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The American Journal of Accountable Care September 2015
Optimizing the Effect of Electronic Health Records for Healthcare Professionals and Consumers
Maryam Alvandi, RCT, MHS
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ACOs: What Every Care Coordinator Needs in Their Tool Box
Patti Oliver, RN, BSN; and Susan Bacheller, BA
A Physician-led Accountable Care Organization: From Award to Implementation
Lauren M. Steckler, MHA; Sue S. Feldman, PhD, MEd, RN; and Carolyn A. Watts, PhD
Applicability of the Omaha System in Acute Care Nursing for Information Interoperability in the Era of Accountable Care
Karen A. Monsen, PhD, RN, FAAN; Elizabeth Schenk, PhD, MHI, RN; Ruth Schleyer, BSN, MSN, RN-BC; and Martin Schiavenato, PhD, RN
Transitioning Our Healthcare System Toward Accountable Care
Michael E. Chernew, PhD

ACOs: What Every Care Coordinator Needs in Their Tool Box

Patti Oliver, RN, BSN; and Susan Bacheller, BA
This article examines the features a care coordinator should look for in care coordination tools to ensure they meet the needs of patients, the care team, and the care coordinator.
A few years ago, Gene Lindsey, president of Atrius Health, told the Wall Street Journal, “An ACO is like a unicorn; everyone thinks they know what one is, but no one has ever seen one.” Although the definition of an accountable care organization (ACO) can vary, and some healthcare systems probably use the term quite liberally, it appears we now have vast herds of unicorns roaming the country. Meanwhile, we have seen a surge in tech startups and new business lines from traditional health vendors offering care coordination tools to help ACOs deliver better care. Given the swell of ACOs and the surge in new technologies designed to support them, we should pause to ask ourselves: What are the features we truly need in care coordination tools to deliver on the promise of the Triple Aim? In this article, we will start with a quick overview of this growing market segment and then look at 5 essential features that care coordination tools must have to be helpful to care coordinators and their patients.

First, it is important to briefly share background on the authors, as we are approaching this topic based on our own experience and to settle on a working definition of an ACO. We have collectively served as a registered nurse with oversight of the clinical components of an ACO-like arrangement (the Intensive Outpatient Care Program started by Boeing in St. Louis to better manage the care of their chronically ill employees), an overseer of both a patient-centered medical home with UnitedHealthcare in Arizona and ACO implementations across the state of California with Blue Shield of California, and a former health plan executive with strategy and implementation oversight for the information and technology enablement of ACOs across California.

For the purposes of this article, we will define an ACO as a “care coordination model designed to improve quality of care, increase patient satisfaction, and lower the cost of care by leveraging and connecting the relationships of hospitals, medical groups, and health plans to work together to decrease fragmented care.” Interestingly, for a care system focused on patient experience, patients are rarely aware that they are part of an ACO and the connectivity between the 3 entities is often invisible to them.

Care Coordination Is Key for Many Reasons
From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults. In these arrangements, it is essential to have a lead care coordinator. An MD can play this role, but given our own experience and backgrounds, this article will focus on what nurses need from care coordination tools.

The Market for Care Coordination Tools Is Exploding
The marketplace for care coordination tools is growing at an exponential rate: in 2014, venture funding for digital health companies surpassed $4.1 billion—nearly the total of all 3 prior years combined.1 A recent online poll from KPMG indicates that a growing number of healthcare leaders think investment in population health management tools will pay off in a big way.2 Additionally, the health plans are investing big and earning dividends too—Optum Health recently saw its revenue jump 33%, compared with the prior year’s second quarter.3 The wearables market is growing exponentially as well, with sales of mobile wearable devices, including health and fitness devices and smart glasses, expected to reach almost 70 million items by 2017.4 Wearables, from fitness trackers to medical-grade devices, are helping to give patients and providers feedback and are thereby playing a growing role in improving care coordination.

Interestingly enough, with all this growth and investment, we also believe we are seeing a sort of “bifurcation” in the market. Some vendors are being very intentional about developing highly specialized tools or services for niche populations, such as an app for teens with diabetes, while others are pursuing a big picture approach, offering comprehensive out-of-the-box tools for complete care coordination.

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