settings—e.g., hospital to home, hospital to nursing home—are points of great vulnerability for patients, and poorly managed transitions are a chief culprit in hospital readmissions (Coleman et al., 2006; Naylor et al., 1999, 2004). Two prominent evidence-based models of care for managing transitions between settings are founded on nursing services: Coleman’s Care Transitions Model and Naylor’s Transitional Care Model. The Coleman model employs advanced practice nurses as “transition coaches” to manage chronically ill patients and their care needs as they transition between settings and to encourage these patients and their caregivers to assume more active roles in managing their care. The Naylor model targets complex chronically ill patients—those with multiple chronic illnesses and other complicating conditions—and uses specially trained transitional care nurses to provide, manage, and coordinate the full complement of clinical care and transitional care services during, between, and after the hospital stay. Both the Coleman and Naylor models have demonstrated significant reductions in hospital readmissions and health care costs. The health reform legislation includes provisions for a startup program of transitional care that is modeled directly on these two evidence-based models.

Accountable Care Organizations (ACOs)

ACOs received noteworthy attention within influential legislative circles during the debate on health reform that led to their inclusion in the final legislation as a pilot program. ACOs, modeled in large part after successful integrated delivery systems like Kaiser Permanente and Geisinger Health System, have been advanced by the Dartmouth Institute for Health Policy and Clinical Practice and Engelberg Center for Health Reform at the Brookings Institution. Their structure grew out of the seminal work on the geographic patterns of health care use and spending from the Dartmouth Institute (Fisher et al., 2009; Goldsmith, 2009; McKethan and McClellan, 2009). Taking advantage of the natural clustering of health care services around hospitals which the analyses on regional patterns of service use revealed, ACOs are envisioned as locally integrated groups of hospitals, physicians, and other providers that are responsible for the health service needs of a defined population of patients (Crosson, 2009a). Their structure draws from the current Medicare Physician Group Practice demonstration program and the prior decade’s Physician Hospital Organization program (Crosson, 2009b).

ACOs offer a pathway to cost control through payment reform, by establishing collaborations of providers that enter agreements with payers to be financially accountable for the provision of health care services to a defined population. These provider collaborations can take a variety of configurations to accommodate and build upon existing local relationships among providers. The payment methods that have been proposed embody a variety of provider incentives to meet cost targets including shared savings, shared risk, partial capitation, and beneficiary incentives such as differential co-pays. Performance measurement

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