New Toolkit Highlights Strategies Accountable Care Organizations Use to Coordinate Care for Medicare Beneficiaries

Mathematica Operates CMS’s Accountable Care Organization Learning Systems
Apr 16, 2019

Learning Systems for Accountable Care Organizations

Under a contract with the Centers for Medicare & Medicaid Services (CMS), Mathematica’s health experts worked with 21 Medicare Accountable Care Organizations (ACOs) and End-Stage Renal Disease (ESRD) Seamless Care Organizations participating in the Shared Savings Program, Next Generation ACO Model, and the Comprehensive ESRD Care Model to identify promising practices and innovative strategies to coordinate care for Medicare beneficiaries. The resulting practices and strategies helped form the ACO Care Coordination Toolkit, which focuses on care coordination for Medicare beneficiaries who have experienced or are experiencing one or more of the following:

  • Recently received care in an emergency department
  • Require treatment in a skilled nursing facility
  • Have recently been discharged home after a hospital or emergency department visit
  • Have been diagnosed with a chronic condition or have a complex medication regimen
  • Have conditions affected by the social determinants of health

The ACO Care Coordination Toolkit is the first in a broader series of topic-focused resources that will explore different aspects of Medicare ACOs’ operations to help them improve the quality of their care and their patients’ health as well as reduce costs. Through this and future toolkits, CMS aims to not only educate the general public about strategies ACOs use to provide value-based care, but also present actionable ideas to current and prospective ACOs to help them improve or begin operations.

CMS released the ACO Care Coordination Toolkit on April 10 along with a series of case studies highlighting initiatives implemented by ACOs. For more information on these resources, please visit the CMS Innovation Center website.

“Mathematica has partnered with CMS to operate the Medicare ACO learning systems since 2013. We are excited to share what we have learned from ACOs during that time with a broader audience,” said project director Kate D'Anello. “By sharing promising practices and distilling lessons learned from attempted interventions, we aim to help current and prospective ACOs continue to improve care for their patient populations.”

Mathematica’s health experts are pioneers in advanced health services research, clinical quality improvement and measurement, data quality, analytics, and emerging methodologies—an expertise paired with a strong understanding of health care policy and adoption of technological advancements. Leading with clarifying questions, our close, collaborative approach adapts to evolving policy contexts and moves beyond process to deliver solutions that aim to improve health outcomes, quality, affordability, community well-being, and value.


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