4 Steps to Creating an ACO Care Management Team

Developing a population disease profile, and targeting large patient populations with a fairly common list of conditions, is one of the first steps necessary to developing an effective care management team for the ACO, explains Colin LeClair, executive director of accountable care at Monarch HealthCare.

The interdisciplinary team looks like this; it’s comprised of a primary care physician who quarterbacks the team; a care navigator, also known as a care coordinator, who performs most of the patient onboarding into the care management program and performs an initial triage of the patient’s needs. The care manager is often a non-complex patient’s primary point of contact. And the complex care manager is responsible for most of the complex cases.

Then as needed, we also deploy a behavioral health clinician, a community services coordinator, a clinic dietician, and a palliative care nurse as needed. The other resources may include a pharmacist or a Pharm D to perform post-discharge medication reconciliation. We also have a team of medical directors, employed and contracted hospitalists, and employed and contracted skilled nursing facility (SNF) people to support us as well.

The idea is that the team is tailored for the patient’s need at enrollment, and then can be augmented as the patient’s health status changes. This model scales best when you can target large patient populations with a fairly common list of conditions, which allows you to hire and assign clinicians with the appropriate expertise to each patient. So for example, we can afford to hire and assign a registered nurse (RN) or a nurse practitioner (NP) who has experience in a dialysis clinic or a nephrologist office if we have enough renal disease patients to fill their caseload. However, we couldn’t justify hiring a nephrologist physician extender if we only have 12 renal failure patients.

Next, we identified appropriate staffing ratios for our target population. We have a fixed budget, the ACO’s is a year revenue product, so we have to be very judicious with our investments. Best practice in Medication Advantage (MA) is 60 cases per case manager, and with those 60 cases, usually between 20 and 25 of those patients are actually in active case management. To manage a population of 1,200 patients like we’ve targeted, the Monarch Pioneer ACO has three dedicated care coordinators and two dedicated case managers. Then we borrow additional resources from our MA business. Having that existing MA infrastructure was a really critical part of our success in year one.

Source: Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care
Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care

Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care provides first-year advice from Monarch HealthCare’s Medicare accountable care organization, one of 32 original CMS Pioneer ACOs engaged to test alternative payment and program design models for accountable care organizations.

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