One of the toughest challenges facing Accountable Care Organizations (ACOs) is caring for medically complex patients. Now, after 11 years of ACO performance, research is revealing ACO strengths and weaknesses regarding care for chronically ill and medically complex patients. The picture that emerges reveals flaws, strengths, and the potential for medically directed home care to make a difference in ACO performance.

Looking at ACO performance in complex care

Initial evidence presented in 2018 claimed that while most ACOs have programs in place for helping those with complicated medical needs, care rarely extends into the areas of home visits, mental health care, and patient engagement.

Another study indicated that “94 percent of ACOs at least partially identify their seriously ill beneficiaries, yet only 8–21 percent have widely implemented serious illness initiatives such as advance care planning or home-based palliative care.”

As ACOs approach 10 years of operation, the results are encouraging and it appears that ACOs are capable of reducing costs without a reduction in the quality of care. But in the areas of palliative care, serious illness, and medical complexity, ACOs have yet to reach optimal performance.

ACOs “An increasingly dominant feature of the health care delivery system”

1,000 ACOs // 44,000,000 Lives

Health Affairs (2020) reported the rise of Accountable Care Organizations but noted that “most ACOs were not focused on care management strategies targeting high-risk individuals (for example, those with multiple chronic conditions or high rates of utilization) but rather were focusing on utilization reduction across all patient groups.” This underlines the potential for medically directed home care to work with ACOs to stabilize seriously ill patients while better protocols are developed to serve the most at-risk and costly patient populations.

How medically directed home care can fill a critical gap

As a Duke/Margolis Center for Health Policy report pointed out, “While ACOs have great potential in improving serious illness care, there remains substantial opportunities for improvement due to a lack of evidence on what works, a need for practical guidance, and challenges in implementing new initiatives.” ACOs, it added, need to redesign their care delivery models for seriously and chronically ill patients.

Medically directed home care, by contrast, is already positioned operationally to meet the needs of this population. Core capabilities of “skilled” or medically directed home care include:

  • RN supervision. A Registered Nurse Care Supervisor monitors each client’s condition and provides a 24/7 resource to the LPNs, CNAs, and HHAs who deliver care.
  • LCSW involvement. Social workers engage patients and family caregivers in processing the emotional and physical realities of providing care in the home. They also address the psychosocial dimension of the patient’s life and in doing so can significantly improve mental health.
  • Condition-specific expertise. Some medically directed home care providers (such as SeniorBridge) have training in conditions such as:
    • Heart disease
    • Dementia
    • Neurological disorders
    • Stroke recovery
    • Cancer treatment and recovery
    • Mental health
    • Hypertension
  • Palliative care. Too often overlooked, this stage of care can have a significant impact on the quality of the patient’s life and the costs associated with end-of-life care.

“Physician group-led ACOs (72 percent) reported slightly higher rates of… routinely identifying seriously ill individuals than did hospital-led (59 percent) or integrated (55 percent) ACOs.”

Health Affairs (2020)

The integrated care management model by SeniorBridge

Home care services vary widely in the services they provide.

SeniorBridge offers an integrated care management practice model that involves two components:

  1. Clinical care (under the direction of an RNCM/Registered Nurse Care Manager) supported by a Social Worker and a team of caregivers, based on patient’s needs and
  2. A portfolio of home care services and geriatric care management in such areas as nutrition, caregiver education, benefit coordination, transportation, and coordination with discharge planners, physicians, pharmacy, home health agencies, and care managers.

NOTE: We have full COVID-19 safety protocols in place to keep clients, families and associates safe.

For more information on medically directed home care, contact SeniorBridge.

Sources consulted:
Commonwealth Fund (2018)
Health Affairs (2019)
Sage Journals (2020)

Learn more about our services

SeniorBridge has on-call professionals available 24/7 to answer your questions. Contact us now to learn more about our services and how we can help.


Available 24/7