As a care manager, I’m a patient advocate and the first line of defense for keeping high risk patients healthy. My regular calls help build a trusting relationship with these patients so that I can help them control their chronic conditions and prevent any new issues from becoming serious. During my monthly calls with patients, I quickly assess their health concerns and start evidence-based protocols to divert avoidable emergency room visits or unnecessary hospital admissions until they can be seen by their provider. Beyond that, I get to connect with individual patients in a personal way to help them along each step of their health journey.

What follows is a story about the power of these relationships. It’s a story about how I was able to help a patient get through a high-risk situation, in the middle of the ocean, because of the trusting relationship we’d built over time.

Recently, one of my care management patients began experiencing symptoms related to his heart failure while on a cruise ship in the Bahamas – a cruise he was advised not to go on by his cardiologist. Throughout the day the patient had been experiencing dizziness and shortness of breath. During dinner on the formal night of the cruise his symptoms worsened. In a panic, he and his wife called me from the next port.

Building Trust
I wasn’t always the patient’s first call for any healthcare concern. I had been working with this patient since I started at this practice eleven months ago, and it took us time to establish our rapport. We enrolled him in our care management program and began a monthly call to discuss how he was doing and talked through his challenges that could negatively impact his health. When I first met with him his wife was on a month-long visit with their grandkids. One day he came to the office and, very upset, he explained he could not afford his medications and that he was all alone at home. I worked with his primary care physician (PCP) to switch his insulin to a less expensive brand and told him to call me anytime, not to hesitate, and reinforced that I’m here to help him in any way that I can. During these initial conversations about his care, he thanked me over and over again for listening to him and helping him make good decisions about his health. That’s when I knew we were making a connection.

Staying Connected
Three months later, I noticed during our monthly call that he sounded a little off. I called his wife to make sure everything was ok and that’s when she told me what was going on. He was not taking his medications correctly, sometimes forgetting a dose and he had started to increase his alcohol consumption. Right away, I made an appointment for him to come to the office so that we could discuss these new concerns with his PCP. Because of my trusting relationship with the patient we were able to have an open and honest conversation with his care team and develop a plan of care to address the impact of his alcohol use.

A Call During Crisis
It was this relationship that enabled me to extend him a lifeline, even from far away.
When we connected from the cruise port, the patient and his wife were both scared and nervous and had no idea what to do. I reached out to the provider who recommended diet modifications to the patient and to stay on the ship for the remainder of the time. I also made an appointment for him to see his PCP immediately after he and his wife were back on land and I followed up to make sure he attended that visit.

During that appointment, we addressed ways to help get his health back on track. After following the new plan, his health improved!

Lasting Impact
This story is so impactful because it reminds me that Aledade’s care management program works. With support and training from Aledade, care managers across the country are able to help build relationships that keep patients healthier and out of the hospital. That’s what we’re here for – to help patients, even if they’re stuck on a boat in the middle of the ocean.

I’m a Care Manager from Dixie Primary Care in Utah. I am responsible for contacting patients on a regular basis to monitor their care outside our practice. Our calls establish a reliable point of contact for patients with the greatest care demands. This allows us to stay on top of their health. Care Management shows our patients they have someone fighting in their corner, providing the support to make difficult lifestyle changes needed to turn their health around.

High-risk patients, often those with multiple chronic conditions, benefit most from Care Chronic Management (CCM) Program. Reflecting on the success of CCM, one patient comes to mind. This patient had chronic pain, COPD, A-Fib, Depression, Heart Failure, Hyperlipidemia, Hypertension, and Prostate CA, relied on a walker and cane for mobility, endured a number of breathing complications, weighed 265 pounds, and followed a pain medication schedule, when he began CCM in June 2017.

When first enrolled in the program, this patient was not ready to engage with me. After undergoing a knee replacement surgery, he recognized the importance of my team’s support in his recovery, and over time, my calls with him grew increasingly positive. I could begin to hear him smiling. Since his surgery, he is mostly pain free, only taking an occasional pain reliever as needed. Best of all, he is now walking freely, without dependence on a walker or cane.

The patient underwent an additional procedure on his nose that improved his O2 stats. He is able to breathe better and participate in more activities. In fact, he has started exercising and losing weight, thanks to both procedures and our partnership during his recovery. He joined a gym and works out with his wife three times a week. Now, he weighs 255 pounds!

After persistent follow up and unwavering support, this patient is engaged in his health. I am confident CCM and his increased participation in the program benefited him. When this patient and I began working together, we created a plan with the goal of exercising and losing weight. He is accomplishing his goals! Calling him a couple times a month, checking up on him, and providing accountability has catalyzed this process. This patient relishes the fact that he has completed his goals. I would even say he is overall less depressed as he now looks to the future.

If our practice wasn’t a part of an Aledade ACO, he would not have received this level of lasting, proactive support from someone on his team. Once he no longer needed follow-up appointments, he would have been off his doctors’ radars. But, because the patient had a CCM, he had support in reaching long-term goals, attaining holistic wellbeing, and addressing concerns that arose outside of the doctor’s office.

The support that Aledade has provided has given me tools that I can pass along to my patients. Helping a patient achieve their goals and take monumental steps towards wellness does not happen everyday and in every practice, which makes this story- a true success story- all the more exciting!

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.

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.

It was my second day at Aledade when someone told me to get out.

I thought it was a bit early to be fired, but the new colleague sounded convincing enough. I assumed they knew what they were doing.

Luckily, this wasn’t some drastic HR move. It was the first of many times that I’d hear, “You have to get out into the field. Go visit a practice.”

It’s a mantra here at Aledade. Everyone, even the current and former health care professionals on staff, seemed to have a story of the first time they visited one of Aledade’s partner practices. They all said that setting foot in a practice is the best way to find out what works, what doesn’t, and to get a sense of just how challenging and rewarding it is to work in an independent primary care practice today.

So when I first got the chance to visit Kansas, tagging along with New York Times columnist Farhad Manjoo as he worked on his new piece about Aledade’s work, I hopped on a flight to Wichita.

Before joining Aledade, I worked on the public affairs team at the U.S. Department of Health and Human Services. We promoted Open Enrollment for the Health Insurance Marketplace, talked about programs like Head Start, and got key messages out to the public about health threats like Ebola, Zika, and the opioid epidemic. But there was one story we kept coming back to – the future of health care.

We saw it every time we heard from doctors, and every time the Secretary visited a practice. Data had opened up new frontiers. Patients now had the tools to get engaged in their own care. And payment systems focused on value were starting to reward physicians who kept their patients healthy. There was a palpable sense that you could deliver better care and start to lower costs.

It seemed like everything was pointing down this path. Policymakers from both sides of the aisle saw the promise in this new approach. MACRA, the law that changed Medicare’s payment system into one that rewards the value of care, passed the Senate nearly unanimously and the House overwhelmingly. And down the street at HHS, the Department made a historic commitment – saying that, by 2018, half of all payments in Medicare would be payments that rewarded the value of care, not the old fee for service system.

But it wasn’t until I visited Aledade’s partner practices in Kansas that I realized how far down the path these health care professionals already were.

On Wednesday, the New York Times’ Farhad Manjoo published his piece, and he captured this well. “Thanks to Aledade,” Farhad wrote, “the [Kansas] practices’ finances had improved and their patients were healthier. On every significant measure of health care costs, the Aledade method appeared to have reduced wasteful spending.”

Here’s an example of how they were keeping patients healthy:

For example, say you’re a doctor at a small practice in rural Kansas and one of your patients, a 67-year-old man with heart disease, has just gone to the emergency room.

“In the past, we’d only find out our patients were at the hospital maybe weeks afterward,” said Dr. Bryan Dennett, who runs the Family Care Center in Winfield, Kan., with medical partner, Dr. Bryan Davis. With Aledade, Dr. Dennett is now alerted immediately, so “we can call them when they’re at the emergency room and say, ‘Hey, what are you doing there? Come back here, we can take care of you!”

The care management team at Ashley Clinic talks with Farhad.

At Ashley Clinic in Chanute, I saw a larger care team tackle an even larger patient population. As one care manager said, “before, we had the doctor and the patient; a point A and a point C. But there was no one to serve as point B. That’s changed today.”

Two of Ashley Clinic’s patients – a husband and wife – agreed. Both said the care they got now was much better than anywhere they had been before. “We don’t know what an ACO is,” they said. “But we know we hear from our doctor more. And we like that.”

Most importantly, by talking to the care teams and doctors in these practices, I learned that I had been wrong. Value-based care isn’t some new future in the distance; it’s more of a homecoming. As one doctor told me, “This is why I became a doctor in the first place.”

But getting home isn’t always easy.

It’s taking new ways of thinking – focusing on finding the highest risk patients, keeping a close eye on them through chronic care programs, following up with patients as they leave the hospital, and ensuring that patients are going to the most efficient and effective specialists.

While it asks for more time and effort on the part of doctors and care teams, who already put in countless hours caring for patients, the destination is worth the jounrey. And thanks to Aledade’s technology, dedicated support staff in the field, and some inspiring health care professionals, you can find better health care right down a long stretch of Kansas road.

There aren’t too many opportunities when you can get the present and the future of primary care in the same room. But that’s exactly what we found at the Louisiana Academy of Family Physicians’ Annual Conference.

Emma Lisec and Nadine Robin at the Aledade booth

On Wednesday afternoon, we arrived at the historic Roosevelt Hotel in downtown New Orleans – Nadine Robin, Aledade’s Southeast Executive Director, and me, Aledade’s Fellow for the Southeast. We were caffeinated, excited and ready to join a massive room full of displays from local hospitals, pharmaceutical companies, and specialty groups. We set up our booth, with Aledade’s slogan: “A New Model of Primary Care”, and we waited to see who would come through the doors.

Right on cue, as the conference’s main sessions took a break, the showcase room flooded with health care professionals from across Louisiana – independent doctors, curious hospital employees, even medical students from Louisiana State University. (Geaux Tigers!)

They dropped by a number of different booths, but kept lingering by ours, wondering what that “new model of primary care” actually meant. So Nadine explained: with MIPS, the new payment program created by the 2015 Medicare Access and CHIP Reauthorization Act (or “MACRA”), quality reporting was taking center stage.

Small, independent practices are the key to that focus on quality. As our CEO Farzad Mostashari has pointed out, small, physician-owned practices offer more personalization for patients. They have lower average costs per patient, fewer preventable hospital admissions, and lower readmission rates than larger, independent- and hospital-owned practices. In other words, they’re in the best position to succeed.

Nadine explained how Aledade helps their independent partner practices report these quality measures all while maintaining their independence. I noticed that a few physicians’ ears perked up at this – the prospect of having a helpful guide through MACRA and MIPS seemed to be integral to their practices staying independent.

I remember one doctor in particular who pulled us aside. He felt like his clinic was short-staffed, and the pressure to sell his practice was only growing. Nadine and I listened to him, and explained that the whole purpose of Aledade is to help small, independent physicians like his stay independent – and thrive. But to do that, we have to start with an honest relationship. We weren’t going to pressure him into joining Aledade if it wasn’t going to be in the best interest of his practice and his patients. We agreed to pull his QRUR report and follow up to see if a partnership with Aledade would be his best step.

We also spoke with some of the physicians of tomorrow. A few medical students from LSU dropped by our booth, wondering what an ACO was. To many of them, the idea of opening their own independent practice seemed out of reach. The concept of a comprehensive approach to primary care, one where the independent practice is in the center of a high value network, sounded promising. They asked us if they could reach out to us later to get a better understanding of an ACO and value-based care.

Nadine and Matt Wheeler presenting at LAFP

That Friday morning, Nadine and Matt Wheeler, one of our inspiring Office Administrators from Bossier Family Medicine in Bossier City, gave a presentation about the new world of alternative payment models. They laid out the idea of value-based care – that physicians should be empowered to provide quality care, and rewarded for helping their patients stay healthy.

They explained what an ACO is – basically a group of health care professionals committed to the health and well-being of a specific group of patients. And they explained why this future – better health care at lower cost – was inevitable. It’s good for doctors, good for patients and good for society.

Nadine with Dr. Jose Mata, a family medicine doctor in New Iberia, LA

Nadine and Matt weren’t the only ones making the case for value-based care. A number of Aledade’s partner physicians in Louisiana were there too – each of them explaining to other doctors why value-based care works.

This whole move to a better health care system isn’t being led by any single practice or any single company, like Aledade. It’s a partnership – a network of practices who want to keep their patients healthy, and organizations working to help those practices succeed. Value-based care is the best model for today’s primary care physicians here in Louisiana, and tomorrow’s too.

Are conversations between doctors and patients the key to good health care? How well do doctors and patients actually talk to one another? In a 1984 study, Howard Beckman and Robert Frankel surveyed 74 practices and recorded how doctors listened and interacted with their patients. 77 percent of the time, physicians prevented their patients from completing an opening statement by asking questions about a specific concern. On average, it happened 18 seconds after the patient began talking.

Beckman and Frankel’s study was conducted in 1984, but the results resonated in a larger study by Lawrence Dyche and Deborah Swiderski in 2005. Physicians in that study asked a question during a patient’s opening statement in 72 percent of the visits, on average in 23 seconds. A quarter of doctors did not solicit patient questions at all.

The average doctor spends between 13 and 15 minutes with a patient. In only 15 minutes, the doctor and patient are supposed to discuss a full patient history, treatment plan and questions. The question at the root of this problem is why do doctors feel the need to rush?

The current fee-for-service system does not reward doctors for having long, detailed conversations with their patients. It incentivizes them to provide more treatments, because payment depends on quantity of care rather than quality of care. Understandably, this system is infuriating to both doctors and patients. However, the fee-for-service system is not the only healthcare model available to doctors.

At Aledade, we focus on helping doctors do their jobs the way that they want to – so that they can listen longer, ask deeper questions, and get more complete answers from patients without needing to rush through diagnoses and treatment plans. As you may have seen in some of our success stories on our blog we do this in many ways, most often by helping our partner practices effectively conduct Annual Wellness Visits (AWVs), Chronic Care Management (CCM), and Transitional Care Management (TCM). These stories highlight how value-based care and a patient-centered approach improves the patient-provider relationship and improves health outcomes.

Communication is the cornerstone of patient care. A report by the Joint Commission, an organization accredits healthcare programs and organizations,  found that  “communication failure was at the root of over 70 percent of serious adverse health outcomes in hospitals.”  Aledade partner practices have learned the value of good communication between a doctor and a patient.

In 2015, Aledade’s ACOs decreased emergency department (ED) visit rates by 6 to 7 percent. The ED visit rate for the Medicare Fee-For-Service (FFS) population increased by 2.4 percent. Hospitalization rates decreased by 5 to 7 percent, while hospitalization rates for Medicare FFS populations increased by 2.4 percent. And Aledade’s ACOs decreased readmissions by 7 to 11 percent. Across Medicare FFS, readmissions increased by 8 to 9 percent.  

What could account for the difference? For starters, AWV, TCM, and CCM all help  practices catch problems earlier, and provide more consistent care. Annual Wellness Visits help to decrease ED visit rates by helping physicians identify high-risk patients and give them the tools they need to avoid a trip to the emergency room, saving on costly hospital bills. Transitional Care Management lowers readmission rates by helping patients stay out of the hospital when they’ve been discharged from the hospital.he Chronic Care Management program provides high risk patients with intensive ongoing care management support that decreases adverse health events, decreases readmissions and improves self-management skills.

If a provider has the space and time to listen to their patients, they can lay the foundation for mutually trusting and beneficial relationships. This trusting relationship is a key component in providing value-based care as it improves patient satisfaction and health outcomes. It all starts with a conversation, and it is more important than ever to really listen.

Natanya 2

Natanya

At this week’s all-staff meeting, our CEO Farzad Mostashari repeated one phrase again and again. “At Aledade,” he said, “we’re thinking long term.”  

Our work at Aledade helps physicians, patients, and society today, but we’re always looking ahead three years, six years, and even more. A focus on the future resonates in our values and the work we do every day.  In fact, the Aledade Fellows program is born from this long-term thinking. By joining the Aledade team as recent graduates or current students, we have the opportunity to learn what it takes to be the value-based health care champions of the future.

Dr. Ezekiel Emanuel’s new book, Prescription for the Future is similarly forward-thinking. In it, he argues for a positive prognosis for the U.S. health care system – but a prognosis that relies on disseminating a variety of transformational practices to raise the quality and lower the cost of health care.  

At Aledade, we partner with practices to implement these high-value practices every day.  Chronic care management that cares for a whole patient. Wellness visits that take into account a patient’s experience outside the doctor’s office. Referral management that steers patients to high-value specialists. And transitional care management that eases a patient’s discharge from the hospital. These are all initiatives that Aledade undertakes today. They’re practices we’ll keep improving on with an eye toward the future.

What Prescription for the Future offers us, as young people involved in the transformative work that Dr. Emanuel describes, is an understanding of Aledade within the greater context of the movement toward a value-based health care system. His book reminds us that the work we do is integral to that  movement, and that we are not alone in looking to the future.

But I wasn’t the only fellow who learned some valuable lessons from Dr. Emanuel’s work. Below are some additional insights from three Aledade fellows:

 

MargotMargot

In chapter eight, Dr. Emanuel asks the question, “Is transformed healthcare transferable?” In other words, can we replicate high-value care success stories across the country?

He points to factors such as cultural, social, and economic histories as the primary barriers to transferring care. Considering these barriers, it seems to me an organization like Aledade is uniquely positioned to transfer high-value care to patients across the country. With a large network focused on collecting quality data, Aledade is equipped to identify successful ideas and scale them among its partner practices. Coupled with this, and equally essential, is Aledade’s emphasis on local physician leadership.

Our partner practices have the independence and flexibility to adopt successful ideas in ways that fit their communities. Care management in Mississippi is not the same care management performed in New York. Ultimately, practices are accountable for the care of their patients, and practices have the grassroots knowledge to transform care for their patients.

 

Doug Streat1 - Edit

Doug

At Aledade, as in health care in general, we have a tendency to use industry buzzwords to describe what we do. Phrases like “value-based” and “patient-centered (and, scarier yet, our alphabet soup of acronyms like ACO, AAPM, CCM) dominate our conversations. This isn’t necessarily bad—we love our work—but it can be hard to explain exactly what is that we do, and why we do it. Dr. Emanuel’s Prescription for the Future is as much a formula for transformation as it is a chronicle of stories that clearly explain the future we are working to achieve.

The future we envision is good for patients. It is one where patients like Miss Harris in chapter one don’t need six providers to manage their care or, if they do, receive seamless care coordination among these providers. The future we imagine is one where patients have ready access to community interventions, like Mr. Downs in chapter six did. The future we are creating is one where primary care providers are so readily available, that their patients don’t need to go to the ED as often.

The future is good for providers, too. The future we are striving for stands on strong technological infrastructure that supports, but does not replace, the work of medical providers, as discussed in chapter seven. The future we seek is one where primary care providers can create improved care and improved bottom line at the same time, as one of our partners in West Virginia, Julie DeTemple, reported to us when she spoke at our all-staff retreat this May.

These transformations, and the others Dr. Emanuel writes about, will help stabilize health care costs and improve practices at a systemic level. In so doing, we hope to build a future that is good for society, too.

 

KellyKelly

As a widely-contested health care reform proposal dominates national news coverage, reading Dr. Zeke Emmanuel’s “Prescription for the Future” was both uplifting and insightful. Each day since I started at Aledade, I have gained a deeper understanding of the United States’ health care system. But arguably the most important thing that I have taken away is a new perspective on the future of health care.

Working alongside a passionate team dedicated to value-based care, a team that is growing every day, has shown me that health care providers are constantly innovating to improve the quality of care delivered nationwide.

I found the chapter on “Transforming Physician Office Infrastructure” particularly interesting and enjoyed reading the section about measuring and releasing unblinded physician performance data. Dr. Emanuel’s explanation of the effectiveness in releasing this data lies in the principle of peer comparisons, from behavioral economics. Physicians, like all humans, are wired to avoid embarrassment in front of their peers, so releasing unblinded data on their performance motivates changes in underperformance. In one story that Dr. Emanuel features, a physician notes:

“As soon as the system started generating data, I remember my own thought was, ‘This is silly. I know I am going to do great on this performance review.’ And then I saw my data. Holy cow, not nearly as good as I thought. Knowing made me realize, ‘Hey we’ve got to be sharing this data.’ But more importantly made me ask, ‘Who is doing the best?’ I need to look at that person and say, ‘What are you doing? How do you do it so well?’” (p.83)

By looking at positive outliers in performance data and assessing what exactly these outliers do better, providers can deliver better care as individuals and practices. That’s why, at Aledade, we analyze and provide quality metric performance and cost data to our providers, both at the ACO and the practice level. We take this one step further by providing practice support through a field team that works directly with practices to decrease their total cost of care and achieve higher quality performance.

My favorite part about working at Aledade is hearing provider success stories, like the one above that Dr. Emanuel features, shared by our field team after implementing Aledade’s resources in our ACO practices. They prove to me that health care professionals around the country are already making incredible progress, and building the future of health care today.

 

Natanya

Natanya

It is not always easy to explain Aledade’s work, and our work as Aledade Fellows, to our family and friends. With healthcare news dominating the airwaves and Twitter feeds recently, it can be tough to make clear how Aledade fits into all of these changes.  

While the answers to these questions are complex, the goal of everyone involved in the value-based transformation is relatively simple: We want to see a future with lower health care costs and higher quality care. At Aledade, we achieve that by partnering with practices and physicians to make that transition from volume toward value.

After all, an alidade is a device used for determining direction. In our case, we’re aiming our sights on a future with better outcomes for patients, providers, and society. Prescription for the Future has given us a peek into where others are aiming their sights. After reading it, I believe we’re not the only ones thinking long term, and that when we converge on the future, it’s going to be bright.

One day this past spring, I met with a patient for our standing care management appointment. She’s been coming to our clinic for 5 years, and during our conversation, I asked my usual questions. When I asked her how she was feeling, she told me something I didn’t expect.

The patient shared that her mobility was getting worse. She said it was getting hard for her to leave her home, because she couldn’t manage the step down from her porch. We continued the conversation, and I addressed her other concerns. But after the appointment, I got to thinking. How could we make it easier for her to leave her home?

I didn’t have to wait long for an answer. Later that week, my granddaughter was telling me about her day in school, when we suddenly had an idea. Her class could build a ramp for our patient!

I contacted Aaron Haselwood, the Industrial Arts teacher at Fredonia High School, about building a ramp. He joined in right away. He thought it was a great way for the students to learn and help the community.

Here’s Aaron’s story on how his students built the ramp:

When Tara reached out to me, I thought it would be a perfect project for my class. This is my first year teaching this class, and I can already see that the students are getting a lot out of it. They’re learning skills, gaining confidence, and earning certifications, all while giving back to the community.

The ramp was a class project, but five students took the lead on building and installing it. We spent about two class days on this project. On the first day, we met with the patient to discuss our plan, and then took measurements. We built the ramp in our workshop and installed it on the second day. The ramp didn’t cost the patient anything, because we used leftover materials.

My class already has projects lined up for next year, and we’re excited to continue helping more people in the community.

This ramp has helped my patient become more independent. She feels safer when she enters and exits her home. The ramp, combined with her exercise regimen, has reduced the patient’s risk of falling. She has not had a fall yet. I’m so glad that thanks to care management, our patient feels comfortable telling me her concerns. And I’m just as happy to know there are resources and people in our community eager to address them.