The Centers for Medicare & Medicaid Services worked with 21 Medicare Accountable Care Organizations (ACOs) and End-Stage Renal Disease Seamless Care Organizations (ESCOs) participating in the Shared Savings Program, Next Generation ACO Model, and the Comprehensive ESRD Care Model to identify promising practices and innovative strategies for coordinating care for Medicare beneficiaries.
Specifically, the ACO Care Coordination Toolkit focuses on care coordination for Medicare beneficiaries who:
- Recently received care in an emergency department,
- Require treatment in a skilled nursing facility,
- Have recently been discharged home after a hospital or emergency department visit,
- Have been diagnosed with a chronic condition or have a complex medication regimen, or
- Have conditions affected by the social determinants of health.
Working with the same methodology, CMS also has released the ACO Beneficiary Engagement Toolkit which highlights strategies used by ACOs and ESRD Seamless Care Organizations (ESCOs) to engage beneficiaries. Specifically, the toolkit explores how ACOs and ESCOs:
- Engage beneficiaries in ACO governance,
- Elicit beneficiary and family feedback,
- Support beneficiaries in self-care management,
- Enhance beneficiary communication in the clinical setting, and
- Communicate with beneficiaries about the ACO as a value-based care organization.
These toolkits are part of a broader series of toolkits designed to educate the public about the strategies ACOs use to provide value-based care while also providing actionable ideas to current and prospective ACOs to help them improve or begin operations.
For more information on the toolkits and case studies please visit the ACO General Information webpage.