources.

Technology is vital to helping providers connect patient to community resources. Technology is streamlining referrals at the point of care for some Medicare ACOs, allowing clinicians and care coordinators to identify and make direct referrals to community partners.

For example, one ACO added a link in staff computers to a community organization that addresses food insecurity. Another ACO built referral capabilities into its EHR system.

Additionally, successful Medicare ACOs are establishing partnerships with community resources to better coordinate care for patients with social determinants of health challenges. The organizations are working with area agencies on aging, local housing coalitions, food banks, and other community organizations to facilitate referrals and develop interventions that can meet patient needs.

Addressing social determinants of health, improving chronic care management, shifting care to the home, and other care coordination strategies are vital to Medicare ACO success, especially as CMS pushes organizations to assume downside financial risk.

Ensuring Medicare ACOs have strategies in place to improve care coordination will help the organizations avoid financial losses.

Value-Based Care News