ACOs: The Critical Role of Care Coordinators in Discharge Planning and Care Transitions

Lessons from 20 Medicare Shared Savings Programs (MSSP) provide insight into how ACOs manage complex care patients. In this article, we describe strategies and provide examples of successful approaches.

Beneficiaries with costly or complex care needs account for a disproportionate amount of total healthcare spending. These beneficiaries – as well as beneficiaries who are at future risk of needing high-cost or complex care – have a wide variety of health conditions, such as diabetes, chronic lung disease, or congestive heart failure. Without intervention, their cost of care can dramatically increase over time. These beneficiaries are also especially vulnerable to poor-quality outcomes associated with fragmented care.

Let’s take a look at the role of care coordinators at discharge and care transitions.

The role of care coordinators within ACOs (Accountable Care Organizations) is pivotal to enhancing patient care, improving outcomes, and reducing costs. Care coordinators are the linchpin between patients and the complex healthcare system, ensuring seamless communication and coordination among various healthcare providers. By proactively managing patient care, care coordinators help prevent hospital readmissions, ensure compliance with treatment plans, and address any gaps in care. Their work is essential in aligning the goals of ACOs with patient needs, ultimately driving success in value-based care models.

The Role of Care Coordinators

To help manage the care of beneficiaries with costly or complex care needs, almost all ACOs use care coordinators. ACOs typically provide care coordinators with a customized list of beneficiaries. The care coordinators monitor these beneficiaries closely and help them transition from one care setting to another. For example, care coordinators ensure that when beneficiaries leave the hospital, they have the correct medication and equipment, as well as a follow-up visit with their primary care provider.

Care coordinators also help beneficiaries schedule appointments and ensure that beneficiaries have care plans in place. In many ACOs, they also periodically check with beneficiaries in between physician visits to monitor changes in their health.

If a beneficiary reports a condition that requires follow-up, the care coordinator directs the beneficiary to a registered nurse who can request a pharmacy consultation to identify any medication errors or arrange for hospital, home health services, or primary care services, if appropriate. For these beneficiaries, the ACO reported over a 43% reduction in emergency department visits and a 47-percent reduction in hospital readmissions by the second year of the program.

Providing Care Outside of the Physician’s Office

Many ACOs also provide additional support – such as home visits, telephonic support, and monitoring devices – to beneficiaries with costly or complex care needs. These services help manage beneficiaries’ conditions between physician visits.

Over half of the ACOs have care coordinators or physicians who visit beneficiaries in their homes. One ACO sends a respiratory therapist to beneficiaries with chronic obstructive pulmonary disease, while another provides high-risk beneficiaries with at-home services that range from blood draws to ultrasounds. A few ACOs provide home visits by a multidisciplinary team, including a physician, pharmacist, and care coordinator to address beneficiaries’ multiple needs.

Other ACOs offer telephonic support to beneficiaries to help manage their conditions between physician visits. These ACOs provide beneficiaries 24-hour access to a care coordinator, a physician, or a nurse. For example, at one ACO, care coordinators provide their phone numbers to high-risk beneficiaries so that they can call for advice about their health condition. If a call is insufficient to address the beneficiary’s concern, care coordinators triage the symptoms and coordinate with physicians as needed.

Targeting Frequent Users of Emergency Room Services

Many ACOs identify beneficiaries who frequently visit the emergency room unnecessarily so that providers can work with them. Providers in a few of these ACOs educate these beneficiaries on alternatives to the emergency room. Other ACOs collect information on why these beneficiaries are visiting the emergency room and create customized solutions for them to address their needs, such as ACO officials connecting them to social services. For example, one ACO identified a beneficiary who had 30 emergency room visits in a year; by offering a standing weekly appointment with a primary care physician, the ACO reduced the number of emergency room visits to two the next year.

Improving Care Coordination at Hospital Discharge

To help ensure smooth and safe transitions from the hospital, ACO staff commonly participate in discharge planning, assess beneficiaries’ post-discharge needs, and monitor transitions of care. They often educate beneficiaries about their symptoms, arrange for transportation, secure medical equipment, and reconcile their medication to reduce errors.

At one ACO, a pharmacist works with its beneficiaries to address medication adherence issues. Another ACO reconciles its beneficiaries’ medication and provides 30 days of all medications to beneficiaries when they are being discharged from the hospital. This initiative is targeted toward beneficiaries who have numerous medications or who indicate they may not fill their prescriptions right away. As a result of this initiative, the ACO saw a large reduction in medication errors and a significant reduction in the hospital’s readmission rate.

In addition, ACOs emphasize the importance of follow-up visits with beneficiaries’ primary care physicians following a beneficiary’s discharge from a hospital. These visits ensure that beneficiaries understand their instructions and identify any outstanding needs. Many ACOs schedule these visits for the beneficiaries shortly after discharge. One ACO created its own quality measure to ensure that primary care visits occur within 14 days after discharge. Another ACO had a 50% drop in readmissions for beneficiaries with chronic heart failure due to its transition of care efforts, combined with scheduling follow-up visits within seven days.

Conducting Warm Handoffs to Improve Care Transitions

Several ACOs conduct “warm handoffs” – where ACO staff are involved in an in-person transfer of a beneficiary between different care settings, such as a hospital to an SNF or HHA. These handoffs help build relationships between care coordinators, providers, beneficiaries, and their families and provide opportunities to clarify or correct information and improve care coordination. At one ACO, care managers establish relationships with beneficiaries prior to discharge from the hospital to facilitate a more seamless transition; they are responsible for handing off each beneficiary to a post-acute facility and for monitoring his or her care for 30 days after discharge. During this time, they help reconcile medication to prevent any errors and ensure that beneficiaries have adequate transportation to appointments and that medical equipment is delivered.

Background of Medicare Shared Savings Program ACO

The Medicare Shared Savings Program is one of CMS’s largest alternative payment models that incentivizes efficient and quality care. In the program, healthcare providers voluntarily form ACOs and enter into a multiyear contract with Medicare. Providers in each ACO coordinate to reduce Medicare spending and improve quality of care. If an ACO is successful and meets certain Medicare requirements, it is eligible to receive a portion of the savings it generates for Medicare.

REMINGTON’S ACO and HOME CARE COLLABORATIVE

The ACO and Home Care Collaborative is an executive insight exchange for building outcome-based relationships, improving patient outcomes, and sharing best practices. The ACO and Home Care Collaborative is an educational membership platform that brings together ACOs and Home Care stakeholders to actively drive better patient outcomes, align common goals, tackle challenges, and establish a robust foundation for continuous collaboration..

Get More Details to Stay Future-Ready