(ACO) regulations - American Society of Anesthesiologists

CMS-1345-P 93
addressing disparities through provider/management education and the translation of
surveys and health promoting literature distributed by the provider into languages
relevant to the provider's population. Establishing partnerships with a State or local
health department which performs community health needs assessments and applying
these findings to the ACO's population and activities may be another viable option for
meeting this criterion.
Accordingly, we propose that, in order to satisfy this patient-centered criterion,
ACOs would be required to describe in their application their process for evaluating the
health needs of their Medicare population, including consideration of diversity, and a
plan to address the needs of their Medicare population.
d. Implementation of Individualize Care Plans and Integration of Community Resources
Finally, we are proposing that ACOs must have systems in place to identify highrisk
individuals and processes to develop individualized care plans for targeted patient
populations. The plan must be tailored to-- (1) the beneficiary's health and psychosocial
needs; (2) account for beneficiary preferences and values; and (3) identify community
and other resources to support the beneficiary in following the plan. This plan would be
voluntary for the beneficiary, privacy protected, and would not be shared with Medicare
or the ACO governing body; it would solely be used by the patient and ACO
providers/suppliers for care coordination. If applicable, and the beneficiary consents, the
care plan should be shared with the caregiver, family, and others involved in the
beneficiary's care. We propose that an ACO would be required to have a process in place
for developing, updating, and, as appropriate, sharing the beneficiary care plan with