Table 1. Processes That Contribute to Index of Care Management and Coordination Activities by Index Tertile: NSACO Wave 4 Respondents Linking to Older Adult Medicare Beneficiaries With Complex Needs.
| Characteristica | ACOs With MSSP Contract | P Value | ||
|---|---|---|---|---|
| First (Lowest) Tertile (n = 84) | Second (Middle) Tertile (n = 97) | Third (Highest) Tertile (n = 63) | ||
| Care management and coordination index, median (IQR) | 7.0 (6.0-9.0) | 11.0 (10.0-12.0) | 14.0 (13.0-15.0) | <.001 |
| Care management activities | ||||
| Segmentation of high-risk patients, No. (%) | 42 (50.0) | 59 (60.8) | 48 (76.2) | .005 |
| Predictive risk stratification ability score, scale 1-9, median (IQR) | 5.0 (3.5-6.5) | 6.0 (5.0-7.0) | 8.0 (6.0-9.0) | <.001 |
| Chronic care management score, scale 1-9, median (IQR) | 6.0 (5.0-7.0) | 7.0 (6.0-8.0) | 8.0 (7.0-9.0) | <.001 |
| Shared decision making score, scale 1-9, median (IQR) | 5.0 (3.0-6.0) | 6.0 (5.0-6.0) | 7.0 (6.0-8.0) | <.001 |
| Care transition activities | ||||
| Care transitions score, scale 1-9 scale, median (IQR) | 5.0 (4.0-6.0) | 6.0 (6.0-7.0) | 8.0 (7.0-8.0) | <.001 |
| Medication reconciliation, No. (%) with most or all patients | 44 (52.4) | 85 (87.6) | 58 (92.1) | <.001 |
| Use of patient navigator or care manager, No. (%) with most or all patients | 17 (20.2) | 42 (43.3) | 57 (90.5) | <.001 |
| Discharge summaries transmitted to practitioners, No. (%) with most or all patients | 31 (36.9) | 86 (88.7) | 58 (92.1) | <.001 |
| Standardized process in place to ensure timely follow-up with primary or specialty care, No. (%) with most or all patients | 34 (40.5) | 89 (91.8) | 61 (96.8) | <.001 |
| Telephone follow-up within 72 h of discharge, No. (%) with most or all patients | 33 (39.3) | 91 (93.8) | 60 (95.2) | <.001 |
| Use of care manager or health coach after discharge, No. (%) with most or all patients | 13 (15.5) | 57 (58.8) | 59 (93.7) | <.001 |
| In-home follow-up within 72 h of discharge, No. (%) with most or all patients | 2 (2.4) | 13 (13.4) | 24 (38.1) | <.001 |
Abbreviations: ACO, accountable care organization; IQR, interquartile range; MSSP, Medicare Shared Savings Program; NSACO, National Survey of Accountable Care Organizations.
a
Information on the scales is given in the NSACO Wave 4 Survey Data subsection of the Methods section.