§ 425.112 Required processes and patient-centeredness criteria. ( a ) *General.* ( 1 ) An ACO must— ( i ) Promote evidence-based medicine and beneficiary engagement, internally report on quality and cost metrics, and coordinate care;
( ii ) Adopt a focus on patient centeredness that is promoted by the governing body and integrated into practice by leadership and management working with the organization's health care teams; and
( iii ) Have defined processes to fulfill these requirements.
( 2 ) An ACO must have a qualified healthcare professional responsible for the ACO's quality assurance and improvement program, which must include the defined processes included in paragraphs (b)(1) through (4) of this section.
( 3 ) For each process specified in paragraphs (b)(1) through (4) of this section, the ACO must— ( i ) Require ACO participants and ACO providers/suppliers to comply with and implement each process (and subelement thereof), including the remedial processes and penalties (including the potential for expulsion) applicable to ACO participants and ACO providers/suppliers for failure to comply with and implement the required process; and
( ii ) Employ its internal assessments of cost and quality of care to improve continuously the ACO's care practices.
( b ) *Required processes.* The ACO must define, establish, implement, evaluate, and periodically update processes to accomplish the following: ( 1 ) Promote evidence-based medicine. These processes must cover diagnoses with significant potential for the ACO to achieve quality improvements taking into account the circumstances of individual beneficiaries.
( 2 ) Promote patient engagement. These processes must address the following areas: ( i ) Compliance with patient experience of care survey requirements in § 425.500 or § 425.510, as applicable.
( ii ) Compliance with beneficiary representative requirements in § 425.106.
( iii ) A process for evaluating the health needs of the ACO's population, including consideration of diversity in its patient populations, and a plan to address the needs of its population. ( A ) In its plan to address the needs of its population, the ACO must describe how it intends to partner with community stakeholders to improve the health of its population.
( B ) An ACO that has a stakeholder organization serving on its governing body will be deemed to have satisfied the requirement to partner with community stakeholders.
( iv ) Communication of clinical knowledge/evidence-based medicine to beneficiaries in a way that is understandable to them.
( v ) Beneficiary engagement and shared decision-making that takes into account the beneficiaries' unique needs, preferences, values, and priorities;
( vi ) Written standards in place for beneficiary access and communication, and a process in place for beneficiaries to access their medical record.
( 3 ) Develop an infrastructure for its ACO participants and ACO providers/suppliers to internally report on quality and cost metrics that enables the ACO to monitor, provide feedback, and evaluate its ACO participants and ACO provider(s)/supplier(s) performance and to use these results to improve care over time.
( 4 ) Coordinate care across and among primary care physicians, specialists, and acute and post-acute providers and suppliers. The ACO must— ( i ) Define its methods and processes established to coordinate care throughout an episode of care and during its transitions, such as discharge from a hospital or transfer of care from a primary care physician to a specialist (both inside and outside the ACO); and
( ii ) Have a written plan to: ( A ) Implement an individualized care program that promotes improved outcomes for, at a minimum, the ACO's high-risk and multiple chronic condition patients.
( B ) Identify additional target populations that would benefit from individualized care plans. Individualized care plans must take into account the community resources available to the individual.
( C ) Encourage and promote use of enabling technologies for improving care coordination for beneficiaries. Enabling technologies may include one or more of the following: ( 1 ) Electronic health records and other health IT tools.
( 2 ) Telehealth services, including remote patient monitoring.
( 3 ) Electronic exchange of health information.
( 4 ) Other electronic tools to engage beneficiaries in their care.
( D ) Partner with long-term and post-acute care providers, both inside and outside the ACO, to improve care coordination for its assigned beneficiaries.
[76 FR 67973, Nov. 2, 2011, as amended at 80 FR 32835, June 9, 2015; 82 FR 53368, Nov. 15, 2017; 85 FR 85038, Dec. 28, 2020]