Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives
Matthew J. Press, MD, MSc; Marilyn D. Michelow, MD; and Lucy H. MacPhail, PhD
Better coordination of care for patients is an essential component of the broad effort to improve healthcare quality and efficiency in the United States.1
But coordinating care across the various settings in which patients are treated is a daunting task.2
One possible solution to the care coordination challenge is accountable care organizations (ACOs). The great promise of ACOs is that by establishing a structure conducive to clinical integration and a payment system that demands accountability, the care that is delivered will be well coordinated. As a result, our healthcare system would be less fragmented, more fiscally responsible, and higher quality.
However, coordinating care requires more than a shared organizational structure and financial incentives.3
Individual physicians and other healthcare providers within ACOs must also know how to coordinate care. This requires specific professional skills, especially in the areas of collaboration, communication, and teamwork. These skills allow clinicians to integrate actions and expertise, negotiate differences in judgment, and determine shared priorities for patients’ care. In order to deliver coordinated care, ACOs will need to implement organizational strategies that develop and promote care coordination skills among their staff. Many of these strategies have a precedent in medicine or other professions and can be categorized into the following 3 key domains: training, support tools, and organizational culture.
ACOs should establish training programs specifically designed to enhance clinicians’ care coordination skills. Interpersonal communication is fundamental to coordinating care, yet almost one-half of physicians surveyed in 2009 acknowledged the need to improve communication processes.4,5
Some medical schools, physician groups, and nursing organizations have begun to offer training in this area, but ACOs will have to make these efforts more systematic. For instance, at Kaiser Permanente (a system with many characteristics of an ACO), physicians serving as “communication consultants” run workshops on communication between providers. Training should also include education on the roles of staff members within the care team. Understanding who is responsible for what is critical for effective collaboration in any organization, but even more so in an ACO setting, where traditional clinical roles are likely to evolve and staff from a variety of disciplines and specialties will be working together to coordinate patient care.
To build teamwork skills, ACOs can look to programs that have borrowed principles from other fields and applied them in medicine.6
For example, the US Air Force’s Medical Team Training Program was developed with an eye toward using human-factors concepts to reduce medical errors. Medical personnel are trained through a combination of coursework, observation in the work environment, and feedback. Unfortunately, evidence about the impact of this program, and others like it, is limited. Plus, the teamwork skills needed to effectively collaborate in a large, cross-disciplinary clinical setting like an ACO may differ from the emergency department or operating room settings where many of these programs have been focused. As a result, new training programs in ACOs should undergo continuous evaluation, and their success (or failure) should be disseminated so that other ACOs can learn from the experience.
The use of information systems does not obviate the need for this type of training. A study from 4 Kaiser Permanente medical centers showed that while the electronic medical record improved coordination of diabetes care, coordination suffered when providers had discordant views about team member roles.7
Likewise, nurse care managers should not be relied upon to coordinate the care of patients without also cultivating these skills among the rest of the care team. Dedicated support through additional personnel may be an important component of the overall strategy to improve care coordination. However, care coordination should be an organizationwide priority and a valued service in ACOs, and therefore everyone involved in patient care must be fully prepared to participate in the effort. This applies especially to physicians, who will always remain engaged in some of the most complex and important communications, regardless of changes in the healthcare delivery system.
While training will equip clinicians with care coordination skills, tools are necessary to support their use. Support tools provide structure to the content of care coordination activities and help integrate these activities into routine practice. For example, the “Situation, Background, Assessment, Recommendation” (SBAR) technique is a communication tool that has been used effectively to standardize information exchanged by members of the healthcare team, particularly between nurses and physicians.8
Support tools like this must be used thoughtfully, since the information that needs to be standardized varies based on the type of communication (eg, specialist consultation vs hospital unit transfer).9
Another support tool that could help communication is a checklist. In the construction industry, communication tasks are put into checklists, ensuring that experts from different fields coordinate their efforts before the project can proceed.10
Similarly, ACOs could add a checklist for communication tasks to the “plan” section of the electronic medical note template, which might compel clinicians to make communication with each other part of their plan of care.
Support tools—in particular, ones now made possible through new technology—can also enhance the efficiency and quality of collaboration.11
For example, privacy-sensitive text messaging and e-mail allow clinicians to rapidly communicate with each other. In addition, electronic health records can allow them to easily identify patients with particular care coordination needs, such as diabetics overdue for ophthalmic exams. But high-tech support for care coordination could also be taken further through tools with social networking features. For instance, adding a “wiki” to a patient’s electronic medical record would enable physicians and other clinicians to maintain an updated history and comprehensive assessment in a single document (with links to more detailed data) and to share an integrated care plan.12
Another potentially useful tool, particularly for medically complex patients, is activity streams. Fed by alerts on medication changes, transfers in care, physician appointments, and laboratory data, activity streams can be quickly scanned for relevant and important information, allowing clinicians to stay updated and connecting them with others participating in their patients’ care. Use of tools like these must be accompanied by training and evaluation in order to maximize their impact.
ACOs already have the “why” of their mission solidly defined: to provide high-quality, wellcoordinated care for their patients. Leaders within ACOs will need to take this mission and shape an organizational culture that supports the “how” for frontline clinicians. One way to signal the value of care coordination is by protecting time in the workday for care coordination activities and accounting for these demands in clinical scheduling. In addition, ACOs could formally schedule multi-disciplinary meetings to coordinate care for complex patients. Physicians and other healthcare providers should also be given a forum in which to share with each other innovative strategies for care coordination.
ACOs should consider including care coordination skills among the professional standards conveyed to current and prospective clinical staff. Just as good communication with patients is considered to be important, so too should good communication with other healthcare clinicians. Adding these skills to the definition of a high-quality provider and incorporating both patient and peer feedback on this metric into performance reviews will require a culture shift. But leaders of ACOs are uniquely positioned to spearhead this change because of the central role of care coordination in their mission.
There are many new ACOs and organizations similar to ACOs already working to provide coordinated care to patients. These groups will amass a wealth of experience and knowledge, and opportunities to share their best practices will be essential for continued improvement.13
A key component of such learning collaboratives should be the domains that we have outlined—training clinicians, providing support tools, and changing organizational culture—to help build the professional skills necessary for good care coordination. Making the development of these skills a priority will help ACOs live up to their potential to ameliorate the fragmentation and discontinuity that plague our healthcare system.