3 Keypoints to the New Care Coordination Toolkit


As part of the shift towards value-based care, many Accountable Care Organizations (ACOs) have found successful strategies for reducing per capita spending and improving patient outcomes by addressing the individual needs of each patient. In order to help other organizations learn from these successes, the Centers for Medicare & Medicaid Services (CMS) has developed several programs to help facilitate the sharing of these strategies. The first of these programs have involved hosting dozens of Learning System Events, both in person and digitally, in order to give organizations the opportunity to collaborate and learn from each other. The next step in the process is the release of a series of toolkits. These resources bring together insights and strategies from various ACOs across the country in order to provide resources for other ACOs so that they can improve their own operations, as well as educate the general public.

The first toolkit was released in March of 2019. It is titled “Care Coordination Toolkit and includes the following sections:

● Receive emergent care in the ED

● Require treatment in a skilled nursing facility (SNF)

● Have recently been discharged home after a hospital or ED visit

● Have been diagnosed with a chronic condition

● Have conditions affected by the social determinants of health

For the purposes of this article, we would like to highlight three of these topics.

Hospital and Emergency Department Discharge

One challenging transition for many patients is understanding how to manage their own care after having been released from a hospital or emergency department (ED). These individuals may need help understanding how to properly take their prescriptions, they may have questions about what providers to follow up with and when, or even need support in making necessary life changes to manage their conditions. In order to reduce the risk of these individuals facing situations that may lead to avoidable hospitalizations or ED visits, some ACOs have developed programs that help patients manage this critical transition.

A number of these programs actually arrange for a nurse, care coordinator, or social worker to visit the patient in their home in order to make sure that they understand their discharge instructions, have followed up with their primary care provider (PCP), and are capable of managing their own care. These assessments may also help identify when patients are negatively impacted by Social Determinants of Health (SDoH) such as facing food insecurity or lacking an adequate support network.

Chronic Conditions

Poorly managed chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD), end-stage renal disease (ESRD), and diabetes frequently lead to poor outcomes for patients and high costs for payers. In fact, according to the Centers for Disease Control and Prevention, “90% of the nation’s $3.3 trillion in annual health care expenditures are for people with chronic and mental health conditions.” To address these costly conditions, ACOs have developed a number of different strategies. For example, many ACOs provide educational materials and programs that encourage healthy self-care, help patients understand their treatment plans, and teach them how to properly respond to urgent care needs.

There are also medicine support programs to help patients manage what are often complicated prescription routines. One ACO has partnered with pharmacies to help reduce confusion by having the pharmacist fill, sort, and then label 28 days of each of a patient’s prescriptions. This helps to ensure that they are taken correctly. Another ACO addresses the complex needs of patients with chronic conditions by co-locating providers in order to reduce appointments for patients and increase coordination. For example, many ESRD patients spend a considerable amount of time in dialysis centers. This can be an opportunity for other providers to be located in the same facility so that they can provide assessments and treatments while patients are at their regular dialysis appointment.

Social Determinants of Health

The link between the Social Determinants of Health (SD0H) and the long-term health outcomes of patients is well established, but there are limits to what a provider can do to address those needs in a clinical setting. This is why partnering with other providers and community resources is essential to providing comprehensive care. However, to effectively coordinate providers need the right tools. Care coordination software platforms allow care coordinators and other members of the care team to use standardized data assessments, create comprehensive patient records, submit and track referrals, collaborate in real time, and even use business intelligence algorithms to track and identify trends and high-risk individuals.

Facilitated by technology, partnerships between clinicians and community organizations have the ability to identify and address many social determinants. For example, one ACO determined that some of their elderly patients were frequently visiting the ED for situations that were linked to isolation and anxiety. To address this concern, the ACO partnered with a local faith-based organization to develop an adult “buddy” system where volunteers would regularly visit the patients. For those patients who chose to participate, their number of ED visits went down by 50%. A lack of reliable transportation is another frequently identified need. In order to help patients attend their appointments, ACOs have developed programs that include partnering with commercial ride-sharing companies, paying bus fare, and developing an app that allows patients to schedule a ride with a medical transportation company.


One of the keys to improving patient outcomes and controlling costs is focusing on whole-person care. As different ACOs innovate and develop unique strategies to address the needs of their individual patients, it is important for them to have a way to share these experiences. That way, new and existing ACOs can build on what has already been learned as they strive to deliver effective and efficient care.

Blog Resources:

● https://innovation.cms.gov/Files/x/aco-carecoordination-toolkit.pdf

● https://www.cdc.gov/chronicdisease/about/costs/index.htm

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