How ACOs Are Caring for People with Complex Needs

Authors
Kristen A. Peck
Benjamin Usadi
Alexander Mainor
Helen Newton
Ellen Meara
Report
December 2018

This resource describes the strategies employed by ACOs that have comprehensive care management programs for complex patients. This report is from the six-foundation collaborative and is based on responses from the National Survey of ACOs.

  • Most ACOs report having comprehensive chronic care management processes or programs in place to manage people with complex needs.
  • However, more labor-intensive interventions are much less common. Few ACOs report having advanced programs for engaging patients, in-home visits after hospital discharge, or evidence-based services for patients needing mental health or addiction treatment.
  • While ACOs have increased their efforts to target populations with complex care needs, there are opportunities for more extensive and varied strategies.
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Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What strategies are accountable care organizations (ACOs) employing in providing care to patients with complex needs?
  • What are the biggest opportunities for improvement?
Level of Evidence
Expert Opinion
What does this mean?