Drive Change in an ACO

The Hospitalist. 2013 April;2013(04):

April 30, 2013 | The Hospitalist

Mindset Change

If hospitalists are part of the chain of ACO physicians and providers held accountable for the health of a population of patients, we must work more closely with the medical home/neighborhood, post-acute-care facilities, and home-care providers. The change in mindset will occur only if we have a set of tools to get the job done, such as case managers and information technology, and the appropriate incentives to support better care coordination. I encourage my fellow hospitalists to make things happen, instead of taking a passive role in this monumental transformation.

Reference

Muhlestein D. Continued growth of public and private accountable care organizations. Health Affairs website. Available at: https://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations. Accessed March 16, 2013.

The View from The CENTER

As ACOs proliferate across the country, SHM is developing resources and programs to shape the role hospitalists play in care coordination across the ACO continuum. In SHM’s Glycemic Control and Innovative Care Coordination program, a comprehensive survey was conducted of multidisciplinary glycemic management teams, identifying best practices and gaps in care regarding education of inpatients and providers, as well as processes to proactively identify patients at special risk of complications across the spectrum of care. Utilizing the survey results to inform interventions, 10 hospitals will participate in a demonstration program that will focus on improving care transitions between the hospital and post-discharge facilities for patients with diabetes.

Many of SHM’s programs are being developed with population health and post-acute-care transitions in mind. In the near future, SHM will be releasing an implementation guide for atrial fibrillation management. A full chapter is devoted to the patient who has been newly diagnosed and prescribed anticoagulants. This chapter discusses the critical need for careful coordination between the inpatient and post-acute setting and for patients to fully understand their discharge plan in order to ensure optimal outcomes.

SHM’s Project BOOST has long been promoting effective and quality discharges and will receive an update to its toolkit to specifically address transitions to post-acute care.

We also note an increase in SHM members devoting more of their time to caring for patients in skilled nursing facilities, so called “SNFists.” As this trend continues and hospitalists move along the ACO continuum, SHM is committed to staying abreast of the challenges facing our membership and providing the most up-to-date resources and programs to support your work.

For more on quality improvement and care coordination, visit www.hospitalmedicine.org/qi.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.