I’m an independent internal medicine physician with my own practice, Advanced Internal Medicine, in Paducah, Kentucky. My practice has served patients in Paducah for three and a half years. Paducah is a changing medical community. We have two competitive hospitals in our town that employ many of the specialists and physicians in our area. There’s still a good number of independent primary care doctors, like me, who run our own practices.

Three years ago, other independent doctors and I joined a local Accountable Care Organization (ACO). We were excited about the opportunity to come together to offer better care for our patients and leverage our size to compete with hospital employment. However, we didn’t see significant progress in our move to value-based care or a clear vision for how we would get there. At the end of our relationship with our prior ACO, after doing some research, we decided to partner with Aledade.

Working with Aledade has been a completely different experience.  From our first kick- off visits we could see that Aledade was different.  Aledade had a plan to address our local pain points and worked with us to get things right. Before Aledade, for example, our group of doctors didn’t have a plan for Annual Wellness Visits (AWVs) or HCC coding. We were all trying to tackle them separately without insight into an optimal workflow. With the Aledade App we have actionable data and can target our highest priority patients, to keep them healthy.

I have found that it is possible to participate in value based care and remain independent. I was the solo doctor figuring it out on my own, and it was time consuming and hard. When you partner with Aledade you don’t have to figure things out on your own. Having support in moving to the next level of value-based care has made all the difference. We now have someone from Aledade in our office every single week. They help us stay on track and keep in touch between visits. They’re there to help us break down barriers, so we can provide our patients the best care.

I’m looking forward to the next three years working with Aledade. The changes I’ve seen already in my practice are unparalleled.

This is National Healthcare Decisions Day Week (yes, that’s a little confusing). It is a week to consider the importance of end of life planning that is sponsored by The Conversation Project, an organization co-founded by a journalist who wrote:

“In my mom’s last years of life, she was no longer able to decide what she wanted for dinner, let alone what she wanted for medical treatment. So the decisions fell to me. Another bone marrow biopsy? A spinal tap? Pain treatment? Antibiotics? I was faced with cascading decisions for which I was wholly unprepared. After all the years I had written about these issues, I was still blindsided by the inevitable.

The last thing my mom would have wanted was to force me into such bewildering, painful uncertainty about her life and death. I realized only after her death how much easier it would have all been if I heard her voice in my ear as these decisions had to be made. If only we had talked about it. And so I never want to leave the people I love that uneasy and bewildered about my own wishes. It’s time for us to talk”

The Conversation Project was born from this experience, an organization created to help people talk about their wishes for end of life care. At Aledade, we share this vision. It is the right thing to do and aligns perfectly with the mission of Accountable Care Organizations that are trying to improve patients’ healthcare experiences while reducing non-beneficial health care costs. 80 percent of patients who die annually in the U.S. have Medicare as their primary insurance and approximately $170 billion is spent annually by Medicare on the last year of life; this equals 25 percent of all Medicare spending. Much of this spending is useful and important, but not all of it is, and Accountable Care Organizations are in a key position to try to improve end of life care in this country.

Some numbers:

  • 90 percent of people say that talking with their family about their end-of-life treatment preferences is important.
  • 27 percent have had this conversation
  • 23 percent have put their preferences in writing
  • 7 percent have had a similar conversation with their own doctor (the number is higher for Medicare patients: 27 percent)

On the other hand, 64 percent of physicians have completed their own advance directives and discussed it with a family member and 80 percent of physicians have a stated personal preference for comfort care over aggressive medical treatment at the end of life.

What do these statistics suggest? At least two things:

First, that we as physicians have seen what can happen when treatment preferences are not documented and shared with family: unwanted treatment that too often results in needless suffering for patients and their families. We have seen it, and we don’t want that experience for ourselves or our loved ones.

Second, that there are likely barriers that prevent physicians from offering this important aspect of care to all our own patients. Is it a conversation that takes too much time to fit cleanly into a provider’s schedule without spilling into other appointments and backing up a busy clinic? Is it the discomfort with broaching a potentially emotional and uncomfortable subject? The challenge of communicating around uncertain prognoses? Concern about applying our own choices and values to our patients’ most important decisions? Lack of clarity within the medical system around who “owns” end of life planning?

At Aledade, we are taking on the wonderful, difficult and important challenge to understand these barriers and address them. We help primary care practices identify patients who are most in need of end of life planning and offer medical providers training in using the Serious Illness Conversation Guide to discuss end of life preferences. We offer practices the option to partner with Iris Plans, a company with palliative care expertise that offers patients advance care planning via phone and video conference, so these conversations can be held at a time convenient for patients and in a way that allows family members who live far away to join and be included in the conversation in real time. We also have created a scorecard for hospices based on billing data and patient satisfaction surveys to help guide patients to the best possible end of life care.

For ourselves at Aledade we have encouraged our own team to use the Conversation Project Starter Kit to consider their own end of life preferences. This is not only because life usually does not go as planned for any of us, but also so that we can have direct experience with what it means to consider our own treatment preferences and what it is like to communicate our wishes to our families and our own medical providers.

As Robert Frost wrote, “The afternoon knows what the morning never suspected.” What we do know is that helping our patients live the best lives possible includes planning for what happens at the end of it.

If you drive by West Calcasieu Cameron Hospital (WCCH) in Sulphur, Louisiana, you’ll see eight healthcare offices. Inside are 13 physicians and their care teams, providing primary care, obstetrics, gynecology, and pediatric care to the families in Calcasieu and Cameron parishes, the hospital’s service area.
Some of the doctors have been in this community for over 60 years, establishing relationships as they care for generations of families. Throughout the decades, teamwork between the hospital, the primary care physicians (PCPs) who work for the hospital, and the surrounding independent primary care practices has been a constant. As Anne Billeaudeaux, WCCH’s Director of Business Relations and Physician Development, said, “the independence of the practices is just as important as our collaboration.”

At Aledade, our vision is a health care system based on value with independent, primary care practices at the center. WCCH proves that we’re not the only ones who share this guiding principle.

WCCH is working with the Aledade Louisiana ACO to improve the continuity of care, resulting in patients receiving a timelier follow-up and supporting care across the community. This effort started in March of last year, when WCCH’s IT department helped the hospital join an Admission Discharge Transfer (ADT) network. The ADT connects with the Aledade App, practices can find out in a timely way when their patients are in the ED and hospital. When patients are discharged, a case manager faxes practices if a patient isn’t discharged to their home.

Before, practices struggled to follow up if patients had been to the ED or hospital because notification was cumbersome and completely manual. When providers know about a hospitalization they are able to follow up in a timely way. A patient being discharged from the hospital with several new medications and changes in their daily care, can become overwhelmed navigating those changes alone. With the improved communication from the work between WCCH and Aledade PCPs can support their patients and help them better manage recovery.

WCCH wants to help prevent avoidable readmissions and keep patients healthier with the appropriate level of care. Because WCCH joined the ADT, many patients in Sulphur have visited their PCP after discharge and have been able to get the follow up care or education they need to stay healthy and out of the hospital.

Collaboration with the Aledade Louisiana ACO has been good for the hospital, the independent physicians, and most importantly, the patients. I asked a few of the key leaders from the hospital, as well as the independent primary care doctors, to talk about successes to date:

Kathy Doty, Director of Quality Assurance at WCCH

Our outcome-driven journey into quality started more than 10 years ago, with a CMS/JC project. We discussed sharing data with our partner physicians in a meaningful way on a regular basis. We learned how to use and apply this data, alongside our physicians. It led to a few uncomfortable talks, but we all knew this data could help drive improvements in care for our patients.
As care managers, we’re trained to avoid the rain clouds, which motivated us to embrace the shift to value-based care. We warned folks that if we missed the boat on value-based care not only would there be future financial penalties, we’d be left behind. We discussed both sides with our clinical team and chose to embrace the new system and implement at our own pace.

Janie Fruge, Chief Executive Officer at WCCH

We always focused on meaningful ways to share our data and be confident in the data we receive. Through effective communication and actionable plans, we’ve improved care in our surgical initiatives, reduced central line infections, and decreased pneumonia diagnoses.
Our physicians and clinicians formed a virtual medical community home; the experience was mixed. Some primary care providers joined in, some didn’t commit right away. For the doctors who did participate, they found success and started speaking in favor of it. They encouraged the others to join, then Aledade helped everyone get on the same page. Now, the people who were the most skeptical are the biggest fans.
For us, and the physicians around WCCH, joining Aledade was a natural extension of our quality work. Our early efforts showed us how data could promote quality care. Aledade brought the tools, and helped us share ideas in a complete plan that we can all execute, together.

Dr. Maureen Lannan, Cypress Clinic

As we enter agreements aimed at lowering costs and improving care for a defined group of patients, the hospital/PCP relationship is critical, especially when it comes to the discharge process of patients.  Better communication between the hospital medical team, patients, caregivers, and the outpatient medical team is vital, so that patients do as well as possible after they return home.

In conclusion, value-based care is good for our patients, and Aledade has helped improve our systems. At the center is a durable partnership between the hospital and the independent primary care practices in the community. We look forward to seeing what the coming years bring, and continuing to turn our data insights into quality initiatives to better serve the community we’ve served together for over half a century.

I’ve been a family physician in Hoke County, North Carolina for many years. In this role, I walk with patients through all stages of life, from the birth of new babies to comforting patients and families in their loved one’s last days. I believe in the power of human connection: physical, emotional, and spiritual. It’s what my practice offers our patients.

Running an independent primary care practice today brings with it a range of financial and operational challenges. Accountable Care Organizations, often called “ACOs”, are in a unique position to reward providers for quality and better outcomes through preventive care, care coordination and avoiding unnecessary services. I believe that transitioning to value-based care will help my practice remain independent while I continue providing the high quality, personalized care my patients deserve.

I know my practice needs a partner to take our journey in value-based care to the next level. That’s why I’ve chosen to partner with Aledade to help us navigate toward better care at lower cost. Aledade offers us the technology, tools and support we need to succeed, allowing us- the physicians- to focus on quarterbacking our patients’ care.

More than ten years ago I was one of the first rural independent physicians to invest in patient portals, patient kiosks, and an EHR. I saw this as an investment in not only the way I practiced medicine, but also in my patients’ health. I feel the same way about the Aledade Technology Platform. It will provide real time alerts when a patient visits the hospital or emergency room, and tell us when patients visit a specialist or fill prescriptions. The platform creates lists of patients to reach out to for annual wellness visits, emergency room follow-ups and transitional care visits. It integrates data from various sources and provides unparalleled insight into my patient population to help me more effectively manage the quality and cost of their care.

In my rural community, I work with many patients who face tremendous health and socioeconomic challenges. While some may see a case of COPD or uncontrolled diabetes, we see an opportunity to have a conversation with our patients and discuss the larger picture of how we can help them. We are excited to use the Aledade tools to help us flag patients who need extra support so we can reach out and work to keep them out of the hospital.  This tool complements our existing work and supports customized care plans on which our whole team can collaborate.

I’m excited to partner with Aledade to launch an Aledade ACO in North Carolina in 2019. The future looks bright for patients and independent primary care physicians in Hoke County and throughout North Carolina, and I’m proud to be part of it.

For nurse practitioner Kirt Greenlee, it started out as a routine visit at the local nursing center for a ripped toenail. Casually, the patient asked if he could also look at what seemed to be an ant bite on his elbow. Greenlee quickly identified that the small raised bump was not the result of a bug bite, but an abscess caused by Methicillin-Resistant Staphylococcus aureus, commonly known as MRSA. He immediately started the patient on a course of antibiotics to get the condition under control. Had Greenlee not caught this early, the patient could have suffered serious complications, potentially leading to a hospital admission. The bacteria could have also spread to other residents, causing even more harm.

Situations like this are typical in Greenlee’s role as a nurse practitioner at Premier Medical Group. Unlike most providers who work in one clinic all day, Greenlee spends the first part of his morning visiting patients at the local nursing facility, Attala County Nursing Center, and goes into the clinic afterward. On a typical morning, he sees about three to eight patients with a variety of ailments, including congestion, urinary tract infections, COPD exacerbations, and upper respiratory tract infections. Greenlee then goes into the clinic where he sees more patients and is available to the nursing center by phone.

Setting up this workflow took a lot of collaboration with Attala County Nursing Center. Previously, they were hesitant to contact providers for fear that they were bothering them. With this partnership, we set clear expectations upfront so they know when and how to communicate with the practice. Patients receive the best care when we all work together, rather than in individual silos.

Going to the nursing center daily is important. It allows Greenlee to catch conditions early that could otherwise snowball into debilitating illnesses, like a cough that could turn into pneumonia. Greenlee can take simple steps, like prescribing steroids or antibiotics, to keep the patient healthy and prevent an unpleasant and stressful trip to the emergency room.

This work is also important because as a member of an accountable care organization (ACO), Premier Medical Group takes responsibility for the quality and cost of its patients’ care. By catching minor conditions early on, Greenlee prevents expensive emergency room visits and hospital stays.

Greenlee says “my favorite part of my job is taking an active role in protecting the quality of life of my patients.” Once a patient ends up in the hospital, they often lose some of their independence and freedom, and are at risk of contracting additional infections. The care that Greenlee provides truly helps achieve the goal of reducing costs while improving quality, which aligns with the goals of the Aledade Mississippi and Tennessee ACO. Premier Medical Group and the other partner practices are making huge differences in patients’ lives and bringing better value care to their communities through their ACO work.

To succeed in value-based care, practices need to help patients get the right care at the right time in the right setting. At Aledade, we help practices do just that by reducing unnecessary emergency department (ED) use, improving care coordination with specialists, and managing chronic conditions.

Another way we improve quality is by engaging home health providers as key partners. Home health care accounts for eight to ten percent of total spending across our ACOs.

A primary care physician (PCP) can order home health for a patient in a hospital or another setting. Every 60 days after that, the physician needs to recertify the services as medically necessary for the patient. In the past, PCPs had limited insight into home health quality. They might not know when patients started home health care. They might not have clear communication during the recertification (or recert) process. This often leads to significant care gaps, and risks for the patient.

Our partner practices in Arkansas grew frustrated with the recert process, so they decided to revamp it. When a home health agency submits a recert request to the PCP, the practice’s care manager reviews it right away. The care manager checks if the patient is improving, and calls the home health agency to learn more. The office then schedules the patient for an appointment to review their progress towards their health care goals. Together, the PCP and the patient decide if the patient should continue with home health care. Sometimes another service, like Chronic Care Management, social support, transportation, or education, is more appropriate.

One patient in the Arkansas ACO had received home health services for diabetes management for more than a year. Both the patient and the PCP were frustrated. The patient’s A1C hadn’t improved and their ED utilization had increased. The practice stopped home health, and enrolled the patient in an in-office diabetic education program. There, the patient learned about triggers and how to manage insulin levels. The patient was also able to meet with the practice’s nutritionist for help with planning groceries and meals.

According to the team at Dr. Walker’s Clinic in De Queen, Arkansas, the new home health workflow ensures the practice reviews “all patients prior to admission to home health and performed at every recertification. We have a nurse that manages this population and meets with our home health agencies bi-weekly to discuss goals, recerts, and discharges.”

In West Virginia, our partner practices worked with home health agencies to reduce preventable admissions and readmissions. The home health agencies created a Collaborative Performance Review. They identify the hospital utilization of home health patients and find out how many hospital admissions were readmissions. They also look at patients who screened positive for depression, falls risk, and ED overutilization. This summary finds gaps in patient care, showing how the practice could have prevented a patient’s admission or readmission.

According to Dr. Tom Bowden of Charleston Internal Medicine in the Aledade West Virginia ACO:

“The transition from hospital to home is a critical step in the well-being of our patients. Partnering with home health agencies that can assist us in this process is vital. Finding the home health agencies that are willing to work with us, make changes, provide the care our patients need and track quality metrics will certainly help reach the triple aim of improving health outcomes, improving the patient experience and lowering health care costs.”

All of this starts with a question: “What information from would be most helpful when making a recert determination?”

By focusing on this question, we’ve developed a form for home health agencies. We found home health agencies were eager to provide the necessary information, as were the PCPs. This summary, and the conversations that came with it, are still in the early stages. However, we expect that more communication will identify the most necessary recerts.

Better home health care means patients get the right, high quality care. We work with our home health partners to transition patients from skilled nursing facilities, nursing homes, and hospitals safely and sooner when possible. Home health also helps to proactively keep high risk patients safely out of the hospital. This requires close partnerships with home health agencies, and the communication to paint a full picture of the patient’s health. Armed with this, Aledade’s partner practices can ensure their patients get coordinated care in the right place at the right time.

The 2016 results are in and Aledade Accountable Care Organization (ACO) practices saved Medicare more than $9.3 million! The Aledade West Virginia ACO not only reduced costs 5% below the Medicare benchmark, but also received a shared savings check. In 2015, we brought together a unique group of 11 independent primary care practices that understood the importance of collaborating on improving health. Together, our partner practices have created a strong network that have reduced unnecessary hospital visits and kept patients safely at home, managed high-risk patients through a robust care management program, and provided better coordination of patient care with specialists and other providers in the medical neighborhood. We are very proud of our partner practices’ incredible progress and dedication in these key initiatives that have helped improve patient outcomes. “Teamwork and quality are always a winning combination. None of us are as smart as all of us together, and that is why we joined the ACO, said Dr. Jonathan Lilly, a Vice Chair of the West Virginia ACO. “We’re so proud of the ACO’s work in improving care and reducing costs in West Virginia.”

At Aledade, we know the value data offers to primary care physicians (PCPs) in helping them to deliver high-quality, coordinated care. We believed that if doctors receive practice workflow support, technology, and analytics, they are in a better position to deliver the highest-quality care while reducing unnecessary costs. In West Virginia, our physicians get a real time report when their patients show up at the hospital. With this knowledge they have been able to coordinate with hospital providers and support patients coming out of post-acute setting, reducing hospital readmissions, unnecessary days spent in ERs and the number of days patients spend in skilled nursing facilities. Dr. Ghali Bacha, an ACO member, said, “By joining the ACO and utilizing Aledade’s technology and support, our practice has significantly reduced our patients’ unnecessary emergency department visits and hospitalizations in 2016. Helping our patients get the right care in the right place at the right time has been a major accomplishment.”

Aledade equips PCPs with direct practice support and tools to utilize data to deliver high-quality, coordinated care. Taking data from multiple sources helps doctors keep patients healthier and out of the ER, makes it easier to prioritize their time and their practice’s time for patients who benefit the most from programs like Transitional Care Management (TCM), Chronic Care Management (CCM), and Annual Wellness Visits (AWVs). By implementing care management programs in our practices, both providers and patients have seen significant benefit. In a recent blog, ACO partner physician, Dr. Beckett talked about how improving patient information and care coordination with the local hospitals has made a real difference. He shared a success story about “the patient who previously went to the ED up to twice a week has now gone six weeks without returning.” While this is only one exceptional example of success, this is fortunately a trend we are seeing across all our West Virginia practices and plan to continue to share future success stories.

As Aledade West Virginia ACO’s Medical Director, Dr. Tom Bowden put it, joining the ACO “helped better foster our relationships with patients and other health care providers and helped form that bridge to other doctors and hospitals.” And we have done just that. Practices have worked with local specialists in improving communication to make the patient experience as seamless as possible. Kanawha County specialists have worked closely with our PCPs on referral management to better coordinate and manage patient care. Whether, it’s meeting in person to strategize referral processes or getting systems aligned virtually to get real time data on their patients, the dedication to improving care coordination has driven unnecessary spending down and quality of care up.

In our first performance year, we have established a strong network of providers who have been able to remain independent by driving down costs all the while improving quality of care for their patients. The ACO strives to get every person the right care at the right time in the right place. The proof is in the numbers. 368 fewer West Virginians needed to be admitted to the hospital, 136 of those were readmissions that were prevented by reducing complications. Over 400 West Virginians ended up in their physician office instead of the emergency room. They spent 566 more days at home instead of in a skilled nursing facility and saw their primary care physician 10% more often to help make all this happen. In 2016, the ACO achieved a total savings of $3,197,252, with shared savings of $1,566,654. With continued dedication and hard work on ACO initiatives, we are moving in the right direction for bigger and better things this year and the coming year. We are excited for the future of our ACO in helping create a better health care system and better care for West Virginians.

We started Aledade with the goal of building a new model of primary care – one that’s good for patients, good for doctors and good for our society. In just three years, we have brought this new model to more than 200 practices across 17 states – practices who collectively care for more than a million patients. We have brought it to the Medicare Shared Savings Program (MSSP) as well as other payers including Medicaid, Medicare Advantage and commercial health plans.

Our model isn’t easy. It combines both on-the-ground support and a cutting-edge technology platform – one that works with over 60 electronic health records. But it also requires sweat equity – investments of valuable time and effort by our dedicated partner practices and Aledade staff. So, it’s important that we take a close look at how we define success. To us, it’s always been a clear but challenging metric: is what we are doing good for patients, good for doctors, and good for the health system?

For patients, Aledade emphasizes more personal, preventive, and coordinated care – the quality of care that you’d want for your own mother or father. In 2016, both of our ACOs from 2015 improved their quality measures for things like controlling blood pressure and ensuring vaccinations and screenings. Our ACOs, overall, are improving their quality scores, and their patients are taking note. In a recent Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, Aledade physicians were rated by their patients at an average of 9.3 on a scale of 0 to 10 – above the average for the over 400 MSSP ACOs.

Our practices are doing the right things. They are delivering many more preventive and primary visits, they are reaching out to patients to help them with transitions from hospital to home, they are, for the first time, hiring care coordinators who help those who need extra help. And it works. In every Aledade ACO– not just those that earned shared savings—avoidable emergency room visits dropped, readmissions plummeted, preventable hospitalizations from congestive heart failure, pneumonia, and pulmonary disease fell. Collectively, our ACOs prevented more than 1,500 hospitalizations. Aledade ACO practices are giving their patients better care – and we hear it in their stories, and we see it in the data.

Second, we want to make sure that what we’re doing is good for health care providers. Being part of an ACO has to be valuable, and sustainable, for our partner practices. In a time of increasing consolidation and a health care market that often doesn’t foster real competition, our goal is to help independent primary care practices thrive, and our partner practices succeed in value-based care.

Aledade ACO practices provide more – and more intense – primary care. By conducting more annual wellness visits, helping patients through transitions of care, and implementing chronic care management programs, our practices are seeing a return for their work. By implementing value-based care and practices transformation initiatives, our ACOs redirected health care dollars toward primary care and away from hospitals and emergency care. That is, our practices delivered better care and kept people healthier. The health of their practices did not suffer; in fact, they thrived.

And it’s important to note that they saw these returns in health and the bottom line while also lowering costs for society as a whole. That’s our third target for success.

During the 2016 performance period , Aledade’s ACOs – comprising 142 practices with over 80,000 patients in 11 states (Arkansas, Delaware, Florida, Kansas, Louisiana, Maryland, Mississippi, New York, Tennessee, Virginia and West Virginia) – saved Medicare more than $9.3 million. Five of our seven ACOs came in under the benchmark set by Medicare, and one was right at benchmark. Two of these – in West Virginia and Florida – exceeded the savings threshold so that Medicare will be sending them a shared savings check. We couldn’t be happier for those practices and the teams that support them, and we’re proud to be their partners.

Proud, but not satisfied.

If not for historically-low rates of inflation nationwide and the idiosyncratic way Medicare measures savings, many more of our ACOs would have earned savings. In Delaware, for example, we reduced costs by a whopping 3.3 percent over last year, and we’re on track to do even better in 2017. In fact, research shows that the savings from ACOs are generally undervalued. ACOs should be rewarded based on whether they improved care and lowered costs more than their local competitors – not a nationwide average. We’ve already proposed some improvements to the way that ACOs are measured.

Medicare also offers a regional inflation update to ACOs in their second three-year contract, which means young ACOs face uncertain market dynamics, but ACOs like many of ours, approaching that second contract, will have more accurate benchmarks. The combination of regional inflation for historical costs and regional benchmarking for this year’s costs reward ACOs that have bent the cost curve persistently in their regions, and have the patience and resources to plan for the long term.

The simple answer is that transforming health care just isn’t a simple thing. It takes a lot of work, a lot of creativity, some patience, and some time. But it works. Studies show that the proportion of ACOs that earn savings nearly doubles from year one to year four. We already have data that our ACOs are performing well in their regions. And with our new partnerships with commercial payers and Medicare Advantage, we’re finding new ways to promote value-based care for independent, primary care practices.

We’re on the right track. Our partner practices are taking the right steps. And the data for 2016 proves it. Despite all you hear about our broken health care system, Aledade practices and our staff are working day in and day out to transform health care in our country so that it delivers better care and lowers costs. That’s why Aledade exists. It’s why we’re so committed to our work. And I’m thrilled to see it’s bearing fruit.

It’s hard to stay healthy if you don’t have a place to call home.

That’s what we learned firsthand, when one of our patients came in for his annual wellness visit.

Thanks to Aledade, we’ve been doing a lot more of these AWVs. They give us a chance to have a conversation with our patients that’s not just about the test or procedure or illness they came in for that day. They help us see the full picture of the patient’s health. Thanks to Aledade’s care management trainings and real-time data and analytics from the Aledade app, we know which patients we need to see for an AWV, and how to work with them when they arrive.

Our patient that day was wheelchair bound, so we asked how his social situation was. Sometimes patients in a wheelchair can get to feeling a bit lonely. In the course of the conversation, though, this patient told us that he had recently lost his home. The waiting list for housing assistance stretched out for three years. In the meantime, the only place he could stay was a shed in his friend’s backyard.

As a care management team, we knew we had to do something.

Housing is such an important part of good health. The National Council on Health Care for the Homeless covers a few reasons for this. A clean, dry and safe environment supports good personal hygiene, the storage of medication, and safety from people and the weather. A private space lets a patient establish stable personal relationships, and have good social interactions with other people. Importantly for us as health care professionals, a patient with a place of their own is more likely to stick with a treatment plan, eat meals regularly, and show up on time for appointments. And housing reduces anxiety and the impact of stress-related illnesses.

Aledade’s practice transformation specialist Connie Perkins and I knew that a three-year wait was too long. So we spent countless hours on the phone with the state’s resources for homeless and disabled persons. Tooele is a rural community. We don’t have that many resources for housing, but after a lot of work and some persistence, we did it.

We were able to find housing for this patient in Wendover. Even though Wendover’s a two hour drive away from our town, the patient was thrilled to have a home of his own. He even started looking for work around his new place.

Thanks to an annual wellness visit – supported by the training, technology, and partnership of Aledade – we helped our patient get healthier, by finding a place to call his own.

In about two weeks, I’m joining the team at Aledade as Chief Administrative Officer – largely because three years ago, I went through a health scare.

It wasn’t me; it was my then 86-year-old father. And what started with a short-term crisis dragged out into a long-term battle with our dysfunctional health care system.

For two years, my dad bounced between doctors, hospitalists and specialists. We never got a clear picture of his health or the care he was getting. His doctors rarely talked to one another, rarely gave him much time and I couldn’t talk to them to understand it all.

At the same time, this was happening while I worked at the Centers for Medicare and Medicaid Services, tasked with running the entire Medicare program. I couldn’t help but put our situation into a broader context: if this frustrating and frightening ordeal could happen to my dad- a brilliant lawyer who was on the Law Review at Penn — and his son who ran the world’s largest insurer, what was it like for other families who didn’t have our resources and our knowledge of how to navigate this confusing health care system?

Fortunately, we were saved by a good quarterback – someone who could take a step back and look at the entire field of my father’s health. For an entire hour, a geriatrician sat with my father just to talk with him. He got a sense of his health conditions, what was giving him the most trouble, and the serpentine path he had taken to get help.

The doctor set up a care plan with him, and took a close look at his medications. When we focused on one drug in particular, my father pointed out that studies had shown it was relatively effective. “That’s true,” the doctor said, “until about 75 years of age.” My dad was taking medication that stopped being effective – and possibly became harmful to him — about ten years ago. In the end, we cleared out about half of my father’s prescriptions. It was as if a switch had been thrown. Over the next few months, my dad returned to the person we knew.

Value-based health care, directed by empowered, independent primary care physicians, is what my father and I needed then. Today, everyone agrees it’s what we all need now.

We need primary care physicians to be the stewards of care, guiding patients through this confusing health care system like the captains of a ship – always pointed to the north star of better health. We need a health care system that doesn’t focus on how many procedures or prescriptions patients get, but on how well their doctors keep them healthy. When those priorities are misaligned, that’s when our health care system doesn’t work. I know, because that’s what my father and I saw firsthand.

I’m joining Aledade because I know the team here is working with incredible physicians best situated to chart that path to value-based care. For years at CMS, I looked at the results and dove into the data – I saw that the future of health care will be led by primary care physicians with the autonomy to act in their patients’ best interests. I saw this potential for success across commercial plans, Medicare Advantage, and traditional Medicare – and Aledade’s covering all of these.

At Medicare, my focus was on the operational integrity of a program that provides insurance for more than 55 million Americans. I worked to ensure the program was run efficiently and responsibly for the taxpayers, and that we kept focused on our strategic goals of improving care and reducing costs. That’s what I’m most excited to do here at Aledade. My focus will be making sure the trains run on time – that our hardworking teams are valued and supported, and that we’re helping our partner practices along every step of this journey.

I’m also joining Aledade because there’s a unique mix of purpose and people in this place. I came from public service, and I wanted to join an organization with a mission that’s bigger than profits or short-term returns. Aledade lives its mission every single day.

I also was lucky to work at CMS with some of the most brilliant people in health policy who were also great colleagues. And I see those same qualities here at Aledade. Thanks to the hard work of so many people, Aledade partners with more than 200 primary care practices in 17 states to actively manage the care of nearly a quarter of a million patients. I can’t wait to be a part of the team that’s building the leading model for a health system that’s good for patients, good for doctors, and good for society.