ALEDADE 91 CA MSSP ENHANCED

The ACO will make payments as necessary to Participants in the ACO to reimburse the staffing costs required to complete certain value based care activities, which includes:

a) Conduct outreach to patients.

b) Contact patients recently discharged from a hospital emergency department or inpatient/outpatient status to assess if needs were met and schedule a follow up visit with their primary care physician if needed.

c) Contact patients who have not been seen by their primary care physician in 6-12 months (depending on chronic conditions) and schedule annual wellness or other diagnostically appropriate appointments.

d) Contact patients who are new to the Medicare program and schedule a “Welcome to Medicare” visit.

e) Implement and routinize use of the Aledade application to provide insights into patient health, diagnosis coding opportunities, and visibility into the total cost of patient care.

f) Reviewing the “care gap worklist” in the Aledade App to apprise patients of test results, conducting outreach to patients to schedule preventive screenings, and follow up with patients concerning medication adherence concerns.

g) Support accurate and complete diagnosis documentation and coding.