Care Coordination Toolkit

Technical Assistance Tool
March 2019

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.
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Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
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?
Level of Evidence
Expert Opinion
What does this mean?