Accountable Care Organization Care Transformation Toolkit

Nazihah Siddiqui
Sonya Streeter
Maggie Glos
Ethan Jacobs
Rumin Sarwar
Candice Talkington
Implementation Tool
January 2021


This toolkit provides practical steps for current or potential future Medicare accountable care organizations (ACOs) to transform the delivery of care, including through telehealth, home visits, and skilled nursing care.


ACOs have common goals to improve care delivery, but they use different approaches to provide value-based care. This toolkit, the fourth in a series from the Centers for Medicare & Medicaid Services, explores best practices for ACOs to implement sustainable care transformation initiatives. The toolkit draws from ACO lessons to detail program strategies related to telehealth, home visits, and skilled nursing care and features snapshots of ACO programs on each of these topics.

About this Tool

While care transformation efforts differ in the services offered, populations targeted, and resources needed, many ACOs implement these initiatives in similar ways. The toolkit outlines common ACO implementation approaches for care transformation initiatives, with step-by-step guidance for: (1) reviewing policy requirements and defining objectives; (2) engaging stakeholders; (3) defining and piloting workflows and processes; (4) identifying and engaging populations; and (5) refining activities-based progress and outcome measures.

As an example, strategies to transform care through telehealth include: (1) determining services offered, the originating site, and the technology used for telehealth initiatives according to the needs of key populations and identified care gaps; (2) obtaining by-in for telehealth programs before launching from relevant practice groups and providers; and (3) measure impacts, such as how many virtual visits are conducted, revenue associated with telehealth, and beneficiary satisfaction with virtual visits.


Many ACOs, especially those looking to move to a two-sided risk model, can use this toolkit to guide the development of care transformation initiatives to improve care for beneficiaries with complex health and social needs. 

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