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

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

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

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

Provide flu shots to high-risk patients

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

Embrace preventive care

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

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

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

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

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


Over the last eight months, my solo practice in Delaware has seen a 60 percent reduction in our monthly Emergency Department (ED) utilization rate. How have we accomplished this? We have undertaken a number of measures to reduce unnecessary ED utilization since joining the Aledade Delaware ACO, but clear communication – both with our patients and with other providers – has made a tremendous difference.


I have always put a focus on being available for my patients. Patients can contact someone from my practice 24 hours a day, seven days a week, and 365 days a year. I know the value – in health and peace of mind – access to a doctor delivers for patients.


As part of joining the Aledade Delaware ACO, my practice placed an emphasis on strengthening our communication with our patients to ensure they know they can – and should – contact my practice about any health need at any time on any day or night. I have reinforced this principle through clear communication during patients’ visits to my office, through my office staff, and with signs in our waiting room, provided by Aledade, reminding patients to call us before they go to the ED or hospital. I also proactively identify frequent ED users in my patient population with the Aledade App, which helps me create a dialogue with these specific patients, while better understanding their health concerns and needs.


During a recent weekend, I received a call from a patient suffering from a cough. Comfortable the patient did not need to seek medical attention immediately in the ED, I arranged a convenient time to see him in the office the next day. Alternatively, I recently advised a patient with chest pain who called after hours to seek immediate medical attention. Given the severity of his medical issue, I called the hospital and had him directly admitted, bypassing what would have been a costly ED visit that would have resulted in a hospitalization.


As a solo physician, I know it takes support to provide this level of communication and service to my patients.  Dr. William Funk, a fellow member of the Aledade Delaware ACO, and I alternate our weekend on-call hours to benefit both our patients and our schedules.


Delivering high-quality care takes much more than clear communication. However, establishing communication between patients and providers goes a long way to increase the quality, timeliness, and cost of care. Ultimately, this benefits our patients’ health and well-being, and that’s what value based care is all about.



The Aledade Delaware ACO is gaining momentum on several fronts in our mission to usher in a new model of primary care. Last year, our ACO doubled in size, and we continue to recruit top independent primary care practices across Delaware that are ready to embrace change by participating in value based programs. Last month, we started participating in the state’s Practice Transformation Services Program in partnership with Remedy Healthcare Consulting. And this week we are excited to announce a new set of agreements that will benefit providers and patients across the state.

Aledade is committed to closing the gaps in health care – coordinating patient care more seamlessly and effectively. In order to do that, primary care physicians need to know what happens to their patients when they see specialists and get treatment outside the four walls of their office. These new arrangements in Delaware will help us do just that – shed light on the care patients receive outside of their primary care practices and empower our Delaware ACO practice partners to deliver coordinated, high quality care.

First, we have recently formed a new partnership with one of the largest groups of hospitalists in Delaware, IPC Healthcare. This will give our ACO practices the ability to share patient data, advise on care, and coordinate with the hospitals where their patients receive care. Partnerships like this are important to value-based care as they reduce unnecessary tests, ER visits, and hospitalizations while improving the care patients receive with provider data access. Aledade’s ACO practices can now also directly admit patients to local hospitals when appropriate, instead of first going to the ER. Doing so, when appropriate, will reduce cost and the time patients spend getting the care they need.

Second, we have upgraded our agreement with The Delaware Health Information Network (DHIN), the state’s health information exchange. While they have long provided patient data on a twice daily basis to our Delaware ACO, the DHIN has now taken the next step, and is providing Aledade ACO practices with real-time patient update. This means primary care physicians will be notified right away if their patient is admitted, discharged, or transferred from a care facility. With real-time data from DHIN, ACO practices will be able to provide more timely follow up with their patients during transitions of care. Transitions of care management are an important focus for Aledade’s ACOs, and an important aspect of providing seamless care.

Another development in Aledade’s data connection with DHIN is that Aledade now receives notifications and data from MedExpress through the health information exchange. MedExpress is a large network of walk-in clinics throughout Delaware, so having real time data from these clinics gives our ACO practices more detailed understanding of the care our ACO patients receive outside of their primary care practices. This too is an important aspect of providing seamless, coordinated care, and we are in the process of arranging further partnerships with walk-in clinics throughout the state.

Lastly, we now have a care compact with The Heart and Vascular Clinic, PA (HVCA) in Delaware. While Aledade believes primary care is the core of a coordinated, effective health care system, we also know that high-quality specialists are a critical piece of the puzzle. That’s why we work to arrange care agreements with high-quality specialists, such as our cardiology referral management program with The Heart and Vascular Clinic, PA (HVCA) in Delaware. These agreements focus on improving care coordination, access, and effectiveness through communication and information sharing, including test outcomes and consultation notes. For patients, this means they can see an HVCA provider within 48 hours for an urgent visit and receive more seamless care.

Taken together, these new agreements and updated services will strengthen the Delaware ACO’s ability to coordinate care, resulting in improved quality and lower overall costs.

Since Aledade’s founding, we have been committed to partnering with Delaware primary care physicians to deliver high-quality, high-value patient care. As one of our first ACOs, the Aledade Delaware ACO has grown to include 26 leading primary care practices responsible for providing care to over 20,000 Medicare beneficiaries. While we have made much progress in bringing value-based care to Delaware, we are truly excited for the future of our Delaware ACO. Why? Our efforts are not alone as the state has expanded its efforts to help doctors and reaffirmed its commitment to being a national leader in health care innovation.

Their latest effort is a Practice Transformation Services Project to help all primary care practices across the state adopt value-based payment models and to improve population health. This effort is being led by Delaware Center for Health Innovation (DCHI), which is committed to guiding a new State Health Care Innovation Plan focused on the “Triple Aim”: improving the health of Delawareans, improving health care quality, and controlling health care costs. This new program is made possible by a State Innovation Model (SIM) grant from the Centers for Medicare and Medicaid Innovation.

Aledade has long supported the State’s health care innovation efforts – but we are most excited about participating in this new effort.

At the core of the Practice Transformation Services Project are 11 milestones related to care delivery transformation, payment reform, and population health management. Aledade worked closely with the State to inform the development of these milestones and they closely align with our company values.

DCHI selected four health care organizations to provide hands-on technical assistance to primary care practices to help them meet the 11 milestones. Aledade has partnered with one of these organizations, Remedy Healthcare Consulting, who will provide care management support services to Aledade ACO practices.

In cooperation with Aledade’s Delaware team, our partnership with Remedy Healthcare Consulting will provide another valuable layer of ACO practice support, including on-site and remote coaching and transformation educational opportunities. For patients, the partnership means primary care physicians delivering the benefits of value-based care, such as seamless coordinated care and a focus on keeping patients healthy. Specifically, the partnership will focus on ensuring sicker patients are receiving more proactive and timely care through a comprehensive care management and team-based approach.

We are confident that participation in DCHI’s Practice Transformation Services Project and work with Remedy Healthcare Consulting will continue to improve and enhance our Delaware ACO.

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.