ACOs: The Role of Care Coordinators in Managing Complex Patients

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.