Translating Evidence into Practice: ACOs' Use of Care Plans for Patients with Complex Health Needs

Area of Science:

• Healthcare Management
• Patient Care Coordination
• Health Services Research

Background:

• Care plans are evidence-based tools encouraged by CMS to manage complex patients, reducing costs and improving outcomes.
• Accountable care organizations (ACOs) are increasingly adopting care plans as part of payment reform initiatives.

Purpose of the Study:

• To investigate how Medicare ACOs utilize care plans for managing patients with complex health needs.

Main Methods:

• A qualitative study design was employed, utilizing semi-structured interviews.
• Interviews were conducted with 39 participants across 18 Medicare ACOs, including leadership and clinical/managerial staff.

Main Results:

• Most interviewed ACOs (11) reported using care plans for complex patients.
• Care plans consistently included patient history, current medical needs, and future care directives.
• Care plan elements varied based on ACO objectives and engagement levels; development and maintenance were often handled by non-clinical staff.

Conclusions:

• Medicare ACOs are actively using care plans for complex patient management.
• Current ACO care plan practices do not consistently align with established best practices.
• ACOs are modifying care plan strategies to better accommodate patient and provider requirements.