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Translating evidence into practice : ACOs’ use of care plans for patients with complex health needs

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Fraze, T. K., Beidler, L. B., Briggs, Adam D. M. and Collatz, C. H. (2021) Translating evidence into practice : ACOs’ use of care plans for patients with complex health needs. Journal of General Internal Medicine, 36 . pp. 147-153. doi:10.1007/s11606-020-06122-4 ISSN 0884-8734.

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Official URL: https://doi.org/10.1007/s11606-020-06122-4

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Abstract

Background
Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients.

Objective
To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs.

Design
A qualitative study using semi-structured interviews with Medicare ACOs.

Participants
Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.

Approach
Development, structure, use, and management of care plans for complex patients at Medicare ACOs.

Key Results
Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO’s planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff.

Conclusions
ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers.

Item Type: Journal Article
Subjects: R Medicine > RA Public aspects of medicine
Divisions: Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences
Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences > Population, Evidence & Technologies (PET)
Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH): Primary health care -- Cost effectiveness, Medical care, Cost of -- United States -- Evaluation, Accountable care organizations, Medical care
Journal or Publication Title: Journal of General Internal Medicine
Publisher: Springer New York LLC
ISSN: 0884-8734
Official Date: January 2021
Dates:
DateEvent
January 2021Published
1 October 2020Available
7 August 2020Accepted
Volume: 36
Page Range: pp. 147-153
DOI: 10.1007/s11606-020-06122-4
Status: Peer Reviewed
Publication Status: Published
Reuse Statement (publisher, data, author rights): This is a post-peer-review, pre-copyedit version of an article published in Journal of General Internal Medicine. The final authenticated version is available online at: http://dx.doi.org/10.1007/s11606-020-06122-4
Access rights to Published version: Restricted or Subscription Access
Date of first compliant deposit: 5 May 2020
Date of first compliant Open Access: 1 October 2021
RIOXX Funder/Project Grant:
Project/Grant IDRIOXX Funder NameFunder ID
20171072Commonwealth Fundhttp://dx.doi.org/10.13039/100000905
18011 Peterson Center on HealthcareUNSPECIFIED
74883Robert Wood Johnson Foundationhttp://dx.doi.org/10.13039/100000867
17-013SCAN Foundationhttp://dx.doi.org/10.13039/100009277
UNSPECIFIEDJohn A. Hartford Foundationhttp://dx.doi.org/10.13039/100000909
UNSPECIFIEDMilbank Memorial Fundhttp://dx.doi.org/10.13039/100002229
U19HS024075United States. Agency for Healthcare Research and QualityUNSPECIFIED
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