ALEDADE 94 VA MSSP ENHANCED

• To subsidize the cost of Recipients’ transition to an electronic health records system and to otherwise support other investments in technological infrastructure and redesigned care processes that will enable Recipients to provide better care coordination for patients, including MSSP Beneficiaries.
• To assist Recipients in operating their clinical practices and providing coordinated care for the ACO Medicare population, which includes without limitation, subsidizing staffing and overtime expenses.
• To enable Recipients’ improvement in accurate and complete record-keeping, submission, and validation (including diagnosis documentation and coding).

The ACO will make payments as necessary to Participants in the ACO to reimburse the staffing costs required to complete certain value based care activities, which includes: 

a) Conduct outreach to patients.

b) Contact patients recently discharged from a hospital emergency department or inpatient/outpatient status to assess if needs were met and schedule a follow up visit with their primary care physician if needed.

c) Contact patients who have not been seen by their primary care physician in 6-12 months (depending on chronic conditions) and schedule annual wellness or other diagnostically appropriate appointments.

d) Contact patients who are new to the Medicare program and schedule a “Welcome to Medicare” visit.

e) Implement and routinize use of the Aledade application to provide insights into patient health, diagnosis coding opportunities, and visibility into the total cost of patient care.

f) Reviewing the “care gap worklist” in the Aledade App to apprise patients of test results, conducting outreach to patients to schedule preventive screenings, and follow up with patients concerning medication adherence concerns.

g) Support accurate and complete diagnosis documentation and coding.