Accountable Care Organization (ACO)

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together to provide coordinated high quality care to patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.


A person, inside or outside of the health care system, who speaks for the patient and makes certain that the patient receives the necessary services.

Aligned Beneficiaries

In the Pioneer ACO, Medicare beneficiaries are "aligned" with the ACO, based on where they have been receiving their primary care over the past three years. If a beneficiary does not have a primary care physician, they may be aligned to the ACO based on specialty care services they have received.

Care Gaps

The difference between what health care services the patient should have received and what the patient actually received. Care gaps are often focused on preventive services such as flu shots, immunizations, and screenings but data analysis can also uncover gaps in care for patients with chronic conditions such as diabetic retina exams or diabetic foot exams.

Care Management

Care Management is the process of taking care of a patient with a chronic or complex condition and helping them manage their health over their lifetime.

Care Coordinator

A health care professional, typically a nurse or social worker, who arranges, monitors or coordinates services throughout a patients lifetime. Care managers accomplish this by combining a working knowledge of health and psychology, human development, family dynamics, public and private resources and funding sources, while advocating of the patients through the continuum of care.

Chronic Illness

A condition that will not improve, that lasts a lifetime, or recurs. Chronic illnesses include coronary, asthma, Alzheimer's disease, diabetes, epilepsy and some mental illnesses.

Clinical Pathway

A health care management tool that suggests the best way to treat a disease. Clinical pathways are designed to reduce the variations in health care through the use of standardized treatment.

Discharge Planning

A process used to decide what a patient needs for a smooth move from one level of care to another. Only a doctor can authorize a patients release from the hospital but the actual process of discharge planning can be completed by a social worker, nurse, case manager or other person. Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach. In general, the basics of a discharge plan are:

  • Evaluation of the patient by qualified personnel
  • Discussion with the patient or his representative
  • Planning for homecoming or transfer to another care facility
  • Determining if caregiver training or other support is necessary
  • Referrals to home care agency and/or appropriate support organizations in the community.
  • Arranging for follow-up appointments or tests

Disease Management

Refers to the process of assisting a patient in the ongoing management of their disease (such as asthma or epilepsy), rather than treating a single episode. Disease management is intended to improve both the patients' condition and manage the cost of care while focusing on the patient's quality of life.


E-prescribing is the act of electronically sending an accurate, error-free, and understandable prescription directly to a pharmacy.

Electronic Medical Record (EMR)

An electronic medical record (EMR) is a computerized medical record. It is capable of being shared across hospital and other health care offices. EMR's may include medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information. Electronic Medical Records (EMR) are also known as Electronic Health Records (EHR).

Evidence-Based Medicine

Evidence-based medicine aims to apply the best evidence available from science to patient care decision making. It seeks to assess the evidence against the risks and benefits of treatment (or lack of treatment).

Medication Reconciliation

The process of reviewing patient medication orders in order to avoid inconsistencies. A health care professional reviews the patient's current medication and compares it with the medication being recommended for the new setting of care (home or nursing home).


Measuring the results of treatments and their effectiveness. Outcomes are usually measured in terms of cost, mortality, health status, quality of life, and/or patient function.

Patient-Centered Medical Home (PCMH)

The Medical Home serves as the central point of contact for the patient and is focused on providing comprehensive and continuous medical care, working to maximize health outcomes. The Primary Care Physician (PCP) office serves as the center of the Patient's Medical Home.

Using a team approach, the staff within the PCP office (physicians, nurses, care managers, etc.) have the responsibility of assessing the physical, social and emotional needs of the patient, providing the care to meet those needs, or arranging for the care to be provided outside the PCP office, when necessary.

Population Health Management

An approach designed to improve the health of an entire population. Population health management looks beyond the individual. Instead, it focuses on mainstream medicine and public health by addressing a broad range of factors such as environment, social structure, and resource distribution.

Value-Based Purchasing

Value-based purchasing (VBP) is a pay-for-performance program. It reduces payment to poorly performing hospitals and redistributes those dollars to high performers.