In 2001 the Institute of Medicine (IOM) released the report "Crossing the Quality Chasm: A New Health System for the 21st Century." The report recommended a redesign of the American health care system by providing six "Aims for Improvement": Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity. These principles set forth a specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others to improve the US health care system. Source: IOM-National Academy of Sciences


Now with the passage of the Affordable Care Act (ACA), we are experiencing a significant redesign of the health care system. This redesign and the emerging models are focused on what you may often hear referred to as the "Triple Aim". Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance by 1. improve the health of the population; 2. enhance the patient experience of care (including quality, access, and reliability); and 3. reduce, or at least control, the per capita cost of care. Source: IHI


The following are some of these emerging health care models - click on the headings below to get more information:


Accountable Care Organization (ACO) (download PDF )

What is an ACO?

An ACO is a local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined population.


The goal of the ACO is to deliver coordinated and efficient care. ACOs that achieve quality and cost targets will receive some sort of financial bonus, and under some approaches, those that fail will be subject to a financial penalty. In order to meet the requirements of this type of incentive system, an ACO needs to be able to:

  1. Care for patients across the continuum of care, in different institutional settings
  2. Plan, prospectively, for its budgets and resource needs
  3. Support comprehensive, valid and reliable measurement of its performance (Note this includes reporting on cardiovascular and diabetes measures in line with 1305 Domain 3)
    Source: Robert Wood Johnson Foundation

The federal government is promoting ACOs to pave the way for the shift from our current volume-based reimbursement model to a model based on quality and efficiency.


ACOs are expanding throughout the United States. You can also explore what's happening in your state by going to the Center for Medicare & Medicaid Services Innovation Center and searching by state for "Where Innovation is Happening".


Community Care Team (download PDF )

The Community Care Team is a multidisciplinary team that partners with primary care offices (specifically Patient Centered Medical Homes), the hospital, and existing health and social service organizations. The goal is to provide patients with the support they need for well-coordinated preventive health services and coordinated linkages to available social and economic support services. States currently implementing the Community Care Team Model have found it a key element in the Patient Centered Medical Home efforts to improve care and reduce avoidable costs, especially those with complex or chronic conditions.


Health Homes (download PDF )

The Affordable Care Act of 2010, Section 2703, created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions by adding Section 1945 of the Social Security Act. CMS expects states health home providers to operate under a "whole-person" philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.


Health Homes are for people with Medicaid who:

  • Have 2 or more chronic conditions
  • Have one chronic condition and are at risk for a second
  • Have one serious and persistent mental health condition

Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease and being overweight. Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval.


Health Home Services:

  • Comprehensive care management
  • Care coordination
  • Health promotion
  • Comprehensive transitional care/follow-up
  • Patient & family support
  • Referral to community & social support services

Health Home providers can be:

  • A designated provider: May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, or other provider.
  • A team of health professionals: May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and can be free-standing, virtual, hospital-based, or a community mental health center.
  • A health team: Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractics, licensed complementary and alternative practitioners.

For more information, contact: healthhomes@cms.hhs.gov.

Source: Centers for Medicare & Medicaid Services


Patient Centered Medical Home (download PDF )

The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.


The medical home encompasses five functions and attributes:

1. Comprehensive Care
The primary care medical home is accountable for meeting the large majority of each patient's physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.


2. Patient-Centered
The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient's unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses.


3. Coordinated Care
The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.


4. Accessible Services
The primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients' preferences regarding access.


5. Quality and Safety
The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

For more information visit: The PCMH Resource Center


Team-based Care (download PDF )

Team-based health care is defined as the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers - to the extent preferred by each patient - to accomplish shared goals within and across settings to achieve coordinated, high-quality care.

Source: Mitchell et al. 2012. Core principles & values of effective team-based health care


Principles of Team-based Care include:

  • Shared goals
  • Clear roles
  • Mutual trust
  • Effective communication
  • Measurable processes and outcomes

In May 2012 the CDC released the Task Force on Community Preventive Services recommendations for team-based care (TBC) for improving blood pressure control on the basis of strong evidence of effectiveness.


To learn more about the Summary of Task Force Recommendations and Findings visit:
The Community Guide


Broader than the Health Care Practice: When we think of team-based care, we think of a wider view to include everyone involved in the patient's care. This may include specialists, dentist, the optometrist, orthopedic surgeon, allergist, surgeon, cardiologist, and endocrinologist. But you have to think beyond this to others like the pharmacists, those involved in home care, visiting nurses, community health workers, mental health specialist, physical and occupational therapists, health educators, dietician, diabetes educator and of course public health partners including state cardiovascular and diabetes programs.


Review the Team-based Care section of this site for more information on the roles of team members.


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