A Geriatrician’s Guide to Accountable Care Implementation: Thickets and Pathways

  • Terry E. Hill


The focus on value and accountable care opens unprecedented opportunities to create effective care systems for older and/or high-need, high-cost patients. The journey to accountable care is far from linear, however. Multimorbidity and the social complexity of these patients resist easy off-the-shelf interventions, particularly given the entrenched fragmentation across primary and specialty care, post-acute and long-term care, palliative care, and community-based services. Each delivery system must find its own way across a landscape strewn with false starts, failures, and avoidable suffering. This chapter will review a broad array of innovations with particular attention to program development and adaptation, as well as the levers of organizational change. Readmissions are one such lever. Readmission reviews provide line of sight into the interstitial spaces of our health delivery systems. Readmission reduction entails addressing multiple services across multiple sites of care, e.g., medication management, advance care planning, and palliative care. Similarly, new partnerships in post-acute care and community care promise to reduce high-cost facility utilization. Predictive analytics tools help match high-touch resources to patients with remediable needs. Your ability to develop and sustain geriatric programs will depend upon your ability to obtain and present credible data on clinical and financial performance. Challenges remain, but the focus on value has begun to align the transactional logic of operating margins and the mission-driven logic of healing relationships. We should take advantage of this overlap wherever we can.


Accountable care Geriatrics Readmissions Post-acute care Implementation Population health 


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© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Hill Physicians Medical GroupSan RamonUSA

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