Preparing for Accountable Care: Coordinated Care
Author: Jane Metzger
Accountable care is more than a new program for Medicare patients. Providers are already finding more of their revenue is coming from accountable care contracts with private payers and Medicaid. An organized, systematic approach to care coordination is central to successful accountable care. Care coordination is not new and the accumulated experience with care coordination organized around the medical home provides important lessons for today's efforts.
There are many models for organizing care coordination; experience to date suggests that the specific model is less significant to success than a close collaboration among providers, care coordinators, and patients. Coordinated care delivery organizations managing care for patients under accountable care contracts will apply the principles of population management, providing low-intensity care coordination for the healthier members of the population and much more intense monitoring and support for patients with complex health challenges.
The foundation for care coordination is a patient coordination plan identifying goals set by the care team and the patient and the care coordination interventions geared to assisting in reaching the goals. For each patient, the plan is based on the unique set of sociodemographic and medical challenges that could be barriers to achieving goals. The work of care coordination is performed by members of the direct care team, as well as dedicated care coordinators.
HIT is critical to both the collaboration across sites and settings of care and extending care coordination to populations broadly.
An organized, systematic approach to care coordination is central to successful accountable care. For accountable care, care coordination will be centered around a medical home for each patient and a close collaboration among the direct care team, care coordinators, and patients.
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