A digital spiritual health collaborative care model within accountable care organizations: a community case study

Spirituality is an established dimension of whole-person care and is increasingly recognized as a determinant of health, yet integrating spiritual care into value-based, population health care models, including Accountable Care Organizations (ACOs), remains rare. This descriptive community case study details the implementation of a novel digital spiritual health collaborative care model within ACOs in New Jersey, USA. The Atlantic Health ACO and Optimus Healthcare Partners ACO have 4,000 providers serving approximately 530,000 attributed patients in 11 different value-based payer arrangements, both risk and non-risk. Drawing on the interprofessional spiritual care framework, the program embedded a board-certified chaplain within the ACOs' Integrated Care team, delivering specialist spiritual care to patients with chronic and serious illnesses via telephone and videoconference visits, with care documented directly in the shared electronic medical record. A two-item spiritual screening tool was administered by ambulatory care team members across primary care and specialty practices; 96/147 (65.3%) patients screened positive, and 58/96 (60.4%) enrolled in spiritual health services. Chaplain assessments identified grief and loss (62.1%), isolation (41.4%), existential concerns (31.0%), and conflicted or challenged belief systems (29.3%) as the most prevalent spiritual health concerns. The chaplain communicated spiritual concerns and spiritual health insights to care team members through consult notes. Nearly half of enrolled patients received referrals to supportive resources within the health system or the broader community through a developing Spiritually Integrated Network. Implementation was supported by targeted staff education on spiritual health and interprofessional spiritual care. The program demonstrated operational feasibility and meaningful patient engagement through a Patient-Centered Medical Home (PCMH) primary care infrastructure. The PCMH principles of person-centered orientation, team-based care, care coordination, and quality-focused value-based incentives offered a practical and supportive framework for embedding spiritual health into ambulatory workflows. These findings suggest that ACOs operating within PCMH models may be particularly suited for integrating spiritual care. This work addresses a critical gap in population health practice and points toward the potential contribution of spiritual health programs to the Quintuple Aim, warranting further research.