Integra Community Care Network's Approach to Advance Care Planning (Case Study)

Learning Systems for Accountable Care Organizations
Publisher: Baltimore, MD: U.S. Centers for Medicare & Medicaid Services
Jun 30, 2019
Natalie Graves and Jessica McNab

Key Findings:

  • Through these efforts, Integra increased the number of completed and documented goals-of-care conversations for beneficiaries in their complex care management program from 39 to 88 percent over the course of 2018. Integra’s experience is informative for other ACOs that are interested in improving their approach to advance care planning.

This case study describes Integra Community Care Network’s (Integra) approach to improving advance care planning for high-risk beneficiaries. The approach includes 1) developing and deloying a curriculum for accountable care organization (ACO) providers on the principles of geriatric and palliative care; 2) refining the process for enrolling beneficiaires in its complex care management program in order to include a conversation between beneficiaries and providers about the beneficiaries’ goals for their care; and 3) supporting the nurse care managers and providers who have these conversations by giving them a discussion guide and tool for documenting the conversations.