Identifying and Designing the Right Care Management Program: Insights from ACOs

Technical Assistance Tool
April 2019

This resource describes four care management models that ACOs are using for individuals with complex needs.

  • Care management programs can involve creating patient care plans, coordinating care across providers, and addressing patient needs.
  • Care management models fall into the following categories: designed, managed, and the staff is located at the ACO-level; designed and managed at the ACO-level with staff embedded in practices; programs are independently developed and managed by practices; and programs are managed and implemented by an external service.

For each, this resource identifies key benefits and challenges, and offers guidance on which care model might be most appropriate depending on the characteristics of a given ACO. 

Posted to The Playbook on
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 are the key elements of care management programs?
  • What are some different care management models used by ACOs?
  • What are the benefits and challenges of each model?
Level of Evidence
Expert Opinion
What does this mean?