This post is the seventh of an 11-part series that proposes structures and actions that characterize successful accountable care organizations. Click here to download A Model for Value-Based Provider/Payer Partnerships white paper that covers the subject more in-depth.

To redesign care delivery processes and coordinate patient care services, a multi-organizational and multi-disciplinary operations and clinical team should be assembled to establish a baseline of current processes and develop new, integrated, innovative care processes. As part of this effort, evidence-based guidelines should be reviewed and approved by the clinical team, and physicians informed of and held accountable to following the protocols.Cynthia Kilroy

In addition to redesigning clinical services and programs, clinical integration necessitates redefining continuity of care. The redesign should focus on care transitions to support patient-centered care delivery across the continuum: from the primary care physician (PCP), to specialty care, to the facility, to long-term care and to the patient’s home.

Changes to clinical processes across services can offer opportunities to improve clinical care and increase overall patient satisfaction. For example, more emphasis could be placed on providing support and services to PCPs to change the way they manage a patient population and deliver care. Clinical processes could also be targeted to the micro level, such as identifying specific physician outliers or less-effective inpatient processes.

As the ACO addresses issues at a macro and micro level, a new integrated process will emerge that removes duplication, leverages resources and improves outcomes.

In the next post in the series, we’ll discuss how empowering patients can improve your population health programs.

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