Five years ago, I joined the Aledade Delaware Accountable Care Organization (ACO) because I saw value-based care as the future of medicine and the best option for my patients. Being a part of the ACO has helped me grow closer to my neighboring physicians and has allowed me to take better care of my patients thanks to better information.

Part of being a successful ACO is providing better quality care to your patients. In the most recent reporting year my practice team earned scores of 100% on all of our MSSP Quality Reporting Measures. This is what we strive for as a practice: we want to always deliver the best possible care. However average scores can vary, so I’m sharing the strategies my team has honed over the last several years, to deliver quality care to our patients.  

Make sure everyone gets a Medicare Annual Wellness Visit (AWV)

Getting patients scheduled for AWVs has helped us to be successful with our MSSP Quality Measure Reporting and a key part of building trusting patient relationships is getting Medicare patients scheduled for their Medicare Annual Wellness Visits (AWVs). The AWV worklist in the Aledade App lets us see who is eligible for an annual visit and prioritizes patients based on their risk factors and eligibility. From August until December, we work especially hard to get eligible patients in the door.  We work from a list of patients attributed to our practice, marking off who has been scheduled and who still needs to be seen. We schedule patients for next year’s AWV before they leave this year’s AWV. Patients now see these visits as a regular part of their care, and I get the opportunity to sit down and discuss important issues with each patient every year.

Provide flu shots to high-risk patients

We typically start with a list of people who had flu shots last year and see who we can bring in or give shots to when they are in the office. The practice staff and I review this regularly and run a list from our EHR at the end of December and try to get the remaining patients vaccinated. We focus on high-risk groups such as those who are 65 years and older and those with asthma and diabetes. We do whatever it takes to get our patients into the office for their flu shot, including sending them reminder cards and calling them at home.

Embrace preventive care

Our approach to preventive measures such as colorectal cancer screening, breast cancer screening, or even HgA1C monitoring is to check each person’s health maintenance list in our EHR. We do this for all visits. We start by checking the Daily Huddle in the Aledade App to see preventative services that have occurred outside of our office, which allows us to update our records. If they are due for their mammogram or bloodwork for diabetes, I give them a prescription and set a reminder.

We bring our diabetic patients into our office every four months for a checkup. Each time they come in, they know they will get their lab slip for their HgA1C so that we have that lab done prior to the next visit. It’s important to make sure patients are getting what they need while they are in the office. Convenience is key for making sure that patients receive the right services – we know that patients will not always get everything done if it isn’t convenient for them.

We have also started to proactively reach out to everyone when they turn 50 years old. We schedule patients for a physical, Prostate-specific antigen (PSA), colonoscopy, mammogram and other preventive care recommended based on the patient’s medical history and risk factors. This approach helps prepare patients for the routine services they will need as they age, and helps them get on a schedule for appropriate preventive measures.

Generate buy-in and create success
As you make these changes to patient care, don’t forget your own team! At my practice we take a team approach to tackling quality. Our practice manager, Michele Weiss, and Karen Green RN have been essential in developing and carrying out these processes to manage and document our quality efforts. Make sure to identify who plays a role in reporting and emphasize the importance of quality reporting and its impact on patient care. Then take time with your team to identify any pain points or particularly low scores and discuss ways you can improve them.

We’ve found success with increasing patient outreach activities, including making calls, sending cards and scheduling next year’s yearly appointments at the patient’s next office visit.  Changing the way you manage patients might seem overwhelming, but you don’t have to do everything at once. Focus on improving one area at a time and building other processes as you go. And remember, the heart of quality reporting is supporting and engaging your patients to provide better quality care.