Accountable care in rural communities

Lessons learned, and what is needed to improve outcomes for patients and sustain primary care in rural communities

About 60 million Americans – 20 percent – live in rural communities. People in rural communities tend to be older, have more health risks as compared to people in urban areas, and are less likely to have access to hospitals. Though there are many challenges to delivering high-value primary care, Aledade has more than a decade of experience working with rural independent primary care practices, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in value-based care. 

Aledade is the largest network of independent primary care, supporting value-based care in rural America since 2014. Over the past decade plus, Aledade has learned successful strategies for addressing some of the unique challenges rural primary care organizations face. We continue to advocate for a number of policy priorities the Centers for Medicare & Medicaid (CMS) and Congress should consider to ensure primary care in these communities — and the patients they serve — can thrive.

More than a decade of experience providing value-based care solutions in rural communities has highlighted strategies that work.

Aledade, a public benefit corporation, helps independent practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Aledade works with more than 2,400 primary care practices including 300+ FQHCs and rural health clinics around the country to provide organizations with data analytics, user-friendly guided workflows, policy expertise, strong health plan relationships and integrated care solutions. Over a quarter of all Aledade practices operate at least one location in a rural community, serving around 70 million rural Americans. More than 60% of Aledade practices are in Primary Care Shortage Areas and 46% are in Medically Underserved Areas.

Aledade serves rural communities by helping physicians have actionable insights at the point of care, improve care coordination, address staffing shortages through the Aledade FIRST residency program, and advocating for policy improvements affecting rural Americans.

"When I went into medicine, the goal was to care for people and keep them healthy. But over the years, the practice of medicine became too focused on making money and 'delivering services.' That's why I've been so thankful to be part of an accountable care organization. Thanks to the shared savings I've earned in value-based care, I'm able to put our small business on a more solid financial footing. We're able to retire debt. We're able to pay our staff fair salaries and reward them for the tireless work they do and keep them close in a tight labor market."

-Richard Cole, MD, family medicine physician at Patrick County Family Practice, a rural health clinic in Stuart, Va., who joined an Aledade ACO in 2018.

How does Aledade help rural health physicians improve health outcomes in their community?

Getting more actionable data at the point of care

In working with rural health clinics, Aledade has learned which point of care data is most useful to practices when the patient is in the office. Aledade tools — including the App and other platforms, are a central resource that facilitates timely access to patient data, identifies care gaps and integrates information from electronic health records (EHR), labs and pharmacies. For patients who are not coming into the office, but are overdue for annual wellness visits, preventive screenings or appointments to manage their chronic conditions, Aledade tools identify these patients and help with proactive outreach. 

The app enables rural clinics to manage complex patient needs and coordinate care effectively, even when specialized services require travel. Staff at many of our partner practices have told us that prior to joining the accountable care organization (ACO), for example, they did not know when a patient was admitted to the hospital or discharged, especially if they were not on the same EHR as their local hospitals. 

Jeni Barham is the chief quality and compliance officer at Mainline Health Systems, Inc., a rural FQHC headquartered in Monticello, Ark. Founded in 1978, this center was created to serve farmers and their communities, and was named a Million Hearts Hypertension Control Champion by the Million Hearts initiative co-led by the Centers for Disease Control and Prevention (CDC) and CMS.  

The Aledade App helped in this effort.

“It's a deeper layer of care you don't have when you're out here alone. There's always more to the patient and more to the picture that you don't get to see unless you have a partner like Aledade that can get that information for you,” Barham said. “By partnering with Aledade, we’re able to see more of the full picture regarding patient health. This supports MHSI in taking better care of the patients. The data provided on the Aledade App helps us stay focused and on track across our multiple sites.”

Addressing workforce shortages

The primary care workforce shortage is often exacerbated in rural areas. Aledade offers resources aimed at alleviating these challenges, which are particularly acute in health provider shortage areas (HPSAs). Aledade’s clinical support teams and practice transformation specialists work alongside existing staff to enhance workflows, track quality metrics and transition to value-based care models.

Our experience with FQHCs and RHCs has demonstrated that the accountable care model is a critical tool to addressing burnout and solving some of the primary care workforce challenges. Shantelle Simpson, the Chief Executive Officer of Appalachian Mountain Care, an FQHC in western North Carolina told us:

“Before joining the ACO, I thought we were highly productive. But now that I’m working with Aledade, I realize how valuable the data we get is. We get more outcomes data, metrics on how we are performing, and information on care gaps. The app helps us prepare for upcoming appointments and get better information from hospitals, as patients are being admitted and discharged.” 

She noted that Aledade has provided training on various topics, which in a time when staff have been overwhelmed has been a helpful addition. 

Fairfield Medical Associates, a rural health clinic in South Carolina, faced additional workforce challenges when the region’s hospital closed in 2016, leaving Fairfield and a free-standing emergency department as the sole sources of care for the community. Combined with the fact that the majority of their physicians are getting closer to retirement, the clinic needed innovative solutions. When they joined an Aledade ACO in 2023, they were able to hire a part-time physician, and their workflows became more efficient.

“We had a flow in the office prior to becoming part of Aledade, but now with up-to-date data, the entire staff is able to see when a patient is due for an annual wellness visit,” Sarah Lewis, Fairfield billing manager, said. “Getting information from outside providers has also been valuable. It’s helped us to follow up on hospitalizations as well.”

While workforce policy solutions are needed, Aledade is providing solutions for independent primary care through Aledade FIRST, a value-based care curriculum program that connects early-career physicians with rural and underserved communities facing critical provider shortages due to a retiring workforce. The program helps to set medical residents up for success through training in value-based care, placement with an Aledade partner practice or community health center, and help with loan forgiveness. In Newton, Kansas, Aledade FIRST participants, Drs. Clennan and Zamzow both have accepted positions at Health Ministries Clinic and Axtell Clinic. Their FQHC placements support ongoing access to high-quality care and reinforce the long-term strength of Aledade’s value-based primary care network.

Advocating for policy improvements

Aledade actively advocates for policies that support rural health initiatives, such as investments in primary care, increasing savings opportunities in value-based care, reducing administrative workloads and continuing telehealth flexibilities. We aim to create a more sustainable economic and health care environment for rural primary care organizations. Through these initiatives, which happen at both the federal and state level, Aledade is deeply committed to enhancing health outcomes for patients in rural areas and ensuring that rural primary care practices can sustain their critical roles in their communities. 

Building a better and more sustainable accountable care model

Aledade was pivotal in shaping ACO benchmarking methodology, and made the case for rural practices to be held accountable for their local cost trends, not the cost trends in urban areas and larger markets and vice versa, a policy which CMS finalized in 2016. Evolving the benchmarking methodology and ensuring that treating the ACO and the region the same has led to more revenue for ACOs in areas where the population is aging and the cost of living is rising. Many of the practices Aledade works with have reported revenue earned by MSSP can be reinvested for hiring staff and providing bonuses to staff who hit performance or quality measure targets. 

Currently, Aledade is advocating for CMS to continue to increase savings opportunities and address cash flow challenges for ACOs and reduce administrative workloads in quality reporting. Aledade is a large part of the Primary Care ACO Flex Model (Aledade ACOs represent 13 of the 24 participating ACOs), a five year model which the Center for Medicare and Medicaid Innovation launched in 2025. The Flex model aims to test whether providing more upfront payments to participating ACOs in the MSSP will lead to better health outcomes. The Flex model incentivized FQHCs and RHCs to join value-based models by offering enhanced prospective payments for primary care services. 

Working for increased primary care investment

Aledade continues to work with community health center advocates to tell Congress that CHCs are the backbone of America’s primary care system and investing in these centers saves lives and taxpayer dollars. 

At the state level, the Aledade Policy Institute has prioritized strengthening primary care investment. While nationally, primary care accounts for 35% of all annual health care visits, it receives on average less than 5% of total health care spending. The Aledade Policy Institute’s state policy wins includes contributing to the introduction of primary care investment legislation in Arkansas (Senate Bill 264), and incorporating exceptions for value-based care in prior authorization legislation in the state. 

Advocating for telehealth flexibilities

Congress waived many telehealth restrictions during the pandemic, and since the Public Health Emergency was lifted, these flexibilities have continued through several short-term extensions. Many Aledade partner practices rely on telehealth and some patients enjoy the convenience for certain services. Telehealth doesn’t automatically solve gaps in care for all populations, but data from our partner practices shows that certain primary care services work particularly well, including annual wellness visits, transitional care management visits, chronic care management services and mental health visits. As more evidence emerges on how telehealth can best serve patients in HPSAs, patients with transportation barriers and other vulnerable patients, Aledade is advocating for telehealth policies that improve access and strengthen the patient-primary care physician relationship.