全球智库信息集成服务系统

This case study describes Integra Community Care Network’s (Integra) approach to improving advance care planning for high-risk beneficiaries. The approach includes 1) developing and deloying a curriculum for accountable care organization (ACO) providers on the principles of geriatric and palliative care; 2) refining the process for enrolling beneficiaires in its complex care management program in order to include a conversation between beneficiaries and providers about the beneficiaries’ goals for their care; and 3) supporting the nurse care managers and providers who have these conversations by giving them a discussion guide and tool for documenting the conversations.