Affordable Care Act Predictive Modeling Challenges and Opportunities for Case Management

Purpose/Objectives: The move to the Accountable Care Organization model of care calls for broad-sweeping structural, operational, and cultural changes in our health care systems. The use of predictive modeling as part of the discharge process is used as a way to highlight just one of the common processes that will need to be transformed to maximize reimbursement under the Accountable Care Organization model. The purpose of this article is to summarize what has been learned about predictive modeling from the population health management industry perspective, to discuss how that knowledge might be applied to discharge planning in the Accountable Care Organization model of patient care, and then to outline how the Accountable Care Organization environment presents various challenges, opportunities, and implications for the case management role. Primary Practice Setting(s): Hospitals, physician practices. Findings/Conclusions: The development of predictive models to identify patients at risk for readmission is described and how such models can positively impact the discharge planning process by lowering readmission rates. Examples of the structural, operational, cultural, and case management role changes necessary to maximize the benefits of an Accountable Care Organization are described. Implications for Case Management Practice: There is a growing need for advanced practice nurses to fill the leadership, resource management, analytical, informatics-based, and organizational development roles that are sorely needed to advance the Accountable Care Organization model of care. Case managers are well-positioned to lend their expertise to the development efforts, but they will need to be educationally prepared for the many advanced practice roles that will emerge as our nation evolves this new system of health care delivery.