Care Coordination Toolkit

Guide
Key Questions Answered
  • How can accountable care organizations (ACOs) coordinate and manage the care of their populations?
  • How do different strategies apply to different subpopulations?
Key Themes and Takeaways

This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs.

  • ACOs use a variety of methods to coordinate and manage the care of their populations, including both system-wide initiatives and targeted interventions.
  • This toolkit explains how ACOs coordinate care for the following categories of beneficiaries: those who receive emergent care in the emergency department (ED); those who require treatment in a skilled nursing facility; those who have recently been discharged home after a hospital or ED visit; those who have been diagnosed with a chronic condition; and those who have conditions affected by the social determinants of health.
  • This toolkit describes ACO strategies to enhance collaboration with post-acute care providers, facilitate information-sharing between clinicians, and leverage community resources for beneficiaries with complex needs.
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Expert Opinion
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