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.

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.

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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.

 

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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.

For over twenty years, I’ve been blessed to receive exceptional care from Dr. Chiarito, my primary care physician at Mission Primary Care Clinic in Vicksburg, MS. I’m a retired English professor, I’m a minister of the Presbyterian Church (USA), and I’m someone who’s had plenty of engagement with the health care system over the last few years. This includes having my hip joint replaced and, recently, having surgery on my shoulder. With the help of Dr. Chiarito, I have also recently lost a significant amount of weight.

I remember meeting Dr. Chiarito, when she was still in medical school, observing at the Mission Clinic. In the years since joining the practice, Dr. Chiarito has been someone I depend on for my medical care. I have never had a better relationship with a doctor. Dr. Chiarito’s warm, outgoing personality helps me know that my medical needs will be supported, and her personal touch with patients is noteworthy. Once, when I was in a skilled nursing facility, Dr. Chiarito came by to check on me, and she brought me some delicious figs from her garden!

In addition to Dr. Chiarito, I’ve also grown close to one of the nurses, Melody, who helps me take proactive measures to prevent future health problems. Examples of these measures include the flu and pneumonia shots I receive and the Prolia shots Dr. Chiarito prescribes for osteoporosis prevention.

I am enrolled in the Mission Clinic’s Care Management Program. Mary, the Care Manager, helps address my unique health concerns and works in partnership with me to identify and implement ways I can positively impact my own health. She calls me once a month to check in, and we have a conversation about changes in my health as well as any health-related questions I may have. Her monthly phone call is a source of confidence and peace of mind. If there is something bothering me, Mary arranges an appointment for me right away.

One example of Mary’s dedication to managing my health stands out. After my shoulder surgery, my physical therapist had a few questions for my surgeon. Unfortunately, my physical therapist had trouble reaching him. Mary called the surgeon every day for a week, and she was able to get the answers needed to continue my physical therapy. Without getting the right physical therapy in a timely manner, my recovery could have been severely impacted.

I encourage everyone to have a primary care physician and build a relationship with their doctor and the rest of the practice staff. The Mission Clinic team has greatly improved my health, and they have positively impacted my life. Because of the relationships I have with everyone at Mission Clinic, I feel confident asking questions, and I know I am receiving the best care. Dr. Chiarito, Mary, and Melody are partners in my care, they help me get all the right information, and they determine the best plan for me. Mission Primary Care Clinic gives me a great sense of being personally looked after, and, with their help, I am confident many healthy years are ahead!