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.
The National Forum of ESRD Networks has introduced or updated several Medical Advisory Council (MAC) Toolkits. Two new Kits include the Transplant Toolkit and the Medication Conversion Toolkit. The Transitions of Care Toolkit was updated in mid-April. Find them all at http://esrdnetworks.org/resources/toolkits/mac-toolkits-1, along with the existing Home Dialysis Toolkit, Medical Directors Toolkit, QAPI Toolkit, Medication Reconciliation Toolkit, Catheter Reduction Toolkit, Vaccination Toolkit, and Assurance of Diabetes Care Coordination Toolkit.
The Department of Health and Human Services (HHS) National Quality Strategy (NQS) is a national effort to align public- and private-sector stakeholders to achieve better health and healthcare for all Americans. It was developed “through a transparent and collaborative process with input from a range of stakeholders. More than 300 groups, organizations, and individuals, representing all sectors of the health care industry and the general public, provided comments.”
The Centers for Medicare & Medicaid Services (CMS) contracts with End Stage Renal Disease (ESRD) Networks to implement the NQS principles and HHS Secretary’s priorities in the ESRD community. Starting in December 2017, Networks will launch a set of new quality improvement activities, data reporting requirements, and educational programs that reflect updated priorities and goals.
HHS Secretary’s Priorities
- Reform, Strengthen, and Modernize the Nation’s Health Care System
- Protect the Health of Americans Where They Live, Learn, Work, and Play
- Strengthen the Economic and Social Well-Being of Americans Across the Lifespan
- Foster Sound, Sustained Advances in the Sciences
- Promote Effective and Efficient Management and Stewardship
- Empower patients to make decisions about their health care
- Usher in a new era of state flexibility and local leadership
- Support innovative approaches to improve quality, accessibility, and affordability
- Improve the CMS customer experience