What are key elements to redesigning care?

Accountable care organizations, health plans, and providers can build more effective, sustainable programs by adopting features shared by the most successful models. These include: identifying and targeting the population most likely to benefit; assessing patients’ individual needs; developing a care plan around these needs and preferences; engaging patients and families; connecting them to appropriate follow-up and support services; coordinating care and facilitating communication among all providers; and monitoring progress.

Common operational elements include leadership buy-in; effective interdisciplinary teamwork; process and outcome measurement aimed at improvement; rapid testing and iterative learning; effective use of health IT; specially trained care managers who focus on relationships; and use of standardized processes. Finally, successful programs adopt quality improvement practices.