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The Role of PCMH and Accountable Care Organizations (ACO) in The Coordination of Patient Care

There are four core functions of primary care as conceptualized by Barbara Starfield and the Institute of Medicine. These four core functions consist of providing “accessible, comprehensive, longitudinal, and coordinated care in the context of families and community.” (National Academy of Sciences, 1996)

In the PCMH model, the integration of diverse services that a patient may need is encouraged. This integration which also involves the patient in interpreting the streams of information and working together to find a plan that fits with the patient’s values and preferences is under-recognized and under-appreciated (Starfield B, 2005).

Appropriate coordinated care depends on the patient or the population of patients and to a large extent, the complexity of their needs. The challenges involved with facilitating the delivery of care increases as the complexity of their needs increase. These complexities include chronic or acute health conditions, the social vulnerability of the patient, and the environment of the patient including the number of providers involved in their care. Other factors that may play a role in the patient’s coordination of care include their preferences and their ability to organize their own care. The increases in complexity may overwhelm informal coordinating functions requiring a care team that can explicitly provide coordinated care and assume responsibility for the coordination of a particular patient’s care (National Academy of Sciences, 1996).

According to the ACO, care coordination achieves two critical objectives-- high-quality and high-value care. ACOs can build on the coordinated care provided by the PCMHs and ensure and incentivize communications between teams of providers that operate in various settings. ACOs can facilitate transitions and align the resources needed to meet the clinical and coordinated care needs of the population. They can develop and support systems for the coordination of care of patients in non-ambulatory care settings. Furthermore, they can monitor health information systems and the timeliness and completeness of information transactions between primary care physicians and specialists. The tracking of this information can be used to incentivize higher levels of responsiveness and collaborations (National Academy of Sciences, 1996).