Dr. Salvatore Volpe, MD, FAAP, FACP, CHCQM, a member of the Aledade Primary Care ACO, was selected by the Patient-Centered Primary Care Collaborative (PCPCC) as the 2016 recipient of its National PCMH Practice Award. Dr. Volpe is the chief medical officer at the Staten Island Performing Provider System and has run his own primary care practice in New York for more than 25 years. Below he explains his unique approach to running a primary care practice and how it’s changed over the years.

For me, a primary care physician and Staten Island “settler,” being recognized at the same ceremony as Dr. Paul Grundy and Dr. Edward Wagner is like being on stage with the Mickey Mantle and Joe DiMaggio of my profession.

Dr. Grundy is the godfather of patient-centered medical homes, or PCMHs, while Dr. Wagner wrote the book on Chronic Care and Care Coordination.

I am honored to receive PCPCC’s award, as I see it as a lifetime achievement award (even though I’m still practicing). And, I am humbled to be recognized, because all I ever set out to do was run a solo-physician primary care practice in my home town. Lastly, I am proud of the award as it marks how far my practice has come since its founding 25 years ago – especially our advances in care delivery, quality, and technology.

In my view, my practice has always been a PCMH in principle. However, it’s been a long-term, step-by-step process: achieving PCMH status, becoming the first solo-practice to achieve PCMH NCQA Level 3 in the nation, becoming chief medical officer of State Island Performing Provider System, and joining an Aledade ACO.

Through this, I have come to appreciate three keys to running a high-performing PCMH primary care practice: technology, care management and communication, and patient relationships

When I founded my practice there was no EHR. I used a medical manager practice system for billing and appointments, and that was it. However, I took advantage of a little-known feature in the system called notes, a place to leave details similar in length to a tweet today. With this, I could keep track of test results, reports, and patient information. I saved a lot of health care spending and improved patient health by having access to these notes whenever I got a call – during or after office hours.

When I finally got an EHR system in 2005, it was both a commitment and a risk. Not only was it a hefty investment for my small practice, but it would require hours of learning and workflow adjustment until my staff and I were fully comfortable with its utilization. The investment was worthwhile though, and many EHR system updates and other IT tools later, today I have technology that empowers my practice with data, insight, and analytics never before imagined. Due to this, I’ve become an advocate for EHRs and health information technology, which has lead me to many advocacy roles, including at the NYS Medical Society HIT Committee, the New York Chapter of HIMSS, and assisting Dr. Mostashari and the Aledade team in developing population health technology tools.

One area that improved technology has helped significantly is care management and communication. Through our EHR, HIE, and population health tools, my practice can better collect, manage, and analyze the patient information we need. A good example of this – involving both patient-to-provider and provider-to-provider communication – occurs when one of my patients is admitted to the hospital. Once notified, I call the hospital to speak with the ED doctor or hospitalist to coordinate care – by sending patient records, explaining health history, requesting a discharge summary, and letting patients know to follow up with my practice.

Today, population health management is driven by patient data and technology tools. I can use the EHR and care management tools to assess which patients are at risk due to chronic disease, recent ED or hospital visits, or even flu season, and ensure we are managing the risk. This means communicating with the patient via the phone, to check in or schedule a visit; during a visit, about health needs or prevention; or, for my practice, throughout our community.

Modernization and technology has certainly impacted my practice greatly, but it can only do so much. Primary care, like many professions, still comes down to the people. I pride myself on personal communication and relationship with my patients. My inspiration comes from the lesson of my parents, who, rather than being physicians, were blue-collar workers, but that took care of their friends and neighbors in the community. This example is how I operate my primary care practice. My patients are part of my community, as I live 15 minutes from my practice, and see them at church and the grocery store. Patient relationships like this are important for improving care as they build trust, as well as encourage open communication about health concerns – both mental and physical.

I consider primary care physicians to be the project manager of health. It’s through this approach, including my continued focus on advancing technology, care management, and strong patient relationships, I have been able to successfully lead a solo-physician primary care practice for over 25 years. Recognitions are always a gratifying surprise, and they only further motivate me to improve my practice and care for what matters most – my patients.

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 a Federally Qualified Health Center (FQHC), Hudson River HealthCare’s mission is to increase access to comprehensive primary and preventive health care and to improve the health status of our community in New York’s Hudson Valley and Long Island, especially for the underserved and vulnerable. We are proud to be a part of the Aledade value based care network, because we share the belief that primary care is the foundation of an effective health care system.

We work hard to coordinate the full range of care our patients receive, including outside of our health centers, to monitor, assess, and manage our patients’ full health and wellness needs, not just care for them when they’re sick. As part of an Accountable Care Organization (ACO), we are quarterbacking our patient’s health care.

One of the ways we do this is through our care management program, which focuses on a team-based, holistic approach to care. This allows Hudson River HealthCare to help patients achieve optimal wellness – from their physical and behavioral health needs, to social services and basic living needs.

As we see every day, low income or underserved patients can experience multiple barriers to care – from transportation challenges to lack of resources to follow up on care options. That’s where Care Managers play an important role, talking with patients individually to understand their specific situations and how they can help. We have seen many examples of how our approach to managing patients’ full-spectrum of health and wellness has made a big difference.

In one recent case, a Care Manager, making a routine check-in call with a patient, learned that the patient had recently canceled a medically necessary surgical procedure she was supposed to have on her eye. After inquiring with both the patient and the surgical center, our Care Manager discovered that it was due to the patient’s inability to afford the required insurance co-pay.

Our care manager took action and helped the patient find a community resource to help cover the co-pay, and ultimately the patient was able to get the surgery thanks to this additional support. Without a pre-surgery check-in call, our practice would not have known about the cancelation, and the patient would have likely skipped the surgery, with disastrous results.

A second case demonstrated the Hudson River’s team-based approach to care. One of our physicians learned during a patient visit that the patient did not have a place to live and was “couch surfing” at multiple friends’ apartments. We knew that without adequate housing, the patient would not be able to focus fully on taking her medications or monitoring her health conditions. Upon relaying that information to the care management team, we worked to get the patient an expedited appointment with a local housing organization. A Care Manager accompanied the patient to the housing organization interview and subsequent lease signing. Because of the swift work of our care management team in addressing an issue outside of basic health care, our patient’s quality of life was greatly improved.

We’ve learned that often, when caring for patients with limited resources, even the smallest barrier to care can become a serious issue, and that’s why we take the time and effort to check in often with our patients. As primary care providers, we know that in order to help keep our patients healthy, we need to focus on what happens beyond the walls of our health centers, from issues like housing or financial wellness. This keeps us up-to-date on our patients, coordinated with other providers, and providing the highest-quality care possible.

Participating in an ACO has allowed us to put even greater emphasis on keeping our patients healthy, and that’s our mission.

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.