Care Coordination Toolkit

1 care CoordinationToolkitCare Coordination ToolkitMarch 2019 Overview of the CMS ACO Learning System and ToolkitSince 2012, CMS has supported ACOs in their efforts to improve the delivery of care for their attributed patient populations through model-specific learning systems. These learning systems provide ACOs with a forum in which they can collaborate with and learn from one another. Across the model-specific learning systems, CMS hosts approximately 70 virtual events and 18 in-person events each year on topics tailored to meet the needs and interests of current ACOs.

care team relays information from the visit to the ACO and key care team members so that they can determine the appropriateness of care management services and any necessary refinements to patients’ care plans. Too often, however, this information is not communicated to the ACO or to key care team members, such as the PCP or care manager.

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