CMS Toolkit for ACOs: 5 Care Coordination Strategies

CMS Toolkit for ACOs: 5 Care Coordination Strategies

Clinical Communication Technology can Help ACOs Implement CMS’ Five Proven Strategies for Driving Better Patient Care at Lower Costs

By embracing the at-risk model, Accountable Care Organizations (ACOs) are leading the charge in the population health movement. Like most early movers, they face formidable challenges, including accountability, namely, managing the health of a large patient population and doing it profitably.

Because of the distributed nature of their workforce across a variety of organization types and geographic areas, ACOs face unique care coordination challenges such as diverting certain patients from costly emergency room visits, who could receive comparable and timely treatment at a different, more economical facility.

To assist entrants in this relatively new approach to healthcare, the CMS has published a toolkit for ACOs developed through informed discussions with 21 successful Medicare ACOs. Through this process, the federal agency discovered five common care coordination challenges that can be optimized with the right processes, resources, and technologies including:

      1. Patients Presenting in the Emergency Department (ED)
      2. Patients Requiring Care from a Skilled Nursing Facility (SNF)
      3. Patients that have Recently Been Discharged Home After a Hospital or ED Visit
      4. Patients Diagnosed with a Chronic Condition
      5. Patients with Conditions Impacted by Social Determinants of Health

TWEET THIS: Five care coordination strategies for #ACO success and how #ClinicalCommunication technology can help


Much of the guidance provided by the CMS relates to care coordination in situations and use cases that are already being solved by clinical communication solutions. One of our clients Innovation Care Partners (ICP) implemented many of these strategies leveraging TigerConnect as the technology underpinning. As a result, ICP realized $19.5 million in shared savings as a part of the Medicare Shared Savings Program (MSSP).

Let’s walk through each of the five care coordination strategies and explore how technology can help support each one:

1. Care Coordination for Patients Presenting in the Emergency Department (ED)

The ED is one of the most expensive care settings and often patients present in the ED unnecessarily. This makes ED reform an area of focus for many ACOs looking to achieve their shared savings goals.

In many cases, a patient presenting in the ED has care needs that can be better met at another facility and at a lower cost. However, without the proper staff in place to intercept these patients and determine a better course of action for getting them the care they need, patients are often unnecessarily admitted only to find they need to be seen by another caregiver.

To address this gap in care coordination, ACOs have adopted strategies to engage hospital leadership, embed staff within the ED environment, and encourage communication between ED clinicians and primary care providers (PCPs). The toolkit elaborates in all these areas.

How Technology Can Help – To facilitate communication between ED clinicians and the PCP, our client Innovation Care Partners has embedded a transitional care manager in the ED environment. When a patient registers in the ED lobby the PCP, any specialists associated with the patient, and the transitional care manager get a real-time alert through TigerConnect. The transitional care manager conducts a short consult with the patient in the lobby and can facilitate communication with PCP and/or the specialist through TigerConnect to possibly avoid an expensive emergency visit and coordinate any follow-up visits needed with the patient’s PCP or specialist.


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Clinical Communication Guide: The 5 Most Vulnerable Patient Handoff Scenarios eBook


2. Care Coordination for Patients Requiring Care from a Skilled Nursing Facility (SNF)

ACOs are still financially responsible for the quality and cost of care provided for any patients transferred to a post-acute facility such as a SNF. Many successful Medicare ACOs are developing networks of high-performing skilled nursing facilities and dedicating staff to support care transitions to better control quality and costs.

Many of the most successful Medicare ACOs establish a network of high-performing SNFs by finding available data or creating scorecards themselves that measure the SNFs performance in areas such as – prevention of rehospitalization, improving patient independence, and length of stay. These SNFs then become preferred facilities that patients are referred to.

Other successful Medicare ACOs are going so far as to dedicate staff to support care transitions and better quality and cost control. This could include a care manager, nurse, or physician. These staff members can either work in a SNF or reside in a corporate office where they can conduct consults via text, video or phone calls and come out for visits only periodically or as needed.

How Technology Can Help – TigerConnect can be used to more easily facilitate communication between the SNF, the patient’s care manager and any caregivers involved in the patient’s long-term care management. This can be done via text, video, or voice communication all using TigerConnect. In many cases, this can help lower rehospitalization, costly transports, and lower length of stay as any early signs of complications can be addressed sooner.

3. Care Coordination for Patients that have Recently Been Discharged Home After a Hospital or ED Visit

Reducing rehospitalization after an ED or hospital visit requires a safe transition back to the home, well-communicated post-discharge care plan, and in some cases at-home follow-ups for patients.

Some of the most successful Medicare ACOs are sending nurses and care managers to the patient’s home following a hospital or ED visit. According to the CMS toolkit – no more than five days after discharge is ideal and during the visit, ACO staff should answer questions, confirm the patient understands post-discharge plans, ensure the patient has the equipment and medication needed for recovery, and determine whether the patient has seen a PCP or needs additional follow-up. ACOs also use medication management to make sure that beneficiaries not only use the correct medications once they return home, but also that they avoid contraindications.

How Technology Can Help – TigerConnect’s new patient-facing solution can be used to empower patients to coordinate care with their caregivers after an episodic event. The hospital or a care manager can initiate the text message conversation with the patient to encourage them to report their recovery status, ask any questions they might have, or report any concerns or complications. This small effort can reduce complications and readmissions. For at home follow-ups, TigerConnect can be used by the attending caregiver to coordinate with other necessary care team members through text, video, and voice communications.


Optimizing Communications in Home Care Settings

Optimizing Communication in Home Care Settings


4. Care Coordination for Patients Diagnosed with a Chronic Condition

When poorly managed, chronic conditions can result in poor outcomes for patients and high healthcare costs. Top performing ACOs have programs focused on high-risk, high-cost patients with chronic obstructive pulmonary disease (COPD) and diabetes, among other conditions, the toolkit stated.

For patients with chronic conditions successful ACOs developed strategies to educate patients about their condition, identify care access barriers, and address potential contraindications or medication gaps.

ACOs also took a team-based approach looking to all members of the patient’s care team including physicians, pharmacists, specialists, and care coordinators to coach patients, promote self-care, and connect patients with resources and support.

How Technology Can Help – Team-based care coordination is at the core of TigerConnects value proposition. We can help all caregivers communicate effectively across time and location. And if a patient with a chronic condition checks into the ED or at a hospital, the entire care team can easily be alerted to help determine the best course of action for treatment.

5. Care Coordination for Patients with Conditions Impacted by Social Determinants of Health

According to a recent survey, 68 percent of American’s are impacted by at least one of the social determinants of health, with financial insecurity and social isolation topping the list of challenges. Others include food insecurity, housing insecurity, addiction, transportation access, and health literacy.

According to the toolkit, successful Medicare ACOs adjust their care decisions based on environmental, social, and financial challenges. They develop partnerships with community organizations that can engage and assist patients with their needs beyond healthcare. These ACOs make referrals to appropriate partner organizations as patient needs arise.

For example, the toolkit describes a use case in which an ACO found many Medicare patients were visiting the ED to address medical issues compounded by loneliness and anxiety. The ACO implemented a partnership with a faith-based organization to establish a buddy system. As a result of the program, there was a drop of 50% in ED visits from patients participating.

How Technology Can Help – Technology at the point of care can help caregivers develop more appropriate treatment plans and connect patients with community resources. 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.

Clinical communication can have an enormous impact in helping ACOs coordinate care, driving high-quality care at lower costs.

“The single most powerful electronic tool we use for the care of our patients is TigerConnect,” said Dr. Savas Petrides, CEO at Innovation Care Partners.

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