Managing Complex Medicare Patients in ACOs: Tom Kim, MD

Medicare patients in accountable care organizations (ACOs) face unique challenges, from advanced illness to fragmented medical records, says Tom Kim, MD, chief medical officer, Sound Long-Term Care Management.

This transcript was lightly edited; captions were auto-generated.

Transcript

How does this population differ from “traditional” ACO populations, and what specific challenges does that bring in terms of care, cost, and quality?

It's a really good question. We serve a very unique patient population. This patient population does have a significant number of chronic diseases, but not only is it the number of chronic diseases and illnesses, but it's also the stage of that chronic illness. They're typically further advanced in their chronic illness than other ACOs. On top of that, our patients who are living in long-term care facilities are typically near the end of life, or some of them are near the end of life. And so, there's also that discussion of ensuring that the goals of care are aligned with what the patient's wishes are and what the family's wishes are, so there's another big emphasis on having advanced care planning discussions.

I think the other component here, too, is that there's a greater reliance for these beneficiaries in these facilities to rely on others to help make decisions for them. And so there's a lot more emphasis on coordinating care between the resident in the facility, or the beneficiary, plus their family members or their sort of decision-makers. There's a lot more coordination of care needed. And talking about coordination of care, it's interesting because of these beneficiaries living in facilities, they're often seen by multiple different members of a care team. You have facility staff members. You have consultants. There are lots of folks that come in and provide care, and it's a bit more challenging to coordinate that care because folks document or record their visits in different places. And so that could be in a facility EHR [electronic health record], and each of the different caregivers or providers may document in their own EHR. Trying to pull information and share information that's pertinent to the patient care is a little bit more challenging in this population.