Introduction
In today’s evolving healthcare landscape, the traditional physician-patient dynamic is being reshaped by team-based delivery models and increasing specialization. While this shift aims to enhance efficiency, it can inadvertently fragment patient care, particularly for those with complex health needs. Patients with multiple chronic conditions, serious illnesses, or behavioral health challenges often require intensive, coordinated, and comprehensive care. For these individuals, a deep understanding of their medical history, life circumstances, and personal goals is paramount for effective treatment. This is where the implementation of robust care plans becomes crucial, and for Accountable Care Organizations (ACOs), leveraging an Advance Care Planning Management Tool For Acos is increasingly vital to navigate these complexities and deliver superior patient outcomes.
Comprehensive patient care plans are recognized as an evidence-based strategy for clinically managing patients with complex health needs. These plans have demonstrated modest yet significant improvements in patient health markers, including blood pressure control and reduced depression symptoms, alongside enhancing patients’ perceived ability to manage their own health. A systematic review of numerous randomized controlled trials underscores that personalized care plans are most effective when they are comprehensive, intensive, and seamlessly integrated into routine care. Beyond improving clinical outcomes, care plans are instrumental in reducing unnecessary hospital utilization. Evidence suggests their potential to decrease inpatient stays and readmission rates, though further rigorous research is continually needed to fully quantify these impacts.
Recognizing the potential of care plans to improve care quality and reduce costs, the Centers for Medicare and Medicaid Services (CMS) has promoted their use as a benchmark of advanced primary care. CMS mandates care plans for providers billing under Chronic Care Management codes and within innovative models like CPC+ and Primary Care First. Ideally, these plans are developed through collaborative consultation with patients and their extended care teams, encompassing primary and specialist care providers. Care plans should serve as a centralized resource, offering a comprehensive view of a patient’s history, current clinical and non-clinical needs, and future healthcare goals. They must be deeply rooted in patient preferences and aligned with their specific clinical requirements.
The healthcare sector is increasingly adopting alternative payment models, such as ACOs and medical homes, to foster accountability across the care spectrum. Providers operating under value-based contracts are incentivized to adopt evidence-based interventions like patient care plans. While not directly reimbursable, these plans can significantly impact overall spending and the quality of care delivered. Medicare’s ACO models have shown promising reductions in total care costs, with evidence pointing towards even greater savings for patients with complex clinical needs. These patient populations, who often drive a substantial portion of healthcare expenditure, stand to benefit most from the care delivery transformations spurred by payment reform. Consequently, ACOs are strategically employing care plans as a mechanism to realize cost savings, especially within the context of managing complex patient needs.
Payers are also actively promoting specialized care for complex patients through chronic condition management billing codes, special needs plans, and advanced primary care models. However, a crucial gap exists in our understanding of how providers effectively utilize care plans in routine clinical practice. While prior research has examined care plans within structured, multifaceted interventions, demonstrating modest improvements in physical health, real-world application outside these formal programs remains under-explored. Frontline providers may encounter challenges in implementing care plans in accordance with best practices, which emphasize collaborative development involving primary care, specialist care, and patients. This study addresses this gap by employing qualitative interviews to investigate how Medicare ACO providers, who have a track record of achieving savings and quality benchmarks, develop and implement care plan processes for patients with complex health needs, potentially using an advance care planning management tool for ACOs to streamline these efforts.
Methods
To gain insights into the processes and strategies employed by ACOs in caring for patients with complex health needs, we conducted 39 semi-structured interviews across 18 Medicare ACOs. The interview process began with executive-level leaders within each ACO, including directors, chief medical officers, and other senior personnel. Subsequently, ACOs were invited to participate in a second round of interviews with frontline staff, such as care managers, directors of care management programs, and practice leaders. Eleven ACOs engaged in these follow-up interviews, yielding an additional 21 interviews with individuals possessing direct, on-the-ground experience in the ACO’s patient care approaches. Detailed characteristics of the participating ACOs are available in the online appendix.
Interviews were conducted via telephone between February and June 2018, recorded, transcribed, and analyzed using QRS NVivo software. ACOs were selected from respondents to the National Survey of ACOs, specifically targeting those with a Medicare Shared Savings Program (MSSP) contract that had achieved shared savings in at least one year. An iterative outreach process was employed to ensure diversity in geography, composition, ownership, and payer mix. Thirteen of the interviewed ACOs also held additional ACO contracts with commercial or Medicaid payers. The semi-structured interviews, lasting approximately one hour each, covered ACO structure, leadership, governance, engagement with primary care practices, and strategies for caring for complex patients.
Within the study, 11 ACOs were identified as utilizing care plans for patients with complex health needs. A care plan was defined as a written document created by a member of the patient’s care team, developed through interaction with the patient and including patient medical history, current clinical needs, and future management strategies. The analytic approach was collaborative and iterative. All transcripts were initially coded by a research assistant, followed by unblinded coding by the lead author. Coding discrepancies were resolved through discussion. A detailed memo summarizing results was developed based on initial coding, identifying key themes and findings across ACOs, supported by illustrative examples. This memo was iteratively refined through team discussions and further data review and coding.
Results
In the 11 ACOs utilizing care plans, these were typically integrated into broader care management programs. Patients included in care management were generally those with frequent hospital utilization (inpatient stays or emergency department visits), multiple chronic conditions, high healthcare costs, or identified as high-risk for costs or utilization through algorithms or provider assessments. Care management staff, including medical assistants, health coaches, care managers, and care coordinators, were primarily responsible for developing and maintaining these care plans. Notably, primary care and specialist physicians were not responsible for care plan development in any of the interviewed ACOs, although they might utilize or review them.
Core Functions and Scope of Care Plans
The scope and development processes of care plans varied considerably across ACOs, reflecting different core functions attributed to these plans. These functions ranged from care plans primarily serving as tools to aid the care team to those designed as instruments for patient engagement (Fig. 1). Most ACOs employed care plans as either a blend of condition and patient-driven approaches or predominantly patient-driven strategies. Fewer ACOs used them solely to organize and share patient information among the care team. These basic care plans often functioned as a “snapshot” of the patient’s condition. For instance, one ACO described their care plan as a “landing space” for providers, featuring a dashboard of crucial data points:
We’ve added customizations [to their health record], so you can quickly see the risk of readmission, other risk factors, the Gagne risk score, the care manager risk score, you can see a summary of their medications, you can see a summary of their encounters. It’s somewhat of a landing place. (ACO executive)
At this end of the spectrum, care plans often relied on condition-based guidelines to define patient goals, aiming to improve specific, measurable aspects of patient health. One ACO, as part of its disease management program, utilized software based on evidence-based clinical guidelines to automatically generate care plans and goals from patient history and clinical markers. These plans primarily addressed clinical needs and were minimally adjusted based on patient priorities, with goals often centered on identified care gaps like immunizations or upcoming lab tests.
In the middle ground, where care plans aimed to support the care team in addressing clinical needs while also engaging patients, plans were typically more comprehensive, requiring greater involvement from both staff and patients. These blended care plans incorporated non-clinical elements such as social needs and patient activation. One ACO included information on medical conditions, preventive care needs, social determinants (e.g., transportation, housing), substance use, and sensory aids. Another utilized standard patient assessment tools, including patient activation measures. As described by one ACO:
We’re able to go in at that time frame and do that comprehensive assessment, which then gives us the ability to see exactly what the problems are, whether it’s a medical problem, whether it’s a psychosocial problem, whether it’s a behavioral health problem, and we can develop care plans that are really individually specific to the patient’s needs, as well as interventions that we can employ to help those patients meet those goals of the care plans. (ACO care management staff)
At the other extreme, some ACOs primarily used care plans as a patient coaching and engagement tool. While clinical aspects were included, the primary motivation and approach were patient-driven. One ACO developed “shared action plans” after 2-hour patient visits with care coordinators, focusing on patient-centric goals like walking to the mailbox or planning a vacation. Another ACO articulated their motivation for care plan development:
Our care coordinators help patients set their own personal goals that they want to achieve as part of, not only what the doctor has indicated the goals they need to meet, but what are their own personal goals that they wanna reach? And ensuring that we’re addressing their psychosocial as well as their clinical needs. We’ve seen that addressing their social determinants of health. Sitting down with them and figuring out, what are the barriers to care, what’s causing them to visit the emergency room or not come in for a visit or reasons why they don’t pick up their medications, trying to identify those underlying issues. (ACO management)
Care Plan Elements
Patient History
The comprehensiveness of patient histories within care plans varied, encompassing immunization records, lab results, utilization data, past procedures, and social histories. ACOs prioritized information deemed most useful for care delivery, focusing on “whatever might be pertinent to that particular patient’s health situation” (ACO executive). For example, one ACO initially emphasized social history, including employment, living situation, and family status, over clinical markers.
Current Clinical Needs
Organizing and documenting current medical needs in a centralized location was a primary focus of care plans. Most ACOs included current medication information, ranging from simple lists to regular reviews and active reconciliation. Beyond general history, care plans highlighted recent, especially costly, hospital-based utilization to better understand patient needs. One ACO explained:
One of the categories was making sure that the longitudinal plan of care served up ED visits and hospitalizations…. That [utilization] would be really relevant for a care team member who’s interested in what’s happening to the patient right now. (ACO executive)
Many ACOs also incorporated specialist care into patient care plans. In most cases, this involved documenting specialist providers and upcoming appointments based on patient-provided information. ACOs integrated within larger systems had greater specialist care coordination. One such ACO indicated full accessibility and integration of patient care plans across primary and specialist care within their healthcare system.
Patient Goals
Care plans frequently included clinical goals aligned with specific conditions or patient needs, such as managing clinical markers. Some ACOs used sophisticated algorithms to generate clinical goals based on patient health markers, setting targets for blood pressure or blood sugar control.
Seven ACOs mentioned patient-developed goals as part of the care plan. One ACO elaborated:
Yeah, we let the patient talk freely about maybe a goal they want to set for themselves and we couple this with the understanding of where their engagement level is because if the patient PAM [patient activation] score is a level one, they’re very disconnected from their health needs and they’re not engaged so it might be learning what they are engaged with, or maybe they’re worried about something, or one gentleman all he wanted to do was get to his granddaughter’s first birthday and he was estranged from his daughter and there was a lot of dynamics there. But if you begin working on those and breaking down the barriers there you can build up a confidence level and a trust level with the care coordinator and pretty soon your interjecting, oh but if you try this [quit] line you could maybe not need your oxygen as often and not smoke. (ACO executive)
ACOs varied in their definition of patient goals. For some, it meant patients prioritizing clinical goals. For others, goals could be entirely patient-generated and non-clinical, such as:
…pieces of their care plan that are specific to what might be important to them. We’ve had people say, ‘It’s important to me that I stay in my home,’ so we might work with and recommend an in-home safety evaluation…. (ACO management)
Access and Use of Plans by the Care Team
Information regarding care team access and utilization of patient care plans was limited. Physician engagement in care management programs—and by extension, care plans—was often minimal, as these programs were frequently centralized at the ACO level, operating independently of primary care. Interviewees did not perceive this as a limitation but rather as a strategy to reduce burden on clinical care teams. Care plans were considered valuable tools for care management staff working alongside physicians.
Only two ACOs explicitly reported physician access to patient care plans. One of these actively involved physicians in standardized care plan development and implementation. In this ACO, care plans were created by care managers and embedded in the electronic health record, making them the first view upon accessing a patient’s record. Care plans were automatically updated with record modifications. Other ACOs embedded care plans within their care management platforms. While physicians could access these platforms, their actual usage was uncertain. One ACO specifically discontinued primary care physician access due to care management software interoperability issues with practice EHRs. This highlights the potential need for an advance care planning management tool for ACOs that integrates seamlessly with existing EHR systems to ensure broad accessibility and utilization.
Discussion
Personalized, comprehensive patient care plans are promoted as essential tools for delivering high-quality, advanced primary care. They are designed to help care teams effectively manage patients with complex clinical or social needs by addressing care requirements across settings and prioritizing patient goals and preferences. Our study reveals that while most interviewed ACOs developed care plans within broader care management programs, and care managers primarily maintained and utilized them, the implementation and scope varied significantly. Although all ACOs included core care plan elements—patient history, current needs, and future goals—the depth and comprehensiveness of these elements differed. Some ACOs used care plans mainly to organize patient information for the care team, while others also leveraged them for patient engagement. We identified three broad approaches: care plans as provider tools, patient engagement tools, or a combination of both.
Our findings suggest that providers may struggle to implement care plans that are collaboratively developed across care settings and aligned with patient-driven goals. This challenge might stem from the separation of care management programs from direct clinical care and the care management-centric usage of care plans. Prior research has shown that care plans are most effective in improving patient outcomes and controlling costs when both providers and patients are actively involved in their development and use. When care plans integrate perspectives from patients and the entire care team, including primary and specialist care, they are more likely to align clinical and patient goals optimally. However, despite many ACOs aiming for a collaborative approach, several primarily viewed care plans as tools to organize patient care for providers. While care plans should indeed serve as centralized records, the most successful plans also foster patient engagement. There is broad consensus that patient outcomes improve with active patient involvement in decision-making and care planning, a practice not consistently observed among the interviewed ACOs. An effective advance care planning management tool for ACOs could help bridge this gap by facilitating better patient and provider collaboration.
Team-based care is a widely adopted strategy for managing complex patients. Unsurprisingly, most interviewed ACOs relied on care team members like care coordinators, medical assistants, and health coaches to develop care plans. Non-clinicians extend primary care reach, ensuring patients receive more intensive and frequent care. However, the optimal interaction between these team members and clinicians in care plan development remains unclear. Only a few ACOs explicitly described regular clinician access to care plans, and in these cases, clinicians were centrally involved in care planning. In other ACOs, while clinician access was possible, it was not emphasized, suggesting limited clinician engagement in developing, reviewing, or implementing care plans. While documenting care plans might not be the most efficient use of clinician time, clinician access to this information could enhance care delivery by better incorporating patient goals and coordinating care across settings. Effective care coordination requires regular communication among all care team members to ensure patient care is effectively managed, a process that could be significantly enhanced by a well-integrated advance care planning management tool for ACOs.
Our study underscores the challenges of coordinating care across multiple providers, a central aim of care plans and ACOs. Patients with complex needs often have numerous specialist providers in addition to primary care. Given the complexities of care silos, interoperability issues, and communication gaps, it is not surprising that ACOs struggled to comprehensively document specialist care within care plans. Most relied on patient-reported information about specialist appointments. Only two ACOs, both part of centralized healthcare systems, had implemented system-wide initiatives to integrate specialist and primary care clinicians into care plans. Even ACOs with hospital affiliations may face care coordination challenges across settings. These obstacles suggest that providers in ACOs and advanced primary care models may struggle to fully realize the potential of care plans without greater policy support and technological solutions to address integration and communication challenges. An advance care planning management tool for ACOs with robust interoperability and communication features is crucial to overcome these hurdles.
Care plans are intended to be a centralized repository of comprehensive patient information, accessible and updatable by the entire care team. Recent guidelines conceptualize care plans as proactively addressing patients’ total health needs, serving as a cornerstone tool for identifying and resolving these needs. However, our findings regarding patient involvement, clinician accessibility, and cross-setting coordination raise questions about the centrality of care plans in ACO primary care today. Even in their most comprehensive forms within the interviewed ACOs, care plans remained fragmented, with key information inaccessible or missing. Care plans that do not actively engage patients in goal development cannot proactively address patient needs, and plans not utilized by the entire care team cannot serve as the central basis for patient care. Few, if any, of the interviewed ACOs used care plans as envisioned by policymakers and scholars. Future research evaluating care plan impact and best practices needs to consider how healthcare organizations operationalize care plans in practice, and the role of tools like advance care planning management tool for ACOs in improving implementation.
This study has limitations. As a qualitative study, findings may not generalize to all ACOs or providers but offer valuable insights into care plan implementation approaches and can inform hypotheses about care planning value within ACOs. Data primarily reflects perspectives of ACO executives and managers, with less input from frontline clinicians, potentially influencing our understanding of clinician involvement. Finally, we lack data on care plan effectiveness, as the study focused on implementation approaches, although ACOs expressed belief in their positive impact.
Despite these limitations, our study provides valuable insights for clinicians and policymakers by highlighting ACO approaches to care plan implementation. It suggests that current care plan practices may not fully align with best practices, which advocate for collaborative, centralized documentation and goal-setting involving primary care, specialist care, and patients. Instead, ACOs may be adapting care plans to create value for both patients and their organizations in pragmatic ways. Providers and payers should consider the optimal engagement of clinicians, care team members, and patients in care planning, and explore the potential of advance care planning management tool for ACOs to facilitate best practices. As clinicians manage increasingly complex patient populations within evolving healthcare and policy environments focused on cost control and quality improvement, effective strategies to enhance care delivery are essential.
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Funding Information
The authors are grateful for support from the Six Foundation Collaborative and the Agency for Healthcare Research and Quality (AHRQ). Adam Briggs was a Harkness Fellow funded by the Commonwealth Fund.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
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References
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