Translating Evidence into Practice: ACOs' Use of Care Plans for Patients with Complex Health Needs

J Gen Intern Med. 2021 Jan;36(1):147-153. doi: 10.1007/s11606-020-06122-4. Epub 2020 Oct 1.


Background: Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients.

Objective: To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs.

Design: A qualitative study using semi-structured interviews with Medicare ACOs.

Participants: Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.

Approach: Development, structure, use, and management of care plans for complex patients at Medicare ACOs.

Key results: Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO's planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff.

Conclusions: ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers.

Keywords: accountable care organizations; care plans; complex patients; primary care.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Accountable Care Organizations*
  • Aged
  • Humans
  • Medicare
  • Patient Participation
  • Qualitative Research
  • United States