Translating Evidence into Practice: ACOs’ Use of Care Plans for Patients with Complex Health Needs

Abstract

BACKGROUND: Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients. OBJECTIVE: To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs. DESIGN: A qualitative study using semi-structured interviews with Medicare ACOs. PARTICIPANTS: Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. APPROACH: Development, structure, use, and management of care plans for complex patients at Medicare ACOs. KEY RESULTS: Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO's planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff. CONCLUSIONS: ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers.

Association of ACO Shared Savings Success and Serious Illness Spending

“…Of ACOs participating in a national survey, 10% selected palliative care/hospice as a top priority, but most hospital-and community-based palliative care was reported as being only partially implemented, suggesting that ACOs are still in the early stages of establishing such programs (Roiland et al, 2020). Interviews suggest some ACOs are using care plans to manage the care of complex patients, and most care plans were developed and maintained by care management rather than clinical staff (Fraze et al, 2020). Promising pilots for models of care, including home-based palliative and primary care for frail and functionally limited persons, have produced savings and reduced unnecessary or harmful care (Ruiz et al, 2017(Ruiz et al, , 2018Szanton et al, 2018;Yosick et al, 2019).…”

“The dream is that there’s one place you go”: a qualitative study of women’s experiences seeking care from Long COVID clinics in the USA

“…However, these models have only been adopted at a limited scale. Moreover, even models such as ACOs have struggled with integrating specialists and coordinating comprehensive patient care plans for complex patients [ 43 , 44 ]. Our findings highlight the importance of developing and implementing effective strategies for care coordination to provide more effective care to Long COVID patients.…”

“Beyond Just a Supplement”: Administrators' Visions for the Future of Virtual Primary Care Services

“…43,44 When a primary care team member can virtually attend a specialist visit with their patient, this shared experience can ensure that everyoneprimary care, specialists, and the patientis included in comprehensive care planning. 45 Whereas primary care teams often communicated with patients via telephone before the pandemic (eg, providing test results), virtual care regulations could enable providers to bill for these interactions. 46 Inspired by patient feedback during the pandemic, administrators considered how to make primary care services more attractive to patients.…”