​​​​​Achieving Accountable Care

Accountability Models

The participants in a collaborative care delivery arrangement must explicitly outline the discrete points of contact with the patient, the services delivered at each step in the process, the critical hand-offs of responsibility and associated communications, and the measures of successful execution.

​Organizations pursuing this stage are​ often seeking to answer key analytical questions such a​s

  • ​How do we Implement & Measure Accountability across our ACO Partnerships?​

  • Where and by Whom are Value and Costs Introduced into our Delivery Processes?

The following Action Plans are concrete steps organizations must consider for progressively achieving this stage.

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Action Plans
​Collaborative Care Delivery Models
  • Define standard processes (and models) for collaborative and coordinated delivery of care services to targeted patients, using the designated resources of the ACO participants

  • Establish criteria and metrics for formalizing coordinated care delivery

​Transitions in Care: Communications, Hand offs, Follow-ups
  • Identify individual processes, entry criteria, observations and data collection, interpretation and assessment, decision criteria, prescribed actions, exit criteria, resource consumption and communications

  • Define metrics for process and collaboration compliance

​Contracts, Roles, Responsibilities
  • Formalize roles and responsibilities of all critical parties, including conditions for substitutability where appropriate

  • Define performance and compliance criteria, and outline contractual terms and governance for ACO participating entities and parties

  • Define individual and shared accountabilities, terms and impacts of performance and/or non-performance

  • Implement measurement programs and tools for monitoring and adjustment as required

​​Shared Metrics, Benefits & Risks
  • Define the core metrics on which both individual party and coordinated ACO performance will be assessed

  • Identify risk areas that will be shared between and among the participating parties and entities, and define metrics for their allocation

  • Identify benefit areas to be shared between and among the participating parties and entities, and define metrics for their allocation