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.

As the Care Manager at the Winston Clinic and a Nurse Practitioner by training, I’ve taken the lead in working with our high-risk patients, as well as those with uncontrolled chronic diseases.

When a patient is identified as “high risk”, whether that’s by Aledade or by a provider, we place the patient’s name on my desktop, and add it to our list of patients who should receive care management. Usually, these are patients who need support for a hospital discharge, or have had a new diagnosis. Sometimes, they’re patients who will need support over a longer time period. One of our new programs is to place patients with uncontrolled chronic disease onto care management before we even refer them out to a specialist.

I have multiple patients who say they benefit from care management, and their clinical numbers show the same thing. But there are two patients who stand out the most.

One was placed on care management for her diabetes. In the past three months, she’s made huge steps forward. She had been diagnosed as diabetic for more than a decade, she’s been on insulin and Metformin for some time and her HgBA1C level hit 15.3. Our clinic was just about to refer her to an endocrinologist, until I asked specifically if she could be referred to Care Management services instead.

On our first care management call, I started by just asking her why she thought her sugars were high. The patient told me that she didn’t know – she wasn’t eating any sweets or white bread. She had no idea that different fruits, vegetables and drinks were driving her sugars up. When I asked what her providers had taught her, she said she felt stupid for asking them questions, and they had assumed she already knew.

I also asked her why she wasn’t taking her insulin. It turns out she had been placed in the hospital once before for hypoglycemia because she had taken too high of a dose of insulin. She was worried about putting herself through that again.  Over the course of several phone calls and an office visit to train her how to manage her diabetes, the patient told me she feels much better about her ability to manage her diabetes.

Her last A1C reading was 11.5. That steady decrease is a win for the practice, and a win for our patient! But we’re not stopping there – we are still working together to lower these numbers this even more!

The other patient who stands out to me was diagnosed with prediabetes. She was due for an Annual Wellness Visit (AWV), so we brought her in. I gave her a health risk assessment, where she remarked that she felt unwell today. But she wasn’t very specific. Then I saw that her PHQ9 – a depression health questionnaire – was off the charts. I put the diabetes aside for a second, and started using some of my coaching skills to help her to open up.

She told me that she was suicidal on most days. Her mother had died three weeks before, and often she would lay in bed and cry all day. She had missed her previous day’s counseling appointment, and wasn’t scheduled to see her outpatient counselor for another several weeks.

I determined that she was not suicidal at that moment, and began to use some of our health coaching strategies. I asked her if she could picture herself happy. She said she could not. She said the only reason she hadn’t killed herself is because she didn’t want her girls to lose their grandmother and their mother in the same year.

Needless to say, we talked a lot. In the end, she decided that she could commit to one change. She would spend time each day trying to picture herself happy. And during the few times a week that she felt happy, she would write down what she was grateful for. As soon as the patient left, I called the counselor, and she called the patient for a phone visit immediately. She’s visited her counselor multiple times.

I have spoken with the patient every week over the course of several weeks. She felt that I wasn’t judging her during the first visit, that I actually cared about the “other stuff”, even though she was there to discuss her diabetes.

Just recently, I asked her how she was feeling.

She responded, “I think I can be!”

I said, “You lost me. You can be what?”

“One day,” she said, “I think I can be happy!”

She has had several bad days since then, and several good days. Through the ups and the downs, I think I’m getting as much from her as she’s getting from me. And I know I would have missed out on this experience if we were not making the effort to reach out to our patients.

I believe in the power of the AWV and care management calls, because I’ve seen it in these two patients, and many others. Here at Winston Clinic, we will continue to support our high-risk patients and patients with uncontrolled chronic diseases through care management and having open, honest conversations.

Trust and good relationships with patients are essential in providing high quality healthcare. A key factor in this equation is being available for patients when they have questions or concerns. This availability is especially important for patients dealing with chronic illnesses or other health issues. Opening an avenue for these patients to have access to care, even outside the clinic, can greatly enhance the trust they feel and the relationship they share with their provider.

Like many others, our clinic is in a state of evolution as we make the transition from a traditional fee-for-service model into a more comprehensive care setting for our patients. We decided last January to begin offering Chronic Care Management as a resource to reach some of our most at-risk patients. Right away it became obvious the success of the program was going to hinge on finding the right person as a liaison between patient and provider. It had to be someone the patients felt comfortable talking to and someone I could trust. It was a very difficult leap of faith, but I decided there was no better choice than Susan Williams, my nurse of 15 years. Susan already has good relationships with all of my patients, and they trust her. I promoted her to the position of Care Manager, and we began enrolling patients.

With Susan leading the way, our patients immediately embraced the program, and we have seen many of our most in-need patients begin to manage their health more effectively and efficiently. We have over 80 patients under management, and only two have discontinued the program.

We launched a new cell phone line so patients in the program could access Susan directly. She carries the phone during office hours so that patients no longer need to speak to the receptionist. They no longer worry about not getting a call back or if their message is lost in translation. If there is a problem, Susan comes to me directly, and we decide whether the patient needs to come to the office or if we can handle the problem remotely.

It became immediately evident, once these patients knew they could get an answer quickly, their tendency to run to the emergency room decreased. Susan began keeping a list of patients who were seen in the office on the same day they called and spoke to her. While this is a number that never shows up in the data, we have counted over 40 occasions since last June where the patient called asking if they should go to the emergency room, and instead they were seen in the office. Even if they actually do need hospitalization, I can admit them to our hospital directly from my office, avoiding the time, stress, and extra cost of a trip to the emergency room.

A specific example of the effectiveness of the program involves a patient who had an outpatient procedure to replace his pacemaker battery. The following day he spiked a high fever and called the number provided by the cardiologist. He was unsuccessful at reaching any of the clinical staff and was told he would get a call back, which never came. Instead of going to the local ER, he called Susan. She informed me of the problem, and I had her call the Cardiology practice. She was quickly able to get the physician on the phone and direct admission was arranged under the care of the patient’s cardiologist. With a simple call, an ER visit was avoided and care was provided quickly.

Aledade ACOs emphasize the special relationships small practices have with their patients, and their guidance helped us launch this beneficial care management program. Our patients value the personal relationship they have with Susan, and we have direct evidence the program has led to better health outcomes and lower hospital and ER utilization by our patients.

Yesterday, Aledade announced that we are forming the first primary care physician-led accountable care organization (ACO) in Arkansas. We are proud to bring independent doctors in Arkansas a new model of primary care that will allow them to stay independent, focus on delivering high-quality care, and be rewarded for keeping patients healthy.

ACOs are part of a significant transformation in health care to value-based care – care in which doctors are reimbursed not for the number of tests or procedures they undertake, but in how successful they are in managing the health of their patients. In Arkansas, practices in the Aledade ACO will benefit from Aledade’s regulatory expertise, best practices from our nationwide network of primary care doctors, technology and data analytics, and in-person practice transformation support.

However, ACOs are not the only way for Arkansas doctors to participate in value-based care.

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) announced a massive new pilot program called Comprehensive Primary Care Plus (CPC+). CPC+ is designed to help practices build capabilities and care processes to deliver better care by offering them greater financial resources and flexibility in care delivery. The goal of CPC+ is to strengthen primary care to enhance the quality of care patients receive, improve patients’ health, and spend health care dollars more wisely.

CPC+ does this by paying physicians monthly care management fees tiered to the patient’s level of need; different from the current “one-size fits all” Chronic Care Management fee that practices have been using to support comprehensive patient care. These payments provide physician practices with much-needed resources to invest in the capabilities and tools to effectively manage population health and the total cost of care.

The good news is that, as Aledade had hoped and proposed to CMS, CPC+ is open to physician practices that are also participating in the MSSP ACO program. Furthermore, CMS recently named Arkansas one of the regions in which CPC+ is being implemented. Together, this means that practices in the state can participate in both CPC+ and the Aledade ACO. The unique combination of CPC+ and the ACO gives both the resources necessary to improve patient care and the incentives to reduce the total cost of care. Upfront care management fees and support with the ACO’s primary care-led efforts to generate shared savings offers great promise in the goal of improving care quality and lowering costs. For physician practices, this means getting the upfront financial resources and support to improve care access, care management and coordination, and patient engagement, while also being rewarded for the resulting improved health outcomes through ACO shared savings payments.

Aledade will help its partner practices in CPC+ work to fulfill the program’s practice, reporting, and care management requirements, much of which align with the efforts Aledade practices are already doing as part of an ACO. Aledade also will continue to monitor what comes out of Washington so that its doctors can understand, adapt, and thrive under whatever new rules or programs are introduced.

A lot is changing in health care delivery, and Arkansas is no exception. With these models and with the right partners, I am confident it will mean better health care for Arkansans and thriving practices for their doctors.

We launched Aledade on June 18th, and by the end of July we had recruited 80 primary care physicians in 4 states to join us in creating the very first Aledade ACOs. We have been work together ever since- but haven’t been able to talk about our wonderful practices until the official notification from CMS that came today.

We are thrilled to announce that beginning January 1, our two new Aledade ACOs will be taking accountability for the care of over 20,000 attributed Medicare patients, and stewardship of nearly a quarter of a billion dollars of health care expenditures each year. We’re building a new delivery system on the foundation of trust between patients and the physicians who have been caring for them in their communities for decades, and enabled and accelerated with cutting-edge technology and analytics.

One ACO will operate in the state of Delaware, in close collaboration with our physician partners and our field team, Quality Insights of Delaware. Our second ACO, the Primary Care ACO, will take the same model spanning three states — New York, Maryland, and Arkansas, where we are also working with local partners like the Arkansas Foundation for Medical Care. Our hand-picked ACOs physician partners are some of the most capable and inspiring primary care physicians in the country. They are leaders in their local, state and national physician associations; they are pioneers of Meaningful Use and Patient Centered Medical Homes; they are much-decorated top doctors in quality; but most of all, they are the pillars of their communities.

Our regional Medical Directors and local field teams in each state have already been busy helping our partner practices:

  • Extracting practice management data and establishing interfaces to EHR data and Admission-Discharge-Transfer notifications.
  • Identifying individuals with multiple chronic conditions at high risk of complications
  • Working with practices on initiating workflows for patient recall, and rolling out lightweight apps to help prioritize and track the outreach
  • Customizing EHR templates and tracking wellness visits
  • Implementing an influenza and pneumonia vaccination program for high-risk seniors
  • Reviewing after-hours and weekend patient access protocols, and working together to make it easier for Medicare beneficiaries to reach their primary care doctors and schedule same-day appointments.

Our performance year for these ACOs will start on January 1, and we are excited to begin the work of delivering the best care possible for our entire population of patients.

We are also looking towards the future. We are looking to grow our base of top physicians in our existing four states, and expand into several new states (likely to include Virginia, West Virginia, Tennessee, and Louisiana). We’re recruiting the leading primary care providers in the country and field partners in these regions, as we continue to refine the customized applications and platforms that will help our doctors thrive.

Alongside this growth, our Aledade team has been growing apace. We’ve assembled a dynamic team with deep expertise in provider engagement and practice transformation, data analytics, technology, and health care policy. As we continue to scale quickly in 2015, we will further expand our team in the coming months. We are looking for talented individuals who are passionate about making a big impact on health care in the United States, who will cherish their colleagues and our primary care physician partners, who are data-driven and tech-savvy, and who are relentless in their pursuit of a better world.

You can learn more about the positions we are hiring for here.

2014 has been a really exciting year for the future of health care, and for Aledade. Far away from the political finger-pointing and ideologically-charged debates, real change is happening in American health care, and momentum is building around what matters most — the health of patients.

Especially at this time of year, I am grateful to be able to contribute to this transformation, and I’m so appreciative of the chance to be working with such a phenomenal team of doctors and colleagues committed to this movement.

– Farzad

On June 18, we launched Aledade – a company built on our belief that independent primary care physicians are best positioned to lead the next revolution in health care delivery – boosting quality of care and bringing down costs.  Over the past six weeks, we traveled across the country meeting doctors, discussing the future of independent primary care practice, and recruiting physician partners for our first wave of Accountable Care Organizations.

Meeting these doctors, from areas and backgrounds as diverse as the populations they serve has been a constant reminder of the reasons we founded this company.  One physician, having spent decades serving the same community from the same office, lamented that in the past, he felt more involved – and more informed – about all aspects of his patients’ care.  Today, he told us, fragmentation in care delivery had given him less insight into his patients’ health, and less influence in coordinating their treatment.

When we started Aledade, these were the type of doctors we wanted to empower.

Today, I am elated to announce that we have formally submitted applications to the Center for Medicare & Medicaid Services to form ACOs serving physicians in Delaware, Maryland, New York, and Arkansas for 2015.  We expect this first wave of Aledade ACOs to serve tens of thousands of Medicare patients beginning January 2015.

The choice of four dissimilar states was intentional. We intend to establish a model that can be replicated across the country, and the diversity in our practices matches the diversity of our country. Each state has strengths to build on. Delaware- ‘the First State’ has been a leader in electronic health record implementation. Maryland and New York’s health reforms set the stage for alignment and collaboration with acute-care facilities. Arkansas’ tradition of independent primary care practice is strong. We’ll also be serving very different patient populations in each state – from practices that serve urban neighborhoods to those that treat folks in small towns and rural communities.

In all four states, we will spend the next five months working closely with our physician partners to tailor custom administrative and technological solutions for their practice needs and help accelerate practice transformation.  Our previous work in policy and outreach has already given us some ideas about how physician-led ACOs can best leverage the value-over-volume care delivery model, and there’s been a great deal of writing on the advantages of physician-led ACOs. But we also know that successful ACOs are built specifically for the communities they serve.  That’s why we will develop tools for our doctors with the unique needs of their practices – and his or her patients – in mind.

As we do, we will focus on three key areas:

Greater Availability to Patients.   Doctor availability and attention to patient needs are not just the key to patient satisfaction; they also are important to avoiding hospital admissions and more serious medical issues down the road.  So we’ll also be encouraging our physicians to place a greater emphasis on wellness visits and preventative medicine – and helping them to do that in as an efficient and effective way as possible.

Tools to Succeed.  I’ve said many times: in today’s health care marketplace, technology is necessary – but not sufficient – for success.  Data doesn’t solve health care problems by itself, but the right information and the right technology can empower doctors to manage patient care, notice trends, and address medical issues before they become serious.  Our team has over two decades with cloud-based medical platforms and electronic health records (EHR) – we know the functionality needed.  Our CTO Edwin Miller will team up with each individual ACO to customize the technological solutions that fit best, and work with doctors and their staff to continually optimize how those tools are used and effectively integrate the EHRs into the practice’s workflow.  We are committed to the success of our doctors, and technology will be a huge part of that commitment.

Passion to Lead Change.  When recruiting partners, we sought out independent physicians eager to participate in – and lead – the trends transforming our health care system.  Doctors in each of our ACOs will work together to explore opportunities for improvement, and share ideas for improving practice operations, technology, and patient management.  We want our doctors to communicate and exchange best practices – we expect to learn a great deal from their daily experience, and we expect them to be active partners in the process of continual improvement.

We founded Aledade on the belief that physician-led ACOs can be the leading edge of health care transformation in the United States.  Our doctor partners share that belief and are equally eager to prove that hypothesis right.

This first wave of sign-ups is over, but we’ll continue to sign up new practices in other states across the country. That means we now have to build as we grow – and we couldn’t be more excited to start.