Care Coordination

Care coordination is vital to managing an individual’s care, especially for beneficiaries with complex care, and should be a core component of all ACOs. When done well, care coordination can reduce fragmentation and improve outcomes, but only if efforts are well-organized and consumer-focused. The suggestions that follow apply to the general population attributed to an ACO and should be considered a floor, with additional requirements necessary for more complex populations, such as dual eligibles.

Does your state Medicaid ACO program do the following?

  • Foster a team-based approach that is centered on the needs, preferences, and circumstances of patients, their families and caregivers.

  • In the certification application, ask ACOs to clearly document how they will pursue a team-based approach to care, with attention paid to coordination of community-based care such as substance use disorders and mental illness services, oral health services and LTSS.

  • Include quality measures focused on care coordination, including patient and caregiver experiences around care coordination.

  • Focus on quality improvement in care transitions.

  • Define how ACOs will ensure care coordination and engage members in their home setting through methods such as home visits or telemedicine.

  • Ensure care coordinators receive ongoing training in best practices for providing coordinated care and are trained on care for mental illness and substance use disorders.

  • Share patient data during care transitions. This is especially important for care transition across multiple health systems, as it prevents consumers from having to undergo duplicative medical testing and allows providers to better understand consumers’ needs. Confidentiality and data security must be maintained.

    • Vermont’s Medicaid ACO originally included three different health care systems. The state obtained a grant to allow all three systems to collaborate with the state’s health insurance information exchange, Vermont Information Technology Leaders, to build one IT infrastructure. This system allowed all providers across health systems to track patient data, provide notices ahead of care transitions, and report on system-wide quality measures.

    • The Trenton Health Information Exchange gives providers one patient record that compiles each consumer’s health information.


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