The holidays are fast-approaching. For some it is a celebratory time with family and friends, while for others it is more difficult.

Many patients with chronic diseases struggle to stay healthy during the holidays. Some tend to eat or drink too much during the holiday season and unfortunately, holiday foods are usually high in fat, salt, or sugar. Traveling and change in routine can lead to skipping or missing important medications. Additionally, holidays can increase stress and depression. Unfortunately, during this time, the hours for primary care clinics and pharmacies are reduced and patients are not always able to get the support they need.

As you gear up for the holiday season, here are our top five tips for helping your patients to stay healthy and “Home for the Holidays.”

1. Focus on high-priority patients. In many Aledade ACOs, partner practices are reaching out to high-priority patients via phone call, email, or mail. High-priority patients are those who frequently visit the Emergency Department (ED), have been recently hospitalized, or are on the chronic care management worklist. Many ACOs are running phone banks, where Aledade staff or contractors call high-priority patients to inform them about their practice’s hours around the holidays. They also remind the patients about same day/next day appointments, the availability of an on-call provider 24/7, and the flu shot. Almost all of our partner practices are hanging Home for the Holidays posters and mailing postcards or emailing high-priority patients. These materials are customized with the practice’s office hours and holiday closures, as well as any specific after-hours information.

2. Reach out to high-risk patients under care management to make sure they have everything they need to avoid a visit to the local hospital. If they are frequent ED users, consider bringing them in for a visit, especially if they lack social support.

3. Take the time to update voicemail with holiday closing and on-call coverage information so patients and families know when you will be available for them. Try to avoid recordings that advise patients to go directly to the ER, rather, encourage them to call the on-call provider and if necessary, go to urgent care.

4. Ask your team to ensure that prescription refills are up-to-date for patients on your “worry list” and or reach out to local pharmacies who may be willing to fill your patients’ prescription by protocol for a short time if your office is closed.

5. Share your closing message about holiday plans through waiting room posters, mailings, website/patient portal, social media, or better yet with a friendly reminder in person with each office visit. The materials mentioned above can be a great place to start!

We know that the holidays can be stressful for some of your patients but hope that you will find a way to help them stay safe and at home while you and your staff enjoy some well-deserved time with your own families.

Download Customizable Poster & Flyer Template

Deborah C. Stamps, Marcella L. Carr, Holiday Season for a Healthy Heart, Critical Care Nursing Clinics of North America, Volume 24, Issue 4, December 2012, Pages 519-525, ISSN 0899-5885, http://dx.doi.org/10.1016/j.ccell.2012.07.007.

David P. Phillips, Jason R. Jarvinen, Ian S. Abramson and Rosalie R. Phillips Cardiac Mortality Is Higher Around Christmas and New Year’s Than at Any Other Time: The Holidays as a Risk Factor for Death Circulation. 2004;110:3781-3788, http://dx.doi.org/10.1161/01.CIR.0000151424.02045.F7.

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!

Every day, physicians are evaluated by a myriad of sources. Think of all the websites with provider ratings: Health Grades, Angie’s List, and even Yelp. These sites ask patients to review the quality of care provided by healthcare providers, and yet give no control to those who are being reviewed. Now, consider insurance companies and other payers who may provide scorecards based on patient metrics. As physicians, we may see a patient four times out of the year for 15 minutes, but we have no control over how they spend the other 8,759 hours of the year.

Also, take into consideration that no physician gets a perfect score across all of these scorecards. In today’s medicine, anything short of perfection is a “ding.” The reality is that dings are part of the new value-based world, and it’s important that we recognize them for what they are—opportunities for improvement rather than points of frustration.

Let’s face it, medical providers do not like to be judged. Many of us, as physicians, have succeeded in our professions due to our hard work and dedication. But, more importantly, our pursuit of excellence is what sets us apart. Perfection is the gold standard and anything less will not suffice. We believe that our patients’ lives depend upon it.

When we see scorecards produced by a payer and see that we do not meet or exceed all measures, many of us find this as being insufficient in the care we provide. As a medical director for Aledade, my conversation with primary care physicians in our national accountable care organization (ACO) network generally go like this:

The Over-Utilization Ding: Frequent Emergency Department (ED) Visits
“You mean to tell me I’m getting dinged for that guy? There is no way I can keep him out of the emergency room. He loves going there.”

The opportunity for over utilizers “frequent flyers” is to have them utilize you more. Less ED visits are a step in the right direction, so rather than trying to “fix” or “make perfect” one frequent flyer, we will instead attempt to reduce a few visits among all of your frequent flyers. We do this by helping practices expand same day access, teach patients to call the physician first, and add robust care management that targets patients who “love” the ED.

The Over-Budget Ding: Costs More Than Expected
“So what you’re saying is that I am getting dinged for his liver transplant? How am I supposed to control his costs? I am just his primary care physician.”
The opportunity for high cost patients is to start thinking ahead. Ask yourself the “surprise question” are the high costs due to a specific medical condition, like cancer? Would it surprise you if the patient died in the next six to 12 months? If the answer is no, has the patient or family received an end-of-life conversation? If this is not an end-of-life situation, is chronic care management appropriate? Are the costs episodic? If so, there might not be much that you can do besides embrace the ding.

The Quality Measure Ding: Failure to Meet a Seemingly Arbitrary Content Management System Defined By Quality Measures that Make No Sense Clinically
“You mean to tell me I’m getting dinged by a patient with diabetes, who refuses to take my medical advice? I am going to dismiss that patient from my practice so I never get dinged again.”

This particular ding can provide the opportunity to improve quality measure performance for an entire population. Can the measure be addressed across the entire population? Are you leveraging standing orders? Are you seeing poorly controlled patients more frequently until they reach a specific goal? Do you recognize the opportunity to improve your risk coding for these complex patients?

It’s time to rethink the ding. It can feel frustrating to have someone tell you that you are not doing your job well, but embrace the ding and let it be your call to action. Keep providing the best quality care to your patients, always with positive outcomes in mind. If you get dinged, then you will know where you need to get better. Focus on providing better care at affordable costs.

Four years ago, enticed by the vision of a better healthcare system in the hands of empowered and elevated primary care providers, I joined my longtime mentors, Farzad Mostashari, MD and Mat Kendall, on our third collective adventure – Aledade.

Since that fateful day, I’ve served in a handful of roles – teacher, learner, confidante, road warrior, doctor, and mediator. I could write of the way our incredible mission has motivated me, kept me centered and determined, driven me to keep learning. I could explain the feeling I get when one of our Aledade physicians relays to me an a-hah moment, having realized that the Annual Wellness Visit they just conducted just saved a patient’s life, simply by opening up a conversation about the patient’s circumstances and risk factors. I could tell of the pride and exhilaration born of gaining momentum, of extending our reach to new patients across the country.

Instead, I want to share the story of Aledade’s four years through its people.

Year One introduced me to our Chief Technology Officer Edwin Miller, fabled builder of Electronic Health Record systems and incredible humanist, who literally feels the pain of our providers in a way I never thought possible. He shares his passion for working on old cars with his son and has quietly amassed the most incredible t-shirt collection I have ever seen. Edwin taught me what it means to serve our providers, to put their needs first, to dive in and do whatever is necessary to reach our goals.

In that first year, Edwin and I both got to meet Becky Jaffe, one of our original Delaware family physicians, a tireless advocate for the independent primary care provider, and the doctor I would choose for myself or any one of my family members. Becky and our indomitable physician partners in Delaware, Maryland, Arkansas, and Staten Island pushed us to be better and helped us build this incredible rocket ship without an instruction manual (and while flying it). Our first Delaware Practice Transformation Specialist, Robin Senft, taught me that you can accomplish anything with a smile – and a homemade, hand decorated cake pop.

In our second year, we blossomed. I was lucky to get to know so many new members of the Aledade team as our company grew, including Christine Dang-Vu, Golden State Warriors’ number one fan and tenacious, brilliant practice advocate and implementation strategist (and executor). A veritable One-Woman Band, Christine exemplified for me the discipline and work ethic necessary to move the needle in this complex ecosystem.

Our third year introduced me to the miracle of motherhood and the challenges of being a working mom. My daughter Nina became the light of my life on October 21, 2016, and even after an extended maternity leave, I was just not ready to suffer being away from her. My Aledade family rose up around me and held my hand, gracious, gentle and patient. Countless colleagues – friends – counselled and supported me and helped me see that there was a balance and serenity to be gained through persistence, self-love and incremental progress. My eyes were opened to so many awe-inspiring examples of Aledade parents – Candice Cortes, Spring Lane, Joe Neumann, to name a few – who have navigated this complex and often heart-wrenching dance. I can’t imagine going back to a time without Candice’s incredible EHR and practice workflow knowledge, Spring’s enthusiasm, can-do-it attitude and results-orientation, or Joe’s quiet progress behind the scenes to get us the data we need to promote practice change.

In our fourth year, our ranks continued to swell with the most inspiring individuals, personally and professionally. We count among us Peace Corps volunteers, foster parents, mountain climbers, church leaders, yoga instructors, acupuncturists, chefs, world travelers, and rodeo athletes. Every day, my colleagues carry our core values of Grit, Service and Inclusion to their communities. I am so proud and grateful to work alongside this incredible team and I cannot wait to see where, and to whom, Aledade’s fifth year takes us.

Earlier this year, my mom was hospitalized with bilateral multifocal pneumonia and the flu. For most patients her age, these infections would have been unpleasant but ultimately manageable. For my mom, though — a patient with a complicated medical history and multiple chronic conditions — the confluence of these illnesses was devastating. She was having trouble breathing and barely getting enough oxygen into her blood to survive. Doctors and nurses gathered in her room, poking and prodding, dripping and injecting, questioning and documenting. But their interventions failed. She decompensated. As she was rushed to the Intensive Care Unit, I rushed back to Connecticut from Washington, DC to be by her side.

Sitting in her hospital room in the days that followed, I met at least a dozen providers, all of whom introduced themselves to me as “her doctor,” as if saying it aloud would somehow make it true. The reality is that although my mom has been passed among specialists like a prized specimen for years (perhaps ever since her first mitral valve replacement), no physician has been truly “her doctor” for as long as I can remember. She has no primary care champion.

She’s not alone. Nationally, 17 percent of women report having no personal doctor, and among those who share my mom’s Hispanic ethnicity, 32 percent (nearly 1 in 3!) have no health care provider.[1] The statistics are even higher for men. These numbers terrify me: primary care is eroding as independent practice gives way to corporate consolidation. This paradigm shift means that there are millions of patients in the United States who have no healthcare quarterback, whose care is not coordinated, who suffer the acute failures of our fragmented healthcare delivery system alone. Working at Aledade, we are lucky to get to whittle away at those statistics. Aledade partners with independent primary care physicians in 18 states, providing exceptional care and acting as the champion for over 200,000 Medicare patients and more than 100,000 patients with commercial health plans.

I’ve gotten to visit some of these primary care champions as part of my work here over the past year. One of my most salient memories is visiting a practice in Collegeville, PA, and shadowing Dr. Fiorillo, one of Aledade’s partner physicians, as he visited with his patients. I knew from having seen his schedule that his calendar was packed with back-to-back 15-minute visits and no breaks, but the moment he entered a patient room and closed the door it was as if he had all the time in the world. He listened intently as patients described their ailments. He asked about birthday parties and Little League baseball games. He knew them personally, and they trusted him. As a healthcare professional, this was my first experience seeing primary care done the right way.

By the fifth day of my mom’s hospital stay, one of “her doctors” began to start making small talk. We learned his name was Dr. Balboa, and that he was a hospitalist. And though he’d spoken only English on days one through four, on this day he asked her in her native language: “¿De donde eres tú?” Where are you from? “Medellín, Colombia,” she replied proudly. He laughed sheepishly. As it turned out, he was Colombian too. Over the next few days, he got to know her personally and she began to trust him. I was reminded of my visit to Dr. Fiorillo’s office.

As we talked with him, we learned that he used to be in primary care. “But, as a primary care physician, every year you work harder and you make less. And everyone says that primary care matters, but the powers that be have not prioritized primary care. I couldn’t afford it anymore. I had no choice; I left to work for the hospital.” Never had my work or our mission at Aledade felt more personal than that moment. By partnering with independent primary care docs, Aledade helps relieve the pressures of decreasing primary care compensation and increasing regulatory complexity, and in so doing helps keep top-notch primary care physicians like Dr. Balboa independent, allowing them to do what they do best by taking care of patients in their communities.

I am in awe of the work that Aledade’s field staff, my colleagues across the country, do each day, acting variably as advocates, healers, coaches, mentors, counselors, and friends to our providers and to our patients. I am lucky to get to contribute to this work myself as part of our tech team, helping to develop tools and reports that provide insights to our docs and their staff members at the point of care. Together, in partnership across our organization, Aledade delivers insights and knowledge that ensure patients all over the country are getting better care every day.

My mom is out of the hospital now and doing much better, but she still doesn’t have a primary care champion. I worry about her every day. I wonder if her various treatment regimens for multiple chronic conditions are being coordinated, or if there might be an adverse drug-drug interaction hidden within her cocktail of more than a dozen medications. As her son I try to help, but I’m no substitute for a primary care provider. If Dr. Fiorillo were her doctor, I would have nothing to worry about; surely he’d be able to keep track of it all. But alas, for now she’s navigating her healthcare journey alone, as she travels from neurologist to cardiologist and many -ologists in between. I can only hope that one day Aledade might expand into Connecticut — the moment we do, I’ll be sure to take her to visit an Aledade partner physician.

Happy Birthday Aledade. Here’s to many more years of health — for Aledade, and for its patients.

[1] https://www.kff.org/disparities-policy/state-indicator/no-personal-doctor/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

As a primary care physician in a small, independent practice, my focus has always been on doing what is best for my patients and community. Over the past twenty years, I’ve continued to come back to this idea. My practice, Scott Family Physicians, has become a trusted, connected part of the community. Being an independent physician offers many benefits to my patients.  One example is the freedom to have open scheduling in my practice, allowing patients to set same day appointments, instead of an expensive, unnecessary visit to the ER. It also allows me to serve my community as the high school football team’s doctor every Friday in the fall.

But, running an independent primary care practice also comes with challenges and tough decisions. As the shift to value-based care gained traction, it became clear that this new model was a great way for primary care practices to be rewarded for the attentive, personal care we provide our patients.

That’s why, two years ago, I decided to join the Aledade Accountable Care Organization (ACO) with other local Acadiana primary care physicians. I knew what this meant for my practice, as the transformation to value-based care is an investment of time, staff, and finances, but was confident that we could succeed with our partner independent physicians in the ACO and with Aledade.

And, I am proud to say, now as the Medical Director of the Aledade Louisiana ACOs with over 30 of the highest quality primary care practices in Louisiana, my practice’s decision to embrace value-based care is showing returns in a big way.

Through the Aledade ACO, our group of local, independent primary care practices partnered with one of the largest payers in Louisiana, Blue Cross and Blue Shield of Louisiana. In our first year providing value-based care to our patients covered by Blue Cross in its value program, Quality Blue, we saw great results. Not only did our patients receive better quality care, our ACO achieved significant savings.

Through our clinical initiatives, population health management, and increased ability to access and share data, we reduced our patients’ total cost of care by 8 percent. But, more importantly, we kept them healthier. Our ACO kept patients out of the hospital and ER, reducing admittances from 65 to 57 per 1,000 patients. By focusing on chronic disease management, we helped increase our patients’ rate of control of diabetes (up 13 percent) and hypertension (up 20 percent) significantly. Through improved visibility into our patient population, we could proactively reach out to high-risk patients, identify patients in need of a PCP visit, and conduct more preventive care – such as mammograms, which we saw rise 5 percent across the ACO.

For my fellow physicians and I in the ACO, this is a sign of our hard work paying off. Many of our practices had been delivering this kind of care for years, but in Aledade’s ACO model we now have the technology, access to data, and ability to participate in value programs, like Blue Cross’ Quality Blue program, to see the benefits and results for our patients and practice. For my practice this means we kept our patients healthier and the savings we achieved let me breathe easier as a small business owner. The savings we shared in, can be the difference between keeping clinic doors open and remaining independent or having to close a practice.

Recently, I had dinner with some of my fellow family physicians and, typical for our group, our conversation ranged broadly. After discussing our favorite basketball teams’ odds of making the final four, we wound up talking about one of the biggest buzzes in health care today: the shift to value-based payment.

The conversation is moving beyond the fact of change to the pace of change acceleration.

Medicare is making this move because value-based care is improving patient outcomes. Increasing preventive medicine services, lowering hospitalizations and readmissions, and performing fewer unnecessary procedures means better medicine for both patients and their healthcare teams. The move to a value-based system is also saving money; in 2016, Medicare accountable care organizations (ACOs) generated more than $652 million in total savings. The private sector is not far behind, with a large coalition of health systems and insurers starting similar initiatives.

For primary care physicians, the implications of this shift are becoming clear. We understand the basic concept of value-based care: rewarding physicians for quality outcomes instead of volume. We are learning that providing value-based care empowers us to put the patients’ health first. A significant question remains: how can independent primary care doctors operate in this new environment?

While many of us feel we have the skills to be strong champions in leading this change, we lack the large-scale tools, regulatory fluency, and dollars to do so without sacrificing the qualities that make our practices our own. Negotiating with an insurance company or digesting volumes of government regulations aren’t skills often taught in medical school. Spending time learning those things in the midst of adopting new technology systems, adhering to regulatory requirements, and overhauling the practice payment structure distracts physicians from doing the job we love most: taking care of our patients.

The solution for independent practices may come from an unexpected direction: through innovative partnerships that don’t require geographic co-location or practice-based infrastructure. Three years ago, my practice made the decision to partner with an organization that believes patients must be at the center of value-based care, and that physicians are happiest and best utilized when providing that care to patients. I have served as the medical director for a Kansas-based ACO with Aledade, Inc. for three years.

I have seen the Aledade model provide support for the business, technological, administrative, and regulatory work of the ACO without placing a burden on my practice. The partnership allows each party to focus on what they know best: the practice takes care of the patient population and Aledade takes care of the infrastructure. The success of each partner is dependent on the other, which aligns priorities and goals across the organization.

Value-based care is the future of health care. From independent practices to large systems, we must adopt innovative strategies to accelerate the pace of change. Our physicians need it, our patients deserve it, and our healthcare system depends on 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.