ACO Integrated Care Coordination - Genesis Health System

ACO Integrated Care Coordination

The Genesis Accountable Care Organization recognizes that many patients struggle to manage their health, especially if they have chronic conditions such as diabetes, heart disease and chronic obstructive pulmonary disease. These patients often juggle frequent office visits, taking the right medications at the right times, and following medical advice from several doctors. Genesis ACO has developed resources and care coordination activities to engage patients dealing with chronic conditions, to encourage self-care management, and to empower patients to take charge of their health care. Our team of registered nurses, licensed clinical social workers, pharmacists, and certified medical assistants offer extra support for those that need help managing their health care needs. 

  • You may notice that your doctor may have a non-physician team member help you with coordinating your care
  • You may receive calls from your doctor’s team asking about your health needs and helping you to arrange services, like transportation.
  • Your doctor and his/her team may talk with you about your care plan and your treatment options
  • You may get reminders to get needed tests or to schedule appointments
  • You may notice that all your physicians are talking with each other, so you don’t have to fill out so many forms repeat your information; and you should not have unnecessary duplicate tests or procedures.

Care Coordination includes six specific activities:

  1. Identify care coordination needs: Care coordination activities are based on your needs and treatment recommendations, which reflect physical, psychological, and social factors.
  2. Create a plan of care: We work with you and your care givers to identify personal goals, then build care plans to help you meet those goals.
  3. Communicate: We exchange information, preferences, goals, and experiences among participants in your care to ensure you are getting the highest quality, safest care among all your providers.
  4. Assist with care transitions: When you move from one place of care to another – from the hospital to a skilled nursing facility for example – we assist in sharing information and accountability for the care you receive.
  5. Connect with community resources: We provide and coordinate services with additional resources available in the community that may help support your health and wellness. Community resources are any service or program outside the health care system that my support your health and wellness. These include financial resources, social services, educational resources, support groups, and support programs.
  6. Identify population needs: At a system – level, the Genesis ACO assesses the needs of populations to identify and address gaps in services. We use feedback from providers and patients to identify opportunities for improvement.