The Centers for Medicare & Medicaid Services (CMS) has released a Care Coordination Toolkit showcasing the work of accountable care organizations (ACOs) and end-stage renal disease care (ESRD) seamless care organizations (ESCOs) participating in the Medicare Shared Savings Program, Next Generation ACO Model, and the Comprehensive ESRD Care Model.
The toolkit highlights innovative care coordination strategies that ACOs and ESCOs use to collaborate with beneficiaries, clinicians, and post-acute care partners. It aims to provide actionable ideas to current and prospective ACOs to help them improve or begin operations.
The new resource includes a section focused on care coordination for beneficiaries with conditions affected by social determinants of health, including topics such as:
- identifying beneficiary challenges;
- leveraging electronic health records and other technology to address social determinants of health;
- strengthening community partnerships; and
- addressing social isolation among beneficiaries.
Essential Hospitals Institute’s Essential Communities website can help hospitals evaluate their community’s greatest needs to determine where population health efforts will be most valuable. The site features a resource library and includes several tools to help essential hospitals develop and implement population health programs.
Case Studies Highlight ACO Innovations
CMS also released seven case studies, available on the agency’s ACO general information website, describing innovative initiatives from ACOs and ESCOs on a variety of topics, including coordinating care in rural settings and promoting health literacy. Each case study includes detailed results and lessons learned.
One case study highlights an ACO at association member Henry Ford Health System, in Detroit, and its work to increase beneficiary engagement. It describes the two-part strategy Henry Ford’s ACO used to develop educational materials for providers and front-line staff and establish dedicated communication channels between the ACO and beneficiaries.