CMSA Today - Issue 8, 2013 - (Page 18)
ACOs Moving Toward Longer-Term View
for Their Journey Ahead
Coordination is key in case managers' evolving
roles in caring for patients with disabilities
BY KAREN HERCULESDOERR, MBA, BSRT, DIRECTOR, COMMUNITYBASED REPRESENTATIVES, ALLSUP
here has been a dramatic increase in accountable care organizations (ACOs), with many
current counts identifying more than 100 Medicare-based entities in operation. When
we expand our view to include Medicaid and commercial payers, the number of ACOs
in 2013 exceeds 400. The most rapid number of expansions has been on the West Coast and
Northeast, although consistent private-sector expansion continues to be seen in the Midwest.
The proliﬁc expansion of private-sector
ACOs demonstrates the important role
employers, payers, and providers have taken
to rein in rising health care costs.
Unfortunately, along with the rising
incidence of younger individuals who have
chronic illness, this expansion includes an
increased frequency of disability.
The goal of an accountable care
organization is to lower health care cost,
improve quality of care, and improve the
overall experience of care being provided.
This process happens in part through
better coordination. Coordinated treatment
systems that avoid duplicative services
and lower the rate of medical errors show
promise as one way to deliver high-quality,
A key component of ACOs includes
shared benchmarks and ﬁnancial incentives
for all participating entities. This one
component is a game changer, as now it is
everyone's responsibility and incentive to
make sure patients are adequately screened
for services and to ensure that the proper
payment mechanism is in place.
patients who meet criteria but are identiﬁed
as having signiﬁcant utilization and costly
provision of care.
I have heard many in the health care
community state that there is a real lack of
understanding between the expansion of
these new programs and beneﬁt options with
day-to-day management of patient care.
Both issues might be addressed by having
a good understanding of diﬀerent
types of ACOs, their focus or clinical
specialty, and expanding the current case
One way in which the expansion of case
management services may be extended is
to take a longer-term look at patient needs
and clinical progression, while including a
robust evaluation that is more outpatient
and community focused.
These evaluations must address speciﬁc
and current clinical, ﬁnancial, and psychosocial
needs while anticipating secondary planning
as a patient's ﬁnancial circumstances and
health insurance coverage changes.
Professional case managers are perhaps
most aware of the gaps in non-coordinated
care that can hamper recovery.
CASE MANAGERS' ROLE IN
COORDINATION: THEY KNOW
EYEING PATIENT CONCERNS
WITH GAZE ON LONG TERM
Some advocacy groups have expressed
concern that ACOs may screen out eligible
These gaps can become "opportunities"
to demonstrate our expert case
Issue 8 * 2013
management and discharge planning skills.
We are trained to identify issues and provide
However, events don't always occur
in the time or manner in which we had
hoped. We provide patient resources to
start the process that will assist them in
receiving utility assistance. We counsel
a family on how to start dealing with a
life-changing illness. In the grand scope
of things, we have to admit our shortfalls
and recognize that many times we have
taken the short view in order to expedite
transfer or discharge.
ACOs may oﬀer the vehicle necessary to
hold all entities responsible for delivering
expert care in the lowest cost environment
while proactively assisting the individual
in managing complex disease process and
Case management and social work are
front and center to a strong foundation for
ACOs to build upon. This requires all of us
to take a longer, more comprehensive look
at patient needs and patient education
regarding their particular health condition
and ﬁnancial resources.
PATIENTS WITH CHRONIC
CONDITIONS: WHEN DOES IT
BECOME A DISABILITY?
Often overlooked is the need to have a
meaningful discussion about how and when
someone recovering from a serious injury or
illness may have to ﬁle for disability beneﬁts.
Many patients don't seek assistance when
they should, waiting until their condition
has progressed to a dangerous point.
Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2013
Where Was Care Coordination?
VIEW FROM CAPITOL HILL
Preparing Patients for Their Journey Ahead
CASE MANAGEMENT AND THE LAW
CMSA CORPORATE PARTNERS
INDEX OF ADVERTISERS
CMSA Today - Issue 8, 2013