How do you see the role of the healthcare worker changing as a result of these challenges of a aco

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Basically we got all the practice mangers in a room and gave them the background that they needed plus the scripts … plus the actual materials to hand to patients, and we left nothing to the imagination.

We set up a call-in line if patients had any questions that the staff or practice manager [did not have to] answer. So we worked very, very hard to make it as easy and burden free as possible for the practices. The goal of this overlay approach and others in our data was to do as much work as possible outside practices. Although in this case the practices still were involved minimally through handing material to patients, the bulk of the work including even answering patient was being structured to happen outside of practices.

An overlay approach typically required a strong central system to develop and implement overlay strategies; no ACOs without a strong centralized leadership or management structure were using a primarily overlay approach. The particular centralized leadership or management structure took varied forms. At some ACOs, centralization was due to the structure of a pre-existing organization, such as an integrated delivery system, multispecialty practice, or physician hospital organization having a centralized department or office charged with ACO efforts.

At other ACOs, the centralized management was new to the ACO and external to providers; two of the ACOs had either created or contracted with a management services organization that functioned as a centralized management structure. In either form of centralization, ACOs were able to take an overlay approach. Notably, however, the overlay approach was not used universally among ACOs with a high degree centralization or standardization; some ACOs with a strong centralized leadership or management structure were using the alternate approach to change, involving changing care within practices.

In contrast, the practice change approach involved ACOs meddling with the work of their clinicians, practices, and other staff.

The interviewee described how work had been reorganized within primary care teams:. We put in a bunch of workflows so that the medical assistants can address the health screening issues and the physicians can address the clinical quality issues. This ACO had worked to change the process within primary care visits to be more effective, increasing the scope of responsibilities of medical assistants to include completing screenings in order to allow physicians to focus more squarely on clinical outcomes.

This type of restructuring of workflows within primary care teams is quite distinct from overlay efforts that leave teams untouched. ACOs working under a practice change approach often acknowledged that the kind of change they were undertaking could be a slow or challenging process. Our chief medical officer of the ACO reviews best practice guidelines on an ongoing basis and distributes them to each of the practices for integration into their day-to-day activities…. The long-term goal of ACOs using primary practice change approaches was often building a new, more effective way of caring for patients that would be a foundation for success in future, larger population health endeavors.

Many ACOs used primarily one of the two major approaches. Of those ACOs whose leaders we interviewed, three ACOs were using primarily or exclusively an overlay approach, and nine were using primarily or exclusively a practice change approach.

Those using primarily one approach often were supplementing with a set of strategies from the alternate approach. For example, one ACO was primarily working on a host of methods for practice change, but had also built a small number of centralized, disease-specific programs to which ACO physicians could refer patients with the given condition. An exception to the combined use of methods was were ACOs that consisted of a single physician group; all four of these ACOs in our data used exclusively a practice change approach.

These ACOs likely have both an easier time structurally intervening in existing practices, since they have a single physician group to intervene rather than several independently owned practices.

In contrast, ACOs with multiple practices may find it challenging to intervene or change care within these practices simultaneously, and thus may gravitate to an overlay approach.

Four ACOs we interviewed were actively using both overlay strategies and practice change strategies. These ACOs generally had a set of overlay programs or personnel and were also working to change how practices or physicians were delivering care. In addition, some ACOs were actively engaged in deciding how to best implement methods for changing care, sometimes debating whether they should move more toward an overlay or more toward a practice change approach for particular programs or strategies.

One ACO leader described a program that embedded case managers in clinics that was struggling to succeed under a practice change approach. We put [registered nurse case managers] in the clinics to be closer to patients, try to move a lot of services to point of care but the challenge has been … R. For this ACO, the dearth of RN case managers and high needs of the clinic context compromised the success of embedded RN care managers.

As this quote demonstrates, ACO leadership were able to identify an obstacle to success and adapt their approach to overcome this obstacle by centralizing case managers. With a shift to an overlay approach, ACO leadership hope to protect the focus and productivity of their case managers.

As this case shows, ACOs looking to identify a successful approach need to think about the specific context in question. In the sections that follow, we outline four methods used by ACOs in implementing change.

Regardless of approach, all the ACOs interviewed used one or more of these strategies. We highlight this variation in each section. We identified four methods ACOs were using to achieve their goals. These methods were patient support roles; targeted programming; patient identification and tracking; and clinical process standardization.

ACOs commonly employed non-physician care team members who provided additional patient support outside of medical appointments and hospitalizations. These support personnel had a wide range of titles such as care manager, care coordinator, community health worker, health partner, and patient navigator. Similarly, their scope of work differed across ACOs, including work such as medication reconciliation, patient outreach, follow up after hospitalization or emergency department use, disease management, patient education, home visits, screenings and assessments, and referrals to community resources.

Patient support roles in the practice based transformation approach were generally non-physician personnel embedded into primary care practices or teams to do work described above. In some cases ACOs were working to standardize the roles of these embedded personnel across practices. We still have the majority of them embedded in the clinic.

We really chose to do that embedded model which I think has been great. This ACO used patient support personnel in medical clinics to help patients with a number of issues including ensuring patients could make their visits as well as following up with patients after hospitalizations.

A number of other ACOs interviewed in our study had similar types of patient support roles embedded in medical clinics, performing similar or related services. ACOs using an overlay approach had patient support personnel often providing the same services but were often stationed in a centralized location, providing support by phone or in homes to patients, rather than from medical clinics.

Additionally, some ACOs were using patient support personnel in creative ways, overlayed over existing practices to overcome challenges faced by ACO patients. For example, one interviewee described,. Because sometimes, that population will trust the community-based organizations much more than they will trust the medical system.

This ACO was using community health workers in non-medical settings to develop relationships with populations and individuals disconnected from the medical system as a way to improve access. Other ACOs were using patient support roles in similar ways, for example stationing personnel in jails to help with access to care for those being released, or stationing personnel in housing developments that had high care utilization.

These types of creative placements for patient support roles, particularly to improve access, were more common among safety net ACOs working to reach unique high utilizing populations. Some ACOs using an overlay approach were in the process of refining how personnel stationed outside clinics could best interface with physicians and practices. One ACO had some patient support personnel embedded in clinics as well as some that were centralized, and discussed:.

There are some challenges here with care coordination with the practices…. In this case, the ACO worked to ensure the centralized and practice based staff were a coordinated not confusing set of individuals.

The ACO was working to use both electronic medical records and other methods to clarify which staff were touching what patients to prevent duplicating work or confusing patients.

A number of ACOs created programming targeting patients with specific diseases or conditions, with a particular emphasis on chronic conditions. Overlay approaches to targeted programming typically involved specialized clinics, center, events, or programs delivered outside the primary care setting. One ACO, for example, created a skin care and abscess clinic located in a subsidized housing complex; registered nurses provided care to residents of the housing complex and homeless individuals to prevent infections in wounds.

Other ACOs created similar dedicated clinics or centers for conditions, such as anticoagulation, diabetes, pregnant women with substance abuse disorders, and congestive heart failure. Additionally, some ACOs held one-time events for specific patient groups, again in an overlay fashion. For example, one ACO identified fifty individuals with diabetes who had not seen a provider within a specified time period, and the ACO invited these individuals to a specialized health fair.

The fair had booths, activities, and giveaways such as food bags for attendees. While at the fair patients also could meet with a nurse and a diabetes educator or nutritionist. These type of special events or venues of care were typically approached as an overlay to ACO primary care; ACOs often created clinics, centers, or events where patients receive specialized care as a new but separate addition to existing care and practices within the ACO.

In contrast to targeted programming that happened in an overlay fashion, several ACOs implemented condition- or disease-specific interventions within practices and clinics. For example, one ACO was working to improve blood pressure control by working to improve both quality of screening and adherence to follow up protocol.

First of all, make sure that everybody in a clinical capacity that takes blood pressure takes them well and accurately, and we have a training initiative going out to all the different pods in the practice to make that happen. And … making sure that we have a two- to four-week follow-up if the blood pressure is found to be high. This ACO was working to improve both the quality of the blood pressure screening by all clinical staff in practices as well as improve adherence to a follow up care protocol.

The hypertension intervention happened within clinics through a multi-prong effort involving both education and incentives to change how practices were working with patients with hypertension. Finally, some ACOs had initiatives aimed at engaging patients more actively through self-management or peer-support programs, typically for individuals living with chronic conditions.

Some ACOs used centralized educational programs that helped individuals manage their conditions. For example, one ACO had a healthy homes program to educate parents of children with asthma how to clean their homes without aggravating the asthma and how to manage asthma to keep kids out of the emergency room. Other ACOs were using a practice change approach. One ACO was training physicians how to engage their patients in self-management of conditions like diabetes and obesity, and was building an EHR process to require self-management goals from patients once a year to support this effort.

Unlike patient support roles and targeted programming, which were methods used in both overlay and practice change approaches, clinical process standardization was almost exclusively being used in a practice change approach. Standardization usually involved an ACO working with protocols or guidelines for how to deliver care for particular conditions, patients, or cases. The major distinction within standardization is the extent to which ACOs were enforcing adherence standard guidelines or protocols.

Most ACOs we interviewed 13 were distributing or educating providers within the ACO on protocols or guidelines for various conditions or patients.

Some ACOs stopped short of monitoring or enforcing compliance. To be honest with you, right now our strategy is not necessarily to monitor compliance. This interviewee reflected a sentiment heard from others: ACOs trying to change physician behavior were weighing how hard they should push physicians to change. In this case, the ACO was not at a point where they wanted to penalize physicians for non-compliance.

Rather, they were distributing protocols and working to improve physician acceptance of protocols and then move physicians toward greater adherence. For ACOs moving to implement guidelines or protocols more strictly, there were a number of approaches. Some ACOs worked to hardwire guidelines into practice procedures through methods such as standing orders or electronic medical record alerts.

Several ACOs were monitoring performance on guidelines or protocols through dashboards or other health information technology. Finally, other ACOs were using incentives to encourage providers to follow guidelines or protocols. The ACO described above implementing a blood pressure control program also had an incentive program. Interviewee: Movie tickets. Well, movie tickets for the staff and then each of the primary care departments have a financial risk of paying money into a pool and then receiving a distribution from this pool of funds based on their adherence to following protocol surrounding hypertension.

The incentives were designed to increased adherence, a way to encourage providers to follow not just read or be aware of new care protocols. These were very direct ways ACOs were attempting to change behavior within existing practices. Although most ACOs were implementing clinical process standardization through a practice change approach, two ACOs were taking an overlay approach to standardization.

For example, these centralized coordinators followed up with patients by phone or in-home a specified number of times, worked with patient on treatment adherence, and helped schedule necessary follow up. Nearly all of the ACOs interviewed used strategies to identify and track particular patients.

This work included activities focused on finding and classifying high-risk, high-need, or high-cost patients; tools monitoring care delivery; and approaches to tracking hospital utilization. Patient classification efforts were focused on grouping patients into useful or actionable categories for providers and varied in complexity and inputs.

In contrast, basic analytic approaches used more simple data approaches to identify patients, such as using claims data to identify and compile a list of patients who were high cost or at the extreme asking physicians to identify high-utilizing patients. Both ACOs that used an overlay or a practice change approach were using sophisticated analytic approaches; more basic approaches were generally used by ACOs that were using a practice change model and had less sophisticated centralized systems or software to identify high need patients.

ACOs used a variety of tools to monitor patient care processes, identify care gaps, and track practice performance on quality metrics. These monitoring tools most commonly involved disease registries, which monitored particular patient groups, and dashboards that could monitor or display care patterns at various levels, such as among particular patient populations, at a practice level, or at a physician level.

One ACO identified care gaps with a platform that allowed physicians and practices to create useful patient lists from the electronic medical record. Across the practice change and overlay approaches there were no major differences in use of registry or dashboard tools. Finally, in addition to these identification strategies, some ACOs created systems to track patient hospital utilization patterns in a timely fashion. ACOs often set up alerts that notified identified providers when one of their patients was admitted to the hospital or had an emergency department visit so that they could appropriately coordinate patient care.

In a practice change model, ACOs often had set up to notify primary care physicians and teams about hospital utilization. We examined our data for evidence of patterns across some of our key descriptive characteristics presented in Table 1. Because we have a small and not random sample, we are careful not to read too much into small differences in pattners.

For example, ACOs that were largely safety net or Medicaid were pursuing similar strategies to ACOs that largely served commercial patients; we similarly found no notable patterns by region, age, or number of ACO contracts. The approaches did differ along one key dimension: if an ACO is a single, existing organization e. Single organization ACOs exclusively pursued practice change approaches to clinical care, whereas ACOs that consist of multiple providers or practices also used overlay approaches.

Despite the similarities in the types of strategies executed across ACOs, it should be noted that specific execution of these strategies varied. For instance, the specific location of patient support personnel varied by patient population. Additionally, as noted above, ACOs without hospitals were forced to pursue different strategies to receiving timely notification of hospitalizations through an insurance verification service whereas ACOs with hospitals were generally working on these notifications within their own system.

Nevertheless, the overall strategies e. Understanding the approaches providers are taking under new payment models is important for researchers and stakeholders interested in accountable care.

In this work, we have shown that providers with ACO contracts underway are pursuing a number of strategies aimed at meeting cost and quality benchmarks. Overall, a major difference across ACOs was whether they were approaching cost and quality goals through transforming care at in existing practices and care settings, or through overlaying supports and programs relatively independent of practice based physician care.

In addition, we identified four methods ACOs were using to change care: the use of patient support roles, targeted programming, clinical process standardization, and identifying and tracking high need patients. The nature of how these were implemented varied across ACOs, including by whether the ACO was using a practice change approach or an overlay approach. The approaches, overlay and practice change, each carry advantages and disadvantages.

Overlay approaches may allow for more creative use of care outside of practices, such as efforts described above for outreach, and may be more efficient for some ACOs; for example, hosting a single centralized program or clinic may be easier and more cost effective than instituting many throughout an ACO.

However, the overlay approach likely has limits on what it can achieve, as some things that ACOs want to effect will likely be very challenging or impossible to do without some change in practices or the delivery of care. Again, however, each approach has unique challenges. Overlay strategies require some degree of centralization, as implementing overlay programs require effort outside of individual practices and hospitals; additionally, these strategies may be initially costly, as they typically involve new programs or staffing with no obvious or simple way to divert or repurpose existing staff.

In addition, ACOs using overlay approaches must find ways to coordinate overlay efforts with practices. In contrast, practice based transformation requires changing existing workflows, roles, and practices; champions hope these efforts have long term pay off, but in the short term it can be a hefty undertaking to achieve significant organizational change.

We believe that ACOs using either the overlay or the practice change approach may succeed at reaching cost and quality benchmarks. Ultimately, a hybrid model of pairing practice based change with overlay programs may be the most successful model if ACOs are able to pull the most effective pieces of centralized and overlay care to wrap around physician practices with efficient and effective care teams.

The approaches taken appear to differ in one key way: ACOs that are a single, existing organization e. This may suggest that ACOs that consist of multiple, independent providers face challenges to changing care from within practices, and look to the alternate approach of overlaying new services. We anticipate that providers under ACO contracts will continue to develop their capacity to manage population health, and as a result ACOs will grow in new and additional areas. We expect that as ACOs solidify core capabilities, providers may expand their work into additional domains.

This mirrors the literature on early ACO programs that found little evidence of change in these domains as a result of ACO programs Colla, Goodney, et al. ACOs may begin to work more in this domain in the future. We anticipate that some ACOs may develop more robust management and organizational strategies around implementation, as well. Though we have focused on the methods ACOs reported pursuing around clinical care, the implementation of these methods is another important area of study.

At the time of interviews, most ACOs were still at a buy in phase and relied on engaging providers with positive incentives or the vision of the ACO. We encountered few if any instances where an ACO enacted any kind of sanction against providers for not complying. As ACO contracts progress, it will be important to understand if and how ACOs become able to enforce new requirements among participating providers. Without mechanisms to enforce new strategies, some ACOs may struggle to achieve long-term success at cost and quality performance.

Our work has important limitations. Our results are based on interviews with leadership at 16 ACOs, which are not a statistically generalizable sample. Emphasis on cost-saving has brought with it increased attention to the health services that can be delivered in the community and the social determinants of health. Connecting disparate services in order to meet efficiency goals is a now a core feature of the work of many health managers mediating this process. Our findings also have implications for the conceptualisation of healthcare management as a profession.

The scale and increasing breadth of the role of health leaders and managers is evident in the review. Increasing migration of the healthcare workforce and of population, products and services between countries also brings new challenges for healthcare.

In response, the notion of transnational competence among healthcare professionals has been identified [ 78 ]. Transnational competence progresses cultural competence by considering the interpersonal skills required for engaging with those from diverse cultural and social backgrounds. Thus, transnational competence may be important for health managers working across national borders. A key aspect of professionalisation is the education and training of health managers.

Our findings provide a unique and useful theoretical contribution that is globally-focused and multi-level to stimulate new thinking in health management educators, and for current health leaders and managers.

These findings have considerable practical utility for managers and practitioners designing graduate health management programs. Most of the studies in the field have focused on the Anglo-American context and health systems. Notwithstanding the importance of lessons drawn from these health systems, further research is needed in other regions, and in low- and middle-income countries in particular [ 79 ].

We acknowledge the nuanced interplay between evidence, culture, organisational factors, stakeholder interests, and population health outcomes. Terminologies and definitions to express global health, management and leadership vary across countries and cultures, creating potential for bias in the interpretation of findings. We also recognise that there is fluidity in the categorisations, and challenges arising may span multiple domains.

This review considers challenges facing all types of healthcare managers and thus lacks discrete analysis of senior, middle and front-line managers. That said, managers at different levels can learn from one another. Senior managers and executives may gain an appreciation for the operational challenges that middle and front-line managers may face.

Middle and front-line managers may have a heightened awareness of the more strategic decision-making of senior health managers. Whilst the findings indicate consistent challenges and needs for health managers across a range of international contexts, the study does not capture country-specific issues which may have consequences at the local level. Whilst a systematic approach was taken to the literature in undertaking this review, relevant material may have been omitted due to the limits placed on the rapid review of the vast and diverse health management literature.

The inclusion of only materials in English language may have led to further omissions of relevant work. Health managers within both international and national settings face complex challenges given the shortage of human resources for health worldwide and the rapid evolution of national and transnational healthcare systems. This review addresses the lack of studies taking a global perspective of the challenges and emerging needs at macro international, national and societal , meso organisational , and micro individual health manager levels.

Contemporary challenges of the global health management workforce orient around demographic and epidemiological change, efficiency-saving, human resource management, changing structures, intensified management, and shifting roles and expectations.

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Designing a physician leadership development program based on effective models of physician education. Using hybrid change strategies to improve the patient experience in outpatient specialty care. Download references. The rapid review is part of a larger study on global health management priorities and qualities, supported by the University of New South Wales, Sydney.

You can also search for this author in PubMed Google Scholar. CF conducted the database searches and identification of relevant literature. RH and AC assessed the selected literature. RH and LM conceived the design of the review and contributed to the interpretation of the review results. CF drafted the initial manuscript while RH, AC and LM reviewed and revised subsequent drafts of the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

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Phone interviews, during which a team of 2 or 3 researchers typically interviewed 1 to 3 representatives from ACO leadership at each site, were conducted between September and June and lasted approximately 1 hour. Representatives from ACO leadership included chief executive officers, chief medical officers, and clinical leads for care management initiatives. In order to gain a richer understanding of the use of this workforce under new care delivery models, we selected 6 of the 17 ACOs for in-person site visits.

These sites were selected based on the discovery of multiple initiatives during the phone call that warranted further study. During site visits, which lasted 1 to 2 days and took place between January and October , 2 researchers conducted individual and group interviews together with a wide range of staff, from ACO leadership as described above, to medical directors at practice sites, to frontline providers.

Providers varied by site, but included physicians, nurse practitioners, registered nurses, social workers, pharmacists, and community health workers. At some sites, administrative staff overseeing quality metrics and data management were also interviewed. During most of the site visits, we visited. In all, more than 50 interviews were conducted by phone or in person.

Research followed an inductive process designed to generate insights from the themes that emerged during the interviews. Researchers took detailed notes for all interviews in which they participated, whether in-person or by phone.

The research team met regularly during the study period to review notes and discuss emerging themes. Once themes were established, 2 researchers independently reviewed and coded the transcripts. The phone interviews and site visits revealed that all of the organizations were using earlier quality improvement initiatives as a starting point for their ACOs, but participation in an ACO provided an opportunity to renew or expand such efforts.

Most of the earlier efforts were funded by grants or participation in demonstration projects where sustainable funding was uncertain. ACO leadership generally set the organizationwide vision and provided some budgetary and administrative support, but let individual practices make the specific staffing decisions, often leading to variation from site to site and even between providers at the same site within an organization.

Although ACO leaders sometimes expressed frustration that shared savings. Across sites, respondents reported increased use of interprofessional healthcare teams. The addition of new workers and expansion of roles tended to be concentrated around care for the highest-cost patients in recognition of the potential to significantly lower the cost of care through enhanced care coordination.

All sites reported using risk-stratification techniques to identify the patients at highest risk of hospitalization and directed increased services to these patients.

However, the sites varied in their exact methods for stratification as well as the number of tiers and percentage of patients in each. The Figure depicts a model of the way that patients were generally stratified by level of risk within ACOs and the corresponding care management strategies that were the focus of new or expanded workforce roles.

To the right of the pyramid are listed the workforce roles and care management strategies that are generally applied to patients at each level. The healthcare workers who were most commonly assigned to manage high-risk patients across ACOs were care coordinators or case managers, roles that were typically filled by registered nurses RNs or social workers at the sites participating in this study.

All sites reported using someone in this coordination role, although the titles varied. Most ACOs embedded them in at least some of their primary care practices, 5 primarily used centralized care coordinators for either telephonic or face-to-face care, and a few used a hybrid approach because not all practices had the patient volume to support an on-site person. Although the number of patients assigned to each care coordinator varied by ACO, there was general agreement among different ACOs that 1 care coordinator or case manager could actively manage somewhere between to high-risk patients.

Some care coordinators expressed a preference for lower patient-to-provider ratios to improve efficacy in addressing individual patient needs; however, not all programs had sufficient funds to support this. These clinics were quite resource-intensive and had much lower patient-to-provider ratios than general primary care practices, allowing providers to devote more time and more frequent follow-up visits to these high-need patients.

These intensive outpatient clinics were staffed by a 0. They also included additional team members, such as addiction and behavioral health specialists, geriatricians, dieticians, pharmacists, and patient navigators, to meet specific needs. Recognizing that social determinants are a major contributor to costly but avoidable hospitalizations and emergency department ED visits, 11 ACOs targeted additional services to high-risk patients that go beyond the scope of traditional primary care services.

Social workers, social service navigators, or, in some cases, community health workers link patients with community resources, such as housing, transportation, public health services, or in-home care, when needed. Many sites also discussed examples of primary care practices coordinating with hospitals in the region to receive daily updates about their patients who had been admitted or visited the ED.

In some cases, this could trigger outreach from a social worker or community health worker affiliated with the practice to ensure continuity of care. Finally, some ACOs were working more closely with skilled nursing facilities. Agreements ranged from developing new protocols for sharing discharge information to placing a full-time NP or other clinician on site with the aim of preventing the need for ED visits and hospital readmissions.

These patients have conditions that are currently stable but, if exacerbated, could push them into the high-risk category. Some ACOs reported devoting some modest care coordination 2 ACOs or nurse-led wellness and education protocols to these patients eg, smoking cessation or motivational interviewing around diet and exercise 8 ACOs to monitor them and prevent them from rising into the higher-risk tier.

For example, 2 ACOs assigned certified diabetes educators, who are registered dieticians with additional training in diabetes medications and management, to meet with patients with diabetes across a number of primary care clinics who have been identified by the ACO as at risk for uncontrolled blood sugar. These professionals help to create a customized care plan for each patient, help the patient understand his or her condition and set goals for improvement, and monitor progress.

Pharmacists are also being increasingly integrated into care teams for moderate- or high-risk patients 8 ACOs , to review medications and help resolve duplications and interactions, and identify strategies to improve patient adherence and health outcomes. A common theme running through services provided for high- and moderate-risk patients was enhanced access to behavioral health services. In 8 ACOs, behavioral health specialists either licensed professional counselors or licensed clinical social workers were embedded in primary care clinics or co-located with primary care teams to provide real-time access for patients dealing with acute mental health issues, or to provide a warm handoff to ongoing care.

Moderate-risk patients who are hospitalized may also receive care transition services from nurse or social worker care coordinators to help smooth the transition from hospital to home or another facility.

All patients in an ACO, including low-risk patients, are generally tracked and flagged for preventive care such as vaccines and screenings, by a patient data analyst.

Some ACOs also reported other changes in care for all ACO patients, including low-risk patients, such as directing referrals to specialists who can demonstrate that they provide high-quality care at lower cost or to those who participate in agreements to send information about the patient back to the primary care office 3 ACOs.

In general, few major workforce changes were found to have taken place for the low-risk patients who make up the vast majority of ACO patients, but additional wellness and patient engagement efforts were often cited in interviews as service areas that ACOs would like to expand in the future, once enough savings had been generated from better management of higher-risk patients to enable investing in other areas.

Directing patients to smoking cessation and weight loss resources were mentioned as common starting points. Although all of the ACOs interviewed had chosen to invest in a team-based model in primary care, the actual structure of the teams varied widely from site to site. Rather, sites tailored the composition of their teams according to the needs of the local patient population and provider availability.

For example, sites with a large proportion of safety net patients were motivated to invest in social workers and others who could address social issues affecting health. Factors affecting the local health workforce, such as nearby nursing or other training programs, professional licensure restrictions, or costs related to the local labor market, also played a role.

First, although many different ACO models are currently being tested, this study aimed to collect information from a broad array of ACO models and to deduce general findings that applied across a majority of sites. It is likely, however, that more nuances might result from individual studies focusing on ACOs in 1 particular model.

Second, because our findings focused primarily on changes in care coordination in primary care and postdischarge, we cannot comment as broadly about the effects of transformation on inpatient or specialist care.

Our data collection efforts were also limited to those sites that we identified through background research, and who consented to phone interviews.

We attempted to mitigate this by speaking to site representatives from multiple levels in the organization, when possible.

Although we share a snapshot of what we found in the current era, it is too soon to make any definitive conclusions about the effects of ACOs on workforce needs. ACOs are making significant investments in the health workforce as part of their larger goal of improving quality while lowering total cost of care. Organizations make this investment primarily by hiring new workers eg, care coordinators and social service navigators and by expanding roles within the existing workforce eg, medical assistants and pharmacists.

In primary care, these new roles are mainly focused on the small but significant high-risk population to maximize the potential to improve quality and lower cost. However, each organization is taking a slightly different approach, which results in differences among sites in the particular personnel used, as well as in specific provider-to-patient ratios. It is unlikely any one model will emerge as the ideal nationwide or that requiring use of particular personnel or ratios would yield even results across all ACOs.

Finally, making significant changes to payment and delivery models takes time; even the sites most experienced in bearing financial risk are still experimenting, measuring, and refining their service models. As payment and delivery models continue to evolve, it will be important to monitor the impact on healthcare providers and patients. The authors gratefully acknowledge funding for salaries and research expenses provided by the AAMC.

The authors also thank Ann Berlin for her assistance with the figure. Author Disclosures : The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Send Correspondence to: Shana F. E-mail: sandberg ncqa. Muhlestein D, McClellan M. Accountable care organizations in private and public-sector growth and dispersion. Health Affairs blog website. Published April 21, Accessed August 17, Erikson CE.

Will new care delivery solve the physician shortage? Healthc Amst. Pittman P, Forrest E. The changing roles of registered nurses in Pioneer Accountable Care Organizations.

Nurs Outlook. Social work participation in accountable care organizations under the Patient Protection and Affordable Care Act. Health Soc Work. Performance differences in year 1 of Pioneer Accountable Care Organizations. N Engl J Med. Association of Pioneer Accountable Care Organizations vs traditional Medicare fee for service spending, utilization, and patient experience.

Changes in health care spending and quality 4 years into global payment. Patients are essential stakeholders in designing systems to capture social needs. The authors present key findings from patient interviews regarding social needs screening through technology-based modalities. On this episode of Managed Care Cast, we bring you part 1 of an 8-part video conversation with Blue Cross Blue Shield of North Carolina and Newton Family Physicians about how they adapted to deliver health care in and Differences in use of telehealth between commercial and Medicaid populations during the COVID pandemic are associated with managed care enrollment.

A survey of all Arizona physicians found that accountable care organization, clinically integrated network, or integrated delivery network participation was associated with higher use of health information exchange. However, there are exceptions and important barriers noted. Primary care provider burnout was analyzed before and after a national initiative to optimize the electronic health record inbox notification system at the Veterans Health Administration.

News All News. Press Releases. We know that the overwhelming quantities of COVID information and data that seem continually to be expanding can place a significant burden on you as clinicians seeking to respond to patient questions and, when appropriate, modify treatment recommendations.

Indeed, COVID is affecting the practice of medicine in many ways, and the FDA has an important role to play in supporting providers and patients through this evolution.

Consider that as recently as this January — just eight months ago — few people, other than a limited group of health care professionals and infectious disease experts, had even heard of the novel coronavirus.

From the very beginning, this has been a perplexing and challenging medical mystery, presenting far more questions than answers. Even for those who have followed this public health crisis from its earliest days, little information or understanding of the disease was available. I learned quickly that despite the relative lack of knowledge, we at the FDA had to make decisions about relative benefits and risks with the data we had.

The FDA regulates the safety, effectiveness and quality of all medical products — drugs, vaccines, and medical devices. We also regulate food safety, which of course also is critical during a crisis like this. There is always a steep learning curve in the response to a public health emergency, particularly when it involves a new disease.

But this learning curve has been especially steep for all of us. I am trained, as many of you are, as a scientist. And when this pandemic emerged, I conveyed to the leadership and staff at the FDA that even in the face of the public response to this emergency, we at the FDA needed to apply scientific rigor to any decisions being made, no matter how quickly they needed to be made,.

It was reassuring to me that the FDA leadership and staff agreed whole-heartedly with this approach. This is how the FDA has always functioned in its role as a federal agency that makes regulatory decisions based on scientific rigor. We at the FDA, and you as health care professionals have had to respond to challenges like these in real time. For this pandemic, in particular, for the FDA this has meant supporting the development of safe and effective medical countermeasures.

These actions also included ensuring that our front-line health care workers had and will continue to have the necessary protective equipment. Since the beginning of this pandemic, FDA scientists have been immersed in providing essential regulatory advice, guidance, and technical assistance needed to advance the development of tests, therapies, and vaccines.

The FDA has also partnered with a number of external partners to gather real world evidence to help inform our understanding of the natural history of COVID, drug utilization and performance of COVID diagnostics and therapeutics. Working together has been an instrumental part in our ability to come so far, so fast. As we learn, we discover more answers. But that, in and of itself, is not enough. We must continue to be vigilant and aggressive, constantly reviewing and evaluating the data as they emerge.

The principle underlying this -- that our decisions must not only be informed by the most rigorous data and best science, but also that the evidence on which we base our continuing review is regularly refreshed and expanded through new experiences and opportunities -- is a basic approach of science.

We are learning more every day. For example, as doctors have treated more cases of COVID, it has become clear that it is not just a respiratory ailment but can affect many organ systems, including the kidneys and heart, and can also cause vascular complications. These cases exhibited clinical features similar to Kawasaki Disease, a rare inflammatory disease primarily affecting young children, which causes blood vessels to become inflamed or swollen throughout the body.

Similarly, some dermatologists revealed that some of their patients who were later diagnosed with COVID had symptoms that could be due to vasculitis, including frostbite like pain, small itchy eczema-like lesions on their extremities.

We are all concerned about the reports of rising case counts in different locations across the U. We have also learned that common sense public health measures such as the wearing of masks, social distancing, hand-washing, protection of the vulnerable, and avoidance of large indoor gatherings particularly in bars, do help stop the spread and mitigate community outbreaks. The emerging data also continue to confirm the disproportionate impact of the disease on different communities, based on age, ethnicity, and race.

The Coronavirus Task Force, of which I am a member, continues to carefully analyze and monitor the prevalence of the virus throughout the U. We are closely watching the entire country and working to determine the reason behind any new outbreaks or the spread of the disease.

At the FDA, our work goes beyond analyzing the numbers. Our responsibilities involve a range of efforts relating to the diagnosis, response, and treatment of COVID and supporting solutions to bring an end to this crisis.

This includes facilitating the development of tests, both diagnostic and serologic, supporting the advance of treatments and vaccines for the disease, and working to ensure that health care workers and others have the personal protective equipment and other necessary medical products needed to combat it. Since day one of this emergency, our focus in addressing these challenges has been to meet the need for speed.

The goal has been to use every available tool in our arsenal to move new treatments to patients as quickly as possible while helping ensure safety and efficacy. As this audience is well aware, preventive vaccines for infectious disease are foundational to modern public health. In particular, the agency emphasized the importance of recruiting diverse populations, especially those patients who have been disproportionately affected by the pandemic.

While I cannot predict when the results from these studies will be ready, I can promise that when the data are available, the FDA will review them using its established, rigorous, and deliberative scientific review process.

We all understand that only by engaging in an open review process and relying on good science and sound data can the public have confidence in the integrity of our decisions. One important tool we have used during public health emergencies to support the scientific investigation, is to employ our authority for Emergency Use Authorization EUA.

An EUA allows the use of unapproved medical products or unapproved uses of approved medical products to diagnose, treat, or prevent serious or life-threatening diseases or conditions when certain criteria are met, including that there are no adequate, approved, and available alternatives.

Though EUA decisions are based on emerging scientific evidence, we are continually evaluating and reevaluating that evidence in order to ensure that the known and potential benefits of products outweigh the known and potential risks. Nevertheless, we understand that the pace of FDA announcements and decisions can cause confusion for the public and providers. For instance, some of you may be wondering whether an EUA changes the approach being used to develop drugs and vaccines. What drugs are under development?

Which are the safest or most effective? This is a good opportunity to reiterate that although EUAs may be made on this emergency basis, they are guided by science and by continuous review of the most recent up-to-date evidence available.

Even after an EUA is issued, we regularly review that decision based on emerging information. We make any necessary changes as appropriate. This dynamic process is continually being informed by new data and evidence, and it always seeks to balance the risks with the benefits of every COVID treatment. Take testing, for example. Since day one, tests have played a key role in the ability to understand and manage this disease.