Accountable Care Organizations (ACOs)

Accountable Care Organizations (ACOs)

ACOs are defined by the Center for Medicare and Medicaid Services (CMS) as groups of clinicians, hospitals, and other health care organizations that are bound by contractual agreements. ACOs share mutual responsibility for improving quality of care, improving health outcomes, and reducing health costs and inefficiencies for defined populations. While CMS requires ACOs to have a strong network of primary care providers, the PCPCC believes that patient-centered medical home (PCMH) practices are a critical foundation of high-performing ACOs, and that diverse stakeholders (primary care clinicians, patients, families, and caregivers) should play an integral role in setting the direction of an ACO.

A strong relationship between PCMHs and other ACO participants is demonstrated by the adoption of:

Formal patient and family engagement strategies that allow patients, families and clinicians to partner in quality improvement activities and care decisions, and enhance accountability and transparency in the patient-provider relationship

Health IT tools that enable the timely, accurate and secure sharing of health information among providers, patients, families and health and community organizations

Population health management strategies that use data, analytics, and technology to inform health care decisions; identify and manage comprehensive health needs in real-time; and direct patients to appropriate health and community-based support services in a timely manner

Consistent quality measures that monitor and analyze quality, population health, costs, and patient and caregiver experience to inform the development of effective care models and processes.

Innovative payment models that reward all participating clinicians for improving care delivery and health outcomes, as well as patients for making healthy, quality-driven choices

With these elements in place, a high-performing PCMH network will enhance an ACO’s capability to engage patients, families, and caregivers and improve their overall health care experience; enhance access to care and preventive services; deliver comprehensive care that addresses the patient’s entire spectrum of health needs, including physical, mental and emotional needs, as well as social determinants; coordinate care across care settings and organizations; document and exchange patient information; smoothly manage care transitions across all services and providers; and identify and close gaps in care.

Go to top