In communities across Mississippi and Tennessee, a group of primary care doctors are changing health care for their patients, their practices, and society: they are practicing the kind of patient-centered care that inspired them to go into medicine and their efforts are creating measurable value.

The work started in January of 2016 when 16 independent primary care offices across Mississippi and Tennessee took a chance on improving quality outcomes and lowering costs for their patients. These practices teamed up with Aledade to form the Aledade Mississippi Accountable Care Organization (ACO) that is now composed of 22 participants. Aledade partners with independent practices, health centers, and clinics across the country to build and lead ACOs anchored in primary care. As a part of the ACO, member practices work collaboratively and share in the savings they create.

The work paid off. The Aledade Mississippi ACO was successful in earning a quality score of 95% while saving Medicare $9.8 million in 2017. We reduced hospital admissions by 9%, cut unnecessary home health spending by $4.8 million and decreased hospital readmissions by 3%. We were also able to increase the number of office visits performed by primary care providers by 33% and increase the number of transitional care visits performed by 7%. These numbers mean healthier patients receiving higher quality care from their local primary care doctors – doctors who are now better-positioned to sustain their independence.

Utilizing Aledade’s combination of resources, technology, and local support, the practices in the Mississippi and Tennessee ACO have influenced a change in the health care system in our region. Dr. Katie Patterson, of Indianola Family Medical Group in Mississippi, recently stated that the ACO work has allowed her to better care for her patients with the knowledge of what’s happening outside of the office walls. “It’s provided me with greater knowledge of total patient care versus just the snapshot we are given in the office.”

Dr. Stephen Hammack of Premier Medical Group in Mississippi also vocalized the impact on his practice: “I am able to be more proactive about my patients’ needs…and identify patients with needs that may have gone unnoticed previously.”

We are achieving these results through a number of initiatives, such as “Home for the Holidays”. There is often an uptick in illness as well as emergency room visits around the holidays and this program helped practices to educate their patients and keep them healthy. This program included proactively calling patients, mailing postcard reminders, and focused conversations during office visits. Practices used same day appointments and twenty-four hour call lines to help patients avoid spending their holidays in a hospital waiting room.

Another initiative we pursued related to managing transitions of care through timely health information sharing with inpatient facilities. We work closely with a few local hospitals and utilize innovative strategies for gathering additional information from others. One clinic hired a nurse to follow patients from admission to discharge, ensuring the patient’s needs were met and that they received timely follow up. Another clinic assigned a nurse to use the local hospital’s health record to monitor the daily patient census, identifying when patients were discharged and then following up with them promptly.

While the revenue generated from savings is a great incentive to keep doing the work, one of our local medical directors, Dr. Syed Zaidi, points to a broader benefit: “We’re able to be a better practice now. We can help our patients more efficiently and provide a higher level of quality care.” That is the goal: efficient, quality care.

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.

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!

Aledade’s growth is about more than adding new practices or forming new ACOs. To us, true growth represents strengthening our network of primary care practices by giving physicians new insight into their patient populations.

This is made possible by creating access to one of the most vital resources primary care practices need – data. Access to timely, relevant data is empowering to practices and impacts everything from workflow to quality of care.

Since our founding, Aledade has emphasized the importance of getting data flowing to – and from – our ACO partner practices. And Aledade’s model is designed to focus on equipping primary care doctors with everything they need to utilize this data and deliver high-quality, coordinated care.

As we grow, Aledade continues to develop relationships with stakeholders throughout the national and local health care markets to equip our ACOs with the data they need. A big part of this is working with Health Information Exchange networks (HIEs) in the communities our ACOs serve.

That’s why Aledade is excited about connecting our ACOs with four new HIEs: Clinisync of Ohio Health Information Partnership, Healthix New York, Louisiana Health Information Exchange (LaHIE), and Mississippi Health Information Network (MS-HIN). Together, these HIEs will connect our partner practices in Louisiana, Mississippi, New York, and West Virginia with more than 130 hospitals.

Across all of Aledade’s ACOs, practices are connected to more than 500 hospitals through our HIE partnerships. The data that physicians access through these connections allows them to see a more holistic view of the care their patients receive, extending well beyond the four walls of their practice.

For instance, Admission Discharge Transfer (ADT) data from local hospitals lets primary care doctors know when their patients have been hospitalized. This allows them to coordinate with hospital providers and support patients with Transitional Care Management (TCM), proven to reduce hospital readmissions.

Connecting our ACOs to HIEs is only the first step in strengthening primary care through data. In addition to HIE data, Aledade ACOs pull together data from a number of sources such as Medicare claims and private payer data – all integrated in the Aledade app. The integration of data from multiple sources allows doctors to effectively manage population health by identifying and prioritizing patients for TCM, Chronic Care Management (CCM), and wellness visits – listing patients by their risk level or time since last appointment.

Aledade knows the value data offers to primary care practices. But, we also know that it is a three step process to use data to improve care. First, practices need to get the data. That’s why we focus on connecting to HIEs to deliver data to practices. Next, practices need to derive insights from the data. The Aledade app integrates all of practices’ clinical and claims data, giving doctors a full picture of patients’ health and care. Finally, practices need to act on the data, as it guides them to deliver high-quality, coordinated care.

As our network grows, so does its value. Aledade’s growth is a learning process, and as we help primary care practices understand how to thrive in a value-based health care system, we continue to learn about the real-world issues that primary care doctors encounter, what they need to deliver the highest quality care, and what our 200 like-minded primary care practices across 15 states can learn from their peers.

This is an important strength of Aledade’s primary care physician-led ACOs. While there is no one-size-fits all solution to improve primary care, we have experience developing and implementing strategies that work across a diverse group of practices. Each independent practice faces its own unique set of challenges – whether driven by geographic, patient population, technology, or policy factors. But, between Aledade’s team, experience, and network of partner practices, together we can empower the delivery of high-quality, coordinated care.

Two members of the Aledade Mississippi ACO (which also includes practices in Tennessee) are leading examples of innovating solutions to their particularly challenging conditions. In both cases, the Mississippi practices have developed successful approaches to Transitional Care Management (TCM). These are valuable solutions as TCM is an effective way to lower hospital readmissions, hospitalization rates, and identify patients needing additional attention. In fact, Aledade has found that for every eight high risk patients who receive TCM, practices can prevent one readmission.

The foundation of TCM is knowing when patients are admitted to and discharged from local hospitals. And one of the easiest ways to acquire that information is through electronic admission, discharge, transfer (ADT) notifications via health information exchanges (HIEs) or from hospitals directly. The Aledade Mississippi ACO has experienced numerous challenges getting electronic ADT data from local hospitals, but the ACO practices haven’t let this technical hurdle stop them. Several practices have adopted their own method of getting critical ADT data in order to implement TCM.

The Indianola Family Medical Group has provided care to patients in Indianola and the South Sunflower County area for over 60 years. In order to get the information they need, Indianola sources directly from the local hospital’s EHR. The practice staff can log-in directly to the hospital’s system and identify which of their patients received care, why the patient was at the hospital, and when the patient was discharged.

Each and every morning, at the same time, their care manager conducts her TCM calls to patients. Indianola has had great success with TCM because, as the care manager describes, “it’s like starting a cup of coffee in the morning.” It’s the first thing she does when she arrives at 8:00am. And, since implementing this TCM process, it has become a tool for identifying patients for Chronic Care Management (CCM). Identifying patients who need a TCM visit, or should be enrolled in the CCM program, is a great way to improve patient health and reduce health care costs.

Kosciusko Medical Clinic has also found a way to coordinate with its local hospital to get the patient data it needs for TCM. However, whereas Indianola used the hospital’s technology to access data, Kosciusko has enlisted their own office support staff. Every day – at least once – a practice employee picks up the paper discharge records from the hospital and walks them across the street to Kosciusko’s desk staff. Originally, the practice only got the triage sheet, limited to names of patients who were discharged, but now they receive a more comprehensive record with the full who, what, when, and why information on their patients who sought care at the ER or were admitted to the hospital.

Kosciusko’s team of care managers uses this information to conduct their TCM outreach every day. The practice brought on a nurse care manager to support each of its providers. This has resulted in a successful work flow to identify high-risk patients who need TCM, and others who should be prioritized for care.

Aledade is proud to help leading primary care practices – like Indianola and Kosciusko – design and utilize the unique solutions they need to deliver high-quality care. It’s entrepreneurial primary care practices like these that join and are successful in Aledade ACOs – helping transform primary care to deliver better care at lower costs.

As a physician in Mississippi, I am acutely aware of the health care challenges facing our state. Mississippi has one of the highest morbidity and mortality rates in the US while also being handicapped by the lowest saturation of doctors per capita in the US.

Together, this means that Mississippi has some of the sickest patients and fewest doctors. This is an incredible burden for the provider community.

However, it is also a call to action for physicians in Mississippi to work together. Coordinating care is important no matter the circumstance, but in the demanding environment Mississippi providers face, it also becomes essential to deliver high-quality, cost-efficient care.

Let me give you an example in my own practice.

As a retina specialist, one of my primary focuses – perhaps surprisingly to some – is diabetes. Diabetes is the number one cause of blindness in Americans under the age of 70, and Mississippi has the second highest rate of diabetes per capita in the nation.

As a result, I work closely with primary care physicians to help manage chronic conditions like diabetes. A key part of this, are the often overlooked – but highly preventive – diabetic eye exams, which I perform daily.

When primary care physicians and eye doctors work together, we can save people’s eyesight, improve their health, and prevent skyrocketing costs. Moreover, since blindness severely affects not only patients’ lives, but also those of their friends and family, this type of care affects the entire community.

When I coordinate care with primary care physicians – like those in the Aledade ACO – I also report back to them what I see in my exams. For instance, eye exams routinely reveal the first signs of a patient’s risk for conditions such as vascular disease, kidney disease, and even a heart attack or stroke. When I see these signs during a patient’s eye exam, I can relay my observations to their primary care physician and recommend additional care or tests. At its best, it’s a two-way street of information between primary care doctors and specialists, and when that happens, those that benefit are the patients.

By coordinating care, we are easing the burden providers face, while ensuring our patients receive the highest quality, most cost efficient care possible.

Since joining Aledade last year, I’ve worked towards our mission of empowering doctors on the front lines of medicine with cutting edge technology to help them deliver high-quality care, while bringing down health care costs. Specifically, as Executive Director for Mississippi and Tennessee, I’ve focused on forming a new primary care physician-led Accountable Care Organization (ACO) in these states.

Today, I am proud to announce Aledade and I have a new partner in this initiative. We have begun a first-of-its-kind partnership with the Mississippi Academy of Family Physicians (MAFP), a statewide professional association of approximately 1,016 members, including physicians, residents, and medical students. At their very core, both Aledade and the MAFP are organizations with the mission of advocating for primary care physicians and their patients.

Aledade ACOs are made up of carefully selected physicians identified for their dedication to and delivery of high-quality care. Our Mississippi ACO is a group of top-level physicians from throughout all of Mississippi and the Memphis area, combined with leading physician members from MAFP.

With this partnership, Aledade continues its work with state-wide physician associations, including several other AFP chapters, focused on helping primary care physicians succeed in a value-based healthcare system. We will work with the MAFP and physicians across Mississippi and the Memphis area to operate a Medicare Shared Savings Program ACO. Our focus is on delivering the highest-quality care to patients, with an emphasis on preventative care, high-value referral networks, customized technology, and unmatched analysis of patient claims and electronic health record (EHR) data to identify patients who need help before serious medical problems arise.

This Aledade ACO means Mississippi and Tennessee patients can continue to see their local family physicians, with whom many have personal relationships. But, these family physicians will be more empowered than ever to manage patient care. Our ACO provides physician partners with the technology and network needed to better assist patients as they navigate a complex healthcare system. Patients can expect improved services as a result of the Aledade ACO, including after-hours care, transitions of care coordination, and long term care coordination. The bottom-line for patients is more personalized, high-quality care from physicians who operate in a system that rewards them for positive health outcomes, not simply services delivered.

For physicians, our partnership with the MAFP will enable the new ACO to provide in-person support throughout the entire setup and operation of the organization. MAFP will provide direct support to help practices within the ACO implement and enhance wellness services and care coordination. MAFP staff will also offer educational resources to help its members understand the benefits of ACO participation and population health, and will serve as a strong presence to aid in creating health policy conducive to empowered primary care.

The combination of top-level practices, MAFP’s resources, and Aledade’s custom technology, policy and regulatory expertise, and practice transformation experience will give independent primary care physicians the opportunity to be leaders in the healthcare transformation to value-based care.

When Aledade launched in June of 2014, we were a small, passionate staff fundamentally committed to a big idea: that independent primary care providers were uniquely positioned to help lead the biggest shift in the American health care system in more than a generation. We believed that if these doctors received practice support, technology, analytics, and regulatory expertise from a true partner, they could reassume their role at the center of their patients’ care – delivering the highest-quality care while bringing down costs across the health care system.

By the beginning of this year, we had partnered with 80 primary care doctors across four states, taking accountability for the care of more than 20,000 Medicare patients. Throughout 2015, we helped these physicians increase vaccinations and preventive care for their patients, decrease hospitalizations, and make investments that will keep patients healthier for years to come. We equipped these doctors with customized platforms that tie together EHR and Medicare claims data, enable them to connect with their high-risk patients, and provide instant notifications when their patients are admitted, discharged, or transferred between care facilities.

But we knew that 2015 would simply be the start.

So today, we are proud to announce that the Center for Medicare and Medicaid Services (CMS) has officially recognized five new Aledade ACOs:

• A Kansas-based ACO contracting with Kansas Foundation for Medical Care, Inc. for practice support
• A West Virginia-based ACO, centered around Charleston, in partnership with the West Virginia Medical Institute
• A Central Florida-focused ACO, partnering with Primary Health Partners LLC
• A Louisiana-based ACO, in partnership with the Louisiana Health Care Quality Forum
• A Mississippi and Tennessee-based ACO, partnering with the Mississippi Academy of Family Physicians, Arkansas Foundation for Medical Care, and Q Source

Beginning January 1, 2016 – less than 18 months after we started this journey – our team grew to include more than 700 physicians in over 110 practices, Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs) across 11 states. We are now responsible for nearly 100,000 Medicare patients, and more than $1 billion in health care expenditures.

In the year and a half since we founded this company, the health care system has accelerated its shift towards outcome-based health care. Early last year, the U.S. Department of Health and Human Services (HHS) set a goal of tying 50 percent of fee-for-service Medicare payments to quality or value through alternative payment models by the end of 2018. It was the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments. In April, the Medicare Access and CHIP Reauthorization Act set a foundation for Medicare’s outcome-focused future. Today, seven in 10 Americans live in an area served by an ACO.

As policy tailwinds have delivered additional momentum, we’ve continued to grow our team and doubled (and tripled) down on our emphasis on preventive care, our development of customized technology for Aledade practices, and the uniquely aligned financial partnership we have with our physicians.

In 2016, we will continue to expand initiatives that have already helped improve our doctors’ practices:

• Care management interventions for specific chronic conditions.
• Behavioral health interventions to support patients battling depression and anxiety.
• Tools and approaches to help ensure patients get the care that aligns with their personal goals at end of life.
• Skilled nursing facility (SNF) transition strategies to ensure patients receive effective care in a SNF and safely return home.

In 2014, Accountable Care Organizations saved Medicare nearly a billion dollars while improving on 80 percent of CMS quality measures – and most observers agree that both the quality and savings effects of these organizations will only grow as ACOs mature. Recent surveys have confirmed what doctors across the country already know – the health care industry’s move towards value-based payment is now inexorable. The question for most physicians – especially those in small, independent practices – is how to navigate this new health care economy.

Aledade was founded to provide an answer – and a resource – for these very doctors. Today’s CMS announcement proves that the appetite for our model, our team, and our services continues to grow. So too does our commitment to our practices and their patients. As we move into next year, our greater scale will enable us to draw more insights about the best way to keep health care costs down and the health of our patients up.