Rocky Mountain ACO’s Approach to Care Coordination in Rural Areas (Case Study)

This case study describes the care coordination initiative for rural providers developed by Rocky Mountain Accountable Care Organization (RMACO). RMACO began this effort after recognizing that participating practices had strong relationships with their patients, and practices could leverage these relationships to provide effective care coordination. However, practices had few resources to invest in improving population health and their staff had limited experience with formalizing care coordination and had varying credentials and training. RMACO’s care coordination initiative supports practice-based staff who serve as care coordinators for high-risk beneficiaries. The support includes the areas of reimbursement, education, and resources. RMACO funds the initiative with pre-paid shared savings from the ACO Investment Model (AIM) and is working to create a sustainable funding model, such as by using appropriate Medicare reimbursement codes. ACOs seeking to implement or refine care coordination strategies, especially in rural areas, may consider RMACO’s experience.