Why Aledade: Q&A With Dr. Michael Maxwell, Port Angeles, Wash.

February 14, 2024

As a community health center (CHC), North Olympic Health Care Network (NOHN), located in Port Angeles, Wash., has officially been a Health Resources and Services Administration (HRSA)-funded federally qualified health center (FQHC) since 2015. 

NOHN joined Aledade’s CHC Accountable Care Organization (ACO) network in 2020. Michael Maxwell, MD, serves as NOHN’s CEO and physician.

What work has NOHN done to provide accessible, quality care to the Clallam County community?

NOHN is one of Clallam County’s largest employers, and the only FQHC in the county that provides integrated primary medical, high-risk OB, pediatrics, behavioral, dental care and vision services to this historically medically underserved area. 

It was also among the first health centers to offer office-based opioid treatment (OBOT) to the community. The county’s population outranks the state’s in both age and poverty, with a median age of 54 (33% higher than the state’s) and 12% of residents living below the federal poverty level, compared to a state average of 9.9%.

Our geographic isolation creates considerable transportation barriers, and health care options are limited, especially for low-income and underserved patients. 

NOHN has greatly increased access to comprehensive, culturally competent, quality primary care services to an additional 12,000 new patients since 2016 – with most of our 18,000 patients having Medicaid, Medicare, or no insurance. We have:

  • Expanded hours 
  • Added dental care, optometry and same-day walk-in access 
  • Expanded behavioral health services, including telehealth and psychiatry
  • Deployed a mobile health clinic to serve all district students
  • Expanded our Family Medicine Rural Training Track Residency
  • Plans to add retail pharmacy to our existing clinical pharmacy program in 2024

Why did your CHC choose Aledade as its value-based care partner?

We were intrigued and excited by the opportunity to capture a financial return on our longstanding focus of providing high-quality, cost-effective care to our patients. The opportunity to join a Medicare Shared Savings Program (MSSP) ACO that was comprised of similarly oriented primary care practices was particularly attractive.

Aledade has a proven track record of facilitating cost-effective care that promotes good clinical outcomes and producing savings. It provides an opportunity for sharing best practices and experiences among ACO members with data to support tracking and improvement efforts.

What results has your CHC experienced as an Aledade ACO member?

In our first year participating in an Aledade MSSP ACO, NOHN saw both a substantial financial reward and a significant impact on clinical workflows across multiple patient populations. By focusing on patient access and quality, point of care services, care transitions and care compass (Aledade’s Core 4) the NOHN team optimized improved patient outcomes and their revenue potential.

Aledade’s focus on the Core 4 principles provided a roadmap for maximizing shared savings to the health care system, as well as our share of those savings. Further, our increased focus on the importance of appropriate documentation has extended beyond the Medicare population and has impacted coding behaviors broadly.

NOHN also gained a better appreciation for the importance of annual wellness visits, both to address care gaps and to optimize patient attribution.

NOHN has thrived with Aledade’s workflow efficiencies. In the 2022 Aledade MSSP ACO performance year, we excelled in patient outreach measures, achieving a 96% emergency department (ED) follow-up, 83% transitional care management (TCM) outreach, and consistently maintained hospital utilization levels below the Aledade-wide MSSP average.

In 2023, NOHN achieved “GOLD PLUS” status recognition from the American Heart Association and American Medical Association for achieving over 70% control for diabetes care, hypertension management and cholesterol targets. We are regularly recognized as Quality Leaders by HRSA.

Our participation with an Aledade ACO aligned well and supported our existing processes that underlie those achievements. We intend to continue our mission of identifying the health needs of our community along with the social factors that drive those needs and work collaboratively to effectively address those needs.

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