Executive Summary

Flexibility is crucial to an accountable care organization model. In order to prevent unnecessary hospitalizations and emergency room visits, case managers working with ACOs need to find creative solutions to the type of lifestyle barriers and funding obstacles that hamper health improvements.

• Case/care managers can meet with patients in their homes and provide education to caregivers and families as needed.

• Front office staff can be enlisted to assist in case management and identifying patient issues.

• Often, rehospitalizations can be avoided when the ACO simply buys a solution that is not otherwise covered in medical treatment, such as a vacuum cleaner for a patient with allergies.


Accountable care organizations (ACOs) make it possible for case/care managers to help patients improve their health through creative and flexible solutions, particularly during transitions, experts say.

CMs work in hospital and clinic settings, collaborating to ensure everyone knows what is going on with patients, says Ann Kirby, MSN, MPA, BSN, regional director of care management for Oregon at Providence Health & Services in Portland.

Their real role is understanding what’s going on with the patient and knowing what changes need to happen, she says.

“The inpatient person is the collaborator at a critical point in the patient’s health, but is not the long-term link,” Kirby explains.

CMs in the clinic meet with patients in their homes to see what they need to stay healthy. For instance, if a patient is unable to get to the clinic for an appointment or is lacking regular meals, the CM can find community resources and solutions to these problems, she adds.

“This intervention care manager can provide a nice way to connect with folks we have not been able to care for before,” Kirby says. “There also are care managers who can go into the home and work with the family, identifying their needs.”

Some organizations are finding less direct ways of monitoring their population’s health. For instance, a community clinic’s front-line staff might pick up on cues that something is wrong, suggests Chris Senz, chief operating officer at Tuality Health Alliance in Hillsboro, OR. Tuality Health Alliance is a physician-hospital-community organization, which includes some practices that are patient-centered medical homes. The Alliance enters into agreements with ACOs.

“One of the first things we embrace is the case management model in a practice,” Senz says. When a patient who typically is low risk comes in for a sprained ankle, the front office staff might get into a discussion with the patient and learn that she had recently lost her sister and inherited her sister’s cats, despite having an allergy to cats and not owning a vacuum cleaner, Senz explains.

The staff can tell the office’s CM about the encounter, and the CM can stop by to talk with the patient before discharge, asking how the patient is doing and whether she is managing her allergies, Senz suggests.

In a ranking of the patient’s risk, the normal low level of one has risen to a three or four because of out-of-control allergies, Senz says.

“That level of case management in a medical home happens with everyone in the practice — everyone who has interaction with patients,” she adds. “We’ve reduced the cost of care for that patient because we’ve identified her problems before she even knows she has them.”

Catching an allergy problem early also provides opportunities for creative solutions. For instance, the organization could buy the woman a vacuum through flexible funds for nonbillable services, Senz says.

Once the patient is able to vacuum up cat hair and dander, her allergy could be controlled well enough to avoid her having to seek nebulizer treatment or a hospitalization for breathing difficulties.

“In a traditional case management model, case managers are nurses who may have arranged transportation or coordinated with home health or talked with hospital case managers to get a patient into a skilled nursing facility,” Senz notes. “Under an ACO model, there are a lot of things that happen outside of healthcare that affect healthcare costs, and case management is becoming more creative, using more social workers, educators, and lots of different people.”

Another strategy is to encourage case/care managers to get out from behind a desk and to meet patients where they are.

“When a patient is in the ER, the care manager will meet with the patient and say, ‘Gosh, I’ve noticed you’ve been here 15 times in the last three months. What’s going on?’” Senz says.

Helping high-risk patients improve their health is sometimes the second, third, or fourth step after removing major obstacles in their path.

For example, Senz recalls the case of an extremely obese, middle-aged woman who was mostly bedridden. She would benefit from bariatric surgery, but was not a candidate for this solution until she lost 75 pounds.

The case manager could have arranged for the woman to receive nutrition counseling, but that would have been of little use because it was obvious to providers that the woman couldn’t cook for herself. “So how is she continuing to hook onto this weight? It wasn’t her — it was her caregivers,” Senz says.

Although nutrition counseling for caregivers is not billable, they used flexible funds to find a solution.

So they sent a nutrition counselor to the patient’s caregivers and had them stop her daily 14-egg omelet breakfast and whole chicken dinner. The nutritionist accompanied the family to the grocery store and helped them shop for healthier food. As a result, the patient lost 75 pounds and qualified for bariatric surgery, which will help her lose another 300 pounds, Senz adds.

“The woman lives in poverty, and her caregivers were not very well educated, so they just did what she told them to do,” Senz explains. “Once we got creative with care management, it worked.”

In another example of using flexible funds, Senz recalls the case of a teenage boy who had cerebral palsy and was wheelchair-bound. He’d outgrown his wheelchair and was developing sores and injuries as his mobility decreased. “He didn’t want to be in his wheelchair because it was painful, so he spent more time in bed,” Senz says.

This problem resulted in increased hospitalizations and inpatient expenses. However, the boy’s insurance payer would only provide a new wheelchair every five years and he would have to wait at least another year to receive one. The traditional healthcare solution would be to treat his symptoms through home health or skilled nursing services.

“I said, ‘What if we paid for the chair now? What would happen?” Senz recalls. With the patient’s care manager on board, the ACO bought the boy a new wheelchair out of a budget set up for that sort of nontraditional solution.

With a wheelchair that fit him, the teenager could get out more and even take some work training to be independent, Senz says.

Having the ability to treat the patient holistically has resulted in reducing unnecessary emergency department visits, Senz says.

In addition to providing care management services, they offer patients flexible appointment scheduling, open access to providers, screening patients in the ED to discourage emergency visits for non-emergency issues, and phone-Internet conversations with doctors — all of which help reduce ED visits, she adds.

“People go into health professions because they want to help people, and it’s exciting to see our creativity come to the forefront,” Senz says. “People understand now that 10% of health is what the health system does for you, and 90% isn’t about healthcare.”