​​​​​​​​Achieving Accountable Care

Targeted Populations & Outcomes

This is a first step toward stratifying patients according to disease severity, comorbidities, treatments tried or successful, complications, and any of a number of characteristics that can enable providers at any scale to measure and begin comparative analysis of clinical, health economic or financial outcomes.

​Organizations pursuing this stage are often seeking to answer key analytical questions such as:

  • What are our current Targets for Patients & Outcomes?

  • What Results are we seeing?​

  • Are they Consistent?

  • Where are we seeing Under- or Over-Performance?

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

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Action Plans​ ​
​Identify Targeted Patients, Beneficiaries or Members
  • Assemble Patient Identifiers and records of care for targeted Patient or Member populations

  • Identify categorical and descriptive attributes for characterizing both individuals and sets of Patients; perform basic population tallies and both quantitative and qualitative summaries

  • Identify most useful and informative attributes and criteria for defining Patient cohorts and other homogeneous Patient segments

  • Prepare for baseline assessment of patient cohorts and/or strata; define and identify potential performance metrics for segment analysis

​Outcomes: Clinical, Operational, Financial
  • ​Identify and assess multi-disciplinary, cross-functional, and/or multi-dimensional outcomes as baseline for initially individual, and ultimately shared, performance targets for ACO entities and participants

​Identify ACO Parties & Roles

  • Identify key Providers and resources participating in care and service delivery for emerging population targets and candidate ACO members

  • Define and align Providers and other resources with care delivery roles, quantify and assess the value of their participation and contribution to the coordinated (and distributed) care processes and outcomes

​Performance Targets & Metrics
  • ​Assemble baseline performance on specific measures, and designate targets for each appropriate segment, to be delivered and monitored at each appropriate organizational and resource level

Targeted Care Plans
  • Identify sources of best practices and standardized care plans for targeted implementation in specific disease areas, populations, geographic or practice locations, or service areas

  • Examine both standardizing/constraining and flexibility elements in care plan models

  • Proactively identify measures of adherence and/or excellence/best practices for executing targeted plans and their associated outcomes or impacts

EBM Guidelines for Required Care for Patient Needs
  • Identify appropriate EBM guidelines specifically targeting patients, disease areas, populations, or service areas

  • Integrate EBM models and related resources into care delivery operations and systems

  • Define measures of adherence and/or excellence/best practices for executing defined EBM guidelines and their associated outcomes or impacts