Accountable Care Success Steps: Care Network & Clinical Program Setup

Once you’ve established a clear picture of your patient population, the next step toward Accountable Care Organization success is to set up a care coordination network with a combination of services:

Across disciplines:

  • medical
  • behavioral
  • pharmacy
  • social

Across care settings:

  • primary
  • specialty
  • acute
  • post-acute
  • long-term
  • care management/community services

This type of care coordination network setup enables the use of an expanded care team and new clinical programs to treat and support patients across your ACO’s entire care continuum.

Your clinical programs need to address patient needs across varying risk categories – low, medium, high – and manage care transitions across the continuum of care based on this acuity.

Examples of clinical programs include:

  • post-discharge management
  • medication management
  • whole-person care
  • intensive care management
  • priority home care programs

The breadth of communication and collaboration required with post-acute care providers and community and social services is considerable. The human resource planning and workforce development for care coordinators, including training new skills for virtual care team management and patient activation, are also considerable.

You must be prepared to undergo the continual re-engineering of your clinical programs as the impact and results are evaluated and ongoing cost and quality improvement strategies are implemented.

A health IT care coordination solution to enable an expanded care team and new clinical programs across the care continuum requires:

  • A patient-centered care coordination plan – dynamically accessible to all members of the care team – that addresses all medical, behavioral, pharmaceutical and social issues, as well as corresponding goals and interventions.
  • Evidence-based guidelines incorporating detailed care steps and clinical protocols based on key metrics, such as 30-day re-hospitalizations. If the care steps are not performed (e.g., the patient has not had a follow-up visit with a primary care physician within 7 days post hospital discharge), then the care team receives a notification so action can be taken and a potential adverse event, such as re-hospitalization within 30 days, can be avoided.
  • Communication tools for the care team members to message each other securely, sending patient information such as care plans and clinical summaries.
  • Clinical workflow tools notifying the care team of adverse events in real time (such as an emergency department admission), so immediate action can be taken and patient care planning is transparent to all members of the care team.
  • Information tools powered by Health Information Exchange (HIE) infrastructure to share relevant, actionable information, in turn creating coordinated care records, critical diagnoses and reconciled medications.

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