Managing an independent medical group of 10 family practitioners, 32 employees and 85,000 patients is difficult even on the rare day that nothing goes awry by 9:30 AM.  Try adding integration to that daily struggle.  That was my experience in 2008, when I worked as a Clinic Manager and the clinic owner/MDs asked me to come up with a plan to tie-together the electronic health record and onsite lab/imaging, with physical therapy and pharmacy in the same building.  This was no small task.  Life after that day was a blur of template building, interfaces, late nights and workflow changes to keep up with patient communication and needs in a constantly evolving world. Every day, I felt three days behind.  By 2012, the onsite integration was complete.

In 2018, I was introduced to Aledade.  After speaking with Aledade’s founders, my first admittedly skeptical impression was that IF they could actually deliver their vision into a daily operating model, it would revolutionize what limited population health tools I had spent a decade trying to mold. And revolutionize they did!

As the clinic cleared the hurdles of quality standards, clinical thresholds, transition to ICD 10, Meaningful Use and PQRS, I realized that what I had in place was not enough to be successful in the next major evolution from fee-for-service to value-based care.  When I surveyed the clouded horizon of virtual care coordination beyond our clinic’s walls, I learned that Aledade was delivering the patient-specific daily action reports and the visibility across a patient’s entire spectrum of care through its technology platform that had I looked for (and never located) during my 30-year healthcare career. Coupled with weekly in person support from a team of practice transformation specialists, I realized this was population health at its finest!

The Aledade Utah ACO is set up to thrive, with 17 enrolled primary care practices, contracts with Medicare and Regence BlueCross BlueShield, and an unstoppable team that I’m proud to be a part of. In the first performance year, Aledade Utah ACO partner providers have: used wellness visits to fight homelessness and same day appointments to help prevent unnecessary ED visits. I’m inspired by Aledade’s vision of a healthcare system in which independent primary care practices can thrive, and I’m truly excited to see this model grow in Utah.

I’m an independent internal medicine physician with my own practice, Advanced Internal Medicine, in Paducah, Kentucky. My practice has served patients in Paducah for three and a half years. Paducah is a changing medical community. We have two competitive hospitals in our town that employ many of the specialists and physicians in our area. There’s still a good number of independent primary care doctors, like me, who run our own practices.

Three years ago, other independent doctors and I joined a local Accountable Care Organization (ACO). We were excited about the opportunity to come together to offer better care for our patients and leverage our size to compete with hospital employment. However, we didn’t see significant progress in our move to value-based care or a clear vision for how we would get there. At the end of our relationship with our prior ACO, after doing some research, we decided to partner with Aledade.

Working with Aledade has been a completely different experience.  From our first kick- off visits we could see that Aledade was different.  Aledade had a plan to address our local pain points and worked with us to get things right. Before Aledade, for example, our group of doctors didn’t have a plan for Annual Wellness Visits (AWVs) or HCC coding. We were all trying to tackle them separately without insight into an optimal workflow. With the Aledade App we have actionable data and can target our highest priority patients, to keep them healthy.

I have found that it is possible to participate in value based care and remain independent. I was the solo doctor figuring it out on my own, and it was time consuming and hard. When you partner with Aledade you don’t have to figure things out on your own. Having support in moving to the next level of value-based care has made all the difference. We now have someone from Aledade in our office every single week. They help us stay on track and keep in touch between visits. They’re there to help us break down barriers, so we can provide our patients the best care.

I’m looking forward to the next three years working with Aledade. The changes I’ve seen already in my practice are unparalleled.

This is National Healthcare Decisions Day Week (yes, that’s a little confusing). It is a week to consider the importance of end of life planning that is sponsored by The Conversation Project, an organization co-founded by a journalist who wrote:

“In my mom’s last years of life, she was no longer able to decide what she wanted for dinner, let alone what she wanted for medical treatment. So the decisions fell to me. Another bone marrow biopsy? A spinal tap? Pain treatment? Antibiotics? I was faced with cascading decisions for which I was wholly unprepared. After all the years I had written about these issues, I was still blindsided by the inevitable.

The last thing my mom would have wanted was to force me into such bewildering, painful uncertainty about her life and death. I realized only after her death how much easier it would have all been if I heard her voice in my ear as these decisions had to be made. If only we had talked about it. And so I never want to leave the people I love that uneasy and bewildered about my own wishes. It’s time for us to talk”

The Conversation Project was born from this experience, an organization created to help people talk about their wishes for end of life care. At Aledade, we share this vision. It is the right thing to do and aligns perfectly with the mission of Accountable Care Organizations that are trying to improve patients’ healthcare experiences while reducing non-beneficial health care costs. 80 percent of patients who die annually in the U.S. have Medicare as their primary insurance and approximately $170 billion is spent annually by Medicare on the last year of life; this equals 25 percent of all Medicare spending. Much of this spending is useful and important, but not all of it is, and Accountable Care Organizations are in a key position to try to improve end of life care in this country.

Some numbers:

  • 90 percent of people say that talking with their family about their end-of-life treatment preferences is important.
  • 27 percent have had this conversation
  • 23 percent have put their preferences in writing
  • 7 percent have had a similar conversation with their own doctor (the number is higher for Medicare patients: 27 percent)

On the other hand, 64 percent of physicians have completed their own advance directives and discussed it with a family member and 80 percent of physicians have a stated personal preference for comfort care over aggressive medical treatment at the end of life.

What do these statistics suggest? At least two things:

First, that we as physicians have seen what can happen when treatment preferences are not documented and shared with family: unwanted treatment that too often results in needless suffering for patients and their families. We have seen it, and we don’t want that experience for ourselves or our loved ones.

Second, that there are likely barriers that prevent physicians from offering this important aspect of care to all our own patients. Is it a conversation that takes too much time to fit cleanly into a provider’s schedule without spilling into other appointments and backing up a busy clinic? Is it the discomfort with broaching a potentially emotional and uncomfortable subject? The challenge of communicating around uncertain prognoses? Concern about applying our own choices and values to our patients’ most important decisions? Lack of clarity within the medical system around who “owns” end of life planning?

At Aledade, we are taking on the wonderful, difficult and important challenge to understand these barriers and address them. We help primary care practices identify patients who are most in need of end of life planning and offer medical providers training in using the Serious Illness Conversation Guide to discuss end of life preferences. We offer practices the option to partner with Iris Plans, a company with palliative care expertise that offers patients advance care planning via phone and video conference, so these conversations can be held at a time convenient for patients and in a way that allows family members who live far away to join and be included in the conversation in real time. We also have created a scorecard for hospices based on billing data and patient satisfaction surveys to help guide patients to the best possible end of life care.

For ourselves at Aledade we have encouraged our own team to use the Conversation Project Starter Kit to consider their own end of life preferences. This is not only because life usually does not go as planned for any of us, but also so that we can have direct experience with what it means to consider our own treatment preferences and what it is like to communicate our wishes to our families and our own medical providers.

As Robert Frost wrote, “The afternoon knows what the morning never suspected.” What we do know is that helping our patients live the best lives possible includes planning for what happens at the end of it.

If you drive by West Calcasieu Cameron Hospital (WCCH) in Sulphur, Louisiana, you’ll see eight healthcare offices. Inside are 13 physicians and their care teams, providing primary care, obstetrics, gynecology, and pediatric care to the families in Calcasieu and Cameron parishes, the hospital’s service area.
Some of the doctors have been in this community for over 60 years, establishing relationships as they care for generations of families. Throughout the decades, teamwork between the hospital, the primary care physicians (PCPs) who work for the hospital, and the surrounding independent primary care practices has been a constant. As Anne Billeaudeaux, WCCH’s Director of Business Relations and Physician Development, said, “the independence of the practices is just as important as our collaboration.”

At Aledade, our vision is a health care system based on value with independent, primary care practices at the center. WCCH proves that we’re not the only ones who share this guiding principle.

WCCH is working with the Aledade Louisiana ACO to improve the continuity of care, resulting in patients receiving a timelier follow-up and supporting care across the community. This effort started in March of last year, when WCCH’s IT department helped the hospital join an Admission Discharge Transfer (ADT) network. The ADT connects with the Aledade App, practices can find out in a timely way when their patients are in the ED and hospital. When patients are discharged, a case manager faxes practices if a patient isn’t discharged to their home.

Before, practices struggled to follow up if patients had been to the ED or hospital because notification was cumbersome and completely manual. When providers know about a hospitalization they are able to follow up in a timely way. A patient being discharged from the hospital with several new medications and changes in their daily care, can become overwhelmed navigating those changes alone. With the improved communication from the work between WCCH and Aledade PCPs can support their patients and help them better manage recovery.

WCCH wants to help prevent avoidable readmissions and keep patients healthier with the appropriate level of care. Because WCCH joined the ADT, many patients in Sulphur have visited their PCP after discharge and have been able to get the follow up care or education they need to stay healthy and out of the hospital.

Collaboration with the Aledade Louisiana ACO has been good for the hospital, the independent physicians, and most importantly, the patients. I asked a few of the key leaders from the hospital, as well as the independent primary care doctors, to talk about successes to date:

Kathy Doty, Director of Quality Assurance at WCCH

Our outcome-driven journey into quality started more than 10 years ago, with a CMS/JC project. We discussed sharing data with our partner physicians in a meaningful way on a regular basis. We learned how to use and apply this data, alongside our physicians. It led to a few uncomfortable talks, but we all knew this data could help drive improvements in care for our patients.
As care managers, we’re trained to avoid the rain clouds, which motivated us to embrace the shift to value-based care. We warned folks that if we missed the boat on value-based care not only would there be future financial penalties, we’d be left behind. We discussed both sides with our clinical team and chose to embrace the new system and implement at our own pace.

Janie Fruge’, Chief Executive Officer at WCCH

We always focused on meaningful ways to share our data and be confident in the data we receive. Through effective communication and actionable plans, we’ve improved care in our surgical initiatives, reduced central line infections, and decreased pneumonia diagnoses.
Our physicians and clinicians formed a virtual medical community home; the experience was mixed. Some primary care providers joined in, some didn’t commit right away. For the doctors who did participate, they found success and started speaking in favor of it. They encouraged the others to join, then Aledade helped everyone get on the same page. Now, the people who were the most skeptical are the biggest fans.
For us, and the physicians around WCCH, joining Aledade was a natural extension of our quality work. Our early efforts showed us how data could promote quality care. Aledade brought the tools, and helped us share ideas in a complete plan that we can all execute, together.

Dr. Maureen Lannan, Cypress Clinic

As we enter agreements aimed at lowering costs and improving care for a defined group of patients, the hospital/PCP relationship is critical, especially when it comes to the discharge process of patients.  Better communication between the hospital medical team, patients, caregivers, and the outpatient medical team is vital, so that patients do as well as possible after they return home.

In conclusion, value-based care is good for our patients, and Aledade has helped improve our systems. At the center is a durable partnership between the hospital and the independent primary care practices in the community. We look forward to seeing what the coming years bring, and continuing to turn our data insights into quality initiatives to better serve the community we’ve served together for over half a century.

The Centers for Medicare and Medicaid Services (CMS) recently extended its novel “all payer” hospital model for an additional year (through 2019), while the state seeks approval for a similar plan for outpatient providers. The State intends to expand its per-capita global budgets beyond the hospital setting and apply them statewide, accompanied by robust CMS investment in primary care via the Maryland Primary Care Program (MDPCP), which will begin next January. This is a welcome change, and one in which we have worked closely with state officials and other stakeholders to craft a viable path for independent primary care physicians.

As proposed, the MDPCP emulates the Comprehensive Primary Care Plus (CPC+) program launched by the Centers for Medicare and Medicaid Innovation (CMMI) in 2017. CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through multi-payer payment reform and care delivery transformation. It builds on a predecessor program and offers selected practices additional financial resources and the flexibility to make investments in primary care to reduce unnecessary services. More information can be found here

Maryland proposes one key difference, namely the Care Transformation Organization (CTO). This coordinating entity serves as a partner to practices to guide, expand and support the intended program aims. CTOs will provide care management resources, infrastructure, behavioral health support (in Track 2) and technical assistance to practices who participate in the MDPCP.

In our opinion, this is a vital and welcome addition. Aledade has written extensively on CPC+ (see here and here), and is actively engaged with practices who participate in the program in Arkansas, Louisiana, Michigan, Pennsylvania and New Jersey. CPC+, though laudable in its aims and generous in its funding, has created complications in its implementation that can create misalignment with other value-based efforts.

The CTO construct solves many of these problems by providing physician practices with a partner who can guide resource allocation and leverage these resources with additional wrap-around services. Indeed, the CTO framework – as proposed – closely mirrors the role that Aledade already plays with its independent physician-led ACOs: we partner with independent physicians to deliver expanded primary care access; risk-stratified care management and care transitions; specialist utilization management and coordination; and real-time population health analytics. We also augment practices’ existing capabilities with the direct support of an integrated behavioral health program and a suite of medication management initiatives, led, respectively, by our Mental Health Director, Dr. Josh Israel, and our lead pharmacist, Megan Cancilla, PharmD.

It is important to note that, as proposed, not all CTOs will be created equal. There will likely be three formal levels: the first, for large practices that wish to participate directly, essentially serving as their own CTO; the second, for CTOs that function to support practice-provided services; and a the third level in which the CTO provides some direct services while also supporting the practice in their efforts. Many different organizations will come forward as CTOs, including hospitals. Some organizations may view this program as a way to support their continued efforts to deepen fee-for-service. Others may create local networks. Still others will combine this work with existing ACO work.

There will undoubtedly be various CTO options from which practices can pick. The work, especially in Track 2, is complex and time consuming; the right CTO will alleviate this burden and enhance a practice’s ability to improve patient outcomes.

A few guiding thoughts for the independent physicians:

  • Be selective. CTOs will offer a variety of services and structures. We advise practices to be selective and seek a partner with similar aims and structures that enhance their sustained, long-term independence.
  • Not all ACOs = CTOs. If you’re in an ACO, ask if your ACO partner can truly offer the services required for your practice to meet the MDPCP program requirements.
  • Beware of unintended hospital integration. Hospitals will likely present themselves as the logical CTO for surrounding practices. This may initially make sense for the practice, but could also lead to unintended consequences of curtailed autonomy.
  • Explore the CTO’s capabilities. Ensure that the group has the capacity to meet the demands of the program, especially if you choose to pursue Track 2 (integrated behavioral health).
  • Seek integration with other value-based models. Done properly, MDPCP aligns incredibly well with the aims of the Medicare Shared Savings Program, CareFirst Patient Centered Medical Home, and various other value-based payment models. Aligning models creates efficiencies that boost practice success.

Aledade is working closely with its existing and prospective physician partners in Maryland to align current efforts with the anticipated announcement of MDPCP. We are excited to expand our work in Maryland in a way that supports high-quality patient care and sustained physician independence.

I’ve been a family physician in Hoke County, North Carolina for many years. In this role, I walk with patients through all stages of life, from the birth of new babies to comforting patients and families in their loved one’s last days. I believe in the power of human connection: physical, emotional, and spiritual. It’s what my practice offers our patients.

Running an independent primary care practice today brings with it a range of financial and operational challenges. Accountable Care Organizations, often called “ACOs”, are in a unique position to reward providers for quality and better outcomes through preventive care, care coordination and avoiding unnecessary services. I believe that transitioning to value-based care will help my practice remain independent while I continue providing the high quality, personalized care my patients deserve.

I know my practice needs a partner to take our journey in value-based care to the next level. That’s why I’ve chosen to partner with Aledade to help us navigate toward better care at lower cost. Aledade offers us the technology, tools and support we need to succeed, allowing us- the physicians- to focus on quarterbacking our patients’ care.

More than ten years ago I was one of the first rural independent physicians to invest in patient portals, patient kiosks, and an EHR. I saw this as an investment in not only the way I practiced medicine, but also in my patients’ health. I feel the same way about the Aledade Technology Platform. It will provide real time alerts when a patient visits the hospital or emergency room, and tell us when patients visit a specialist or fill prescriptions. The platform creates lists of patients to reach out to for annual wellness visits, emergency room follow-ups and transitional care visits. It integrates data from various sources and provides unparalleled insight into my patient population to help me more effectively manage the quality and cost of their care.

In my rural community, I work with many patients who face tremendous health and socioeconomic challenges. While some may see a case of COPD or uncontrolled diabetes, we see an opportunity to have a conversation with our patients and discuss the larger picture of how we can help them. We are excited to use the Aledade tools to help us flag patients who need extra support so we can reach out and work to keep them out of the hospital.  This tool complements our existing work and supports customized care plans on which our whole team can collaborate.

I’m excited to partner with Aledade to launch an Aledade ACO in North Carolina in 2019. The future looks bright for patients and independent primary care physicians in Hoke County and throughout North Carolina, and I’m proud to be part of it.

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.

A few weeks ago, we had a patient call around 9:00 am. She had been recently diagnosed with the flu, and was struggling to keep down any food or fluids. We were able to get her an appointment at the office within two hours of the call and administered IV fluids to prevent dehydration. If the patient hadn’t called us first, or if we didn’t have open-access scheduling, she would have likely ended up in the emergency department.

In the same week, another patient contacted us and said that she didn’t feel quite right. Again, we leveraged our open-access scheduling to get her into the office quickly. This patient was also scheduled for a knee replacement surgery within the next two weeks. She was concerned that her current condition would prevent her from proceeding with the surgery. I evaluated her and determined although she was without a fever, she had pyelonephritis, an infection of the kidney. At the visit, I gave her intramuscular antibiotics to treat the infection and contacted her orthopedic surgeon to provide a report on her visit and treatment plan.

Through the rest of the week, I saw her every day at the office to monitor her progress and keep her surgeon informed on her course of care. She was very anxious about the surgery but trusted that since I was monitoring her closely, I wasn’t going to let her go through it if I felt she wasn’t ready. Thankfully, she was able to make a full recovery in time to have the knee replacement. This could have resulted in significant perioperative complications had she not called us first.

At Dixie Primary Care, our patients know that we can be available if they reach out to us when they experience health concerns. If a patient can contact us before they go to the emergency department, there’s a good chance we can care for them at the office immediately, thereby saving them an unpleasant, lengthy, and expensive visit to the ER. Each of our providers keeps four acute appointments open every day which create 16 same-day consultation slots for the whole practice.

When I tell other doctors about our scheduling process, they often ask whether it is difficult to fill all of the same day appointments. Our response is that this is a conscious choice in an effort to serve our patients, regardless of whether we fill the slots. In some instances, we have used these appointments to reconcile medications after patients get discharged from the ER, hospital or rehabilitation facility. We have decided that it is more important to be available for our patients than to overbook our providers’ days.

This scheduling process parallels our mission to provide value-based care as it leads to remarkably low rates of ED utilization by our patients. Our rates are among the lowest in all of Aledade’s partner practices, which are already lower than many primary care practices across the country. It helps our patients get the right care, at the right time, for the right reason, thereby improving patient experience and compliance and decreasing costs.

A patient’s fears and concerns can be enough for them to turn to just anyone for help. For my family and friends, I would want them to see a doctor who knows them well and whom they can implicitly trust. This is what being a primary care provider is all about.

To succeed in value-based care, practices need to help patients get the right care at the right time in the right setting. At Aledade, we help practices do just that by reducing unnecessary emergency department (ED) use, improving care coordination with specialists, and managing chronic conditions.

Another way we improve quality is by engaging home health providers as key partners. Home health care accounts for eight to ten percent of total spending across our ACOs.

A primary care physician (PCP) can order home health for a patient in a hospital or another setting. Every 60 days after that, the physician needs to recertify the services as medically necessary for the patient. In the past, PCPs had limited insight into home health quality. They might not know when patients started home health care. They might not have clear communication during the recertification (or recert) process. This often leads to significant care gaps, and risks for the patient.

Our partner practices in Arkansas grew frustrated with the recert process, so they decided to revamp it. When a home health agency submits a recert request to the PCP, the practice’s care manager reviews it right away. The care manager checks if the patient is improving, and calls the home health agency to learn more. The office then schedules the patient for an appointment to review their progress towards their health care goals. Together, the PCP and the patient decide if the patient should continue with home health care. Sometimes another service, like Chronic Care Management, social support, transportation, or education, is more appropriate.

One patient in the Arkansas ACO had received home health services for diabetes management for more than a year. Both the patient and the PCP were frustrated. The patient’s A1C hadn’t improved and their ED utilization had increased. The practice stopped home health, and enrolled the patient in an in-office diabetic education program. There, the patient learned about triggers and how to manage insulin levels. The patient was also able to meet with the practice’s nutritionist for help with planning groceries and meals.

According to the team at Dr. Walker’s Clinic in De Queen, Arkansas, the new home health workflow ensures the practice reviews “all patients prior to admission to home health and performed at every recertification. We have a nurse that manages this population and meets with our home health agencies bi-weekly to discuss goals, recerts, and discharges.”

In West Virginia, our partner practices worked with home health agencies to reduce preventable admissions and readmissions. The home health agencies created a Collaborative Performance Review. They identify the hospital utilization of home health patients and find out how many hospital admissions were readmissions. They also look at patients who screened positive for depression, falls risk, and ED overutilization. This summary finds gaps in patient care, showing how the practice could have prevented a patient’s admission or readmission.

According to Dr. Tom Bowden of Charleston Internal Medicine in the Aledade West Virginia ACO:

“The transition from hospital to home is a critical step in the well-being of our patients. Partnering with home health agencies that can assist us in this process is vital. Finding the home health agencies that are willing to work with us, make changes, provide the care our patients need and track quality metrics will certainly help reach the triple aim of improving health outcomes, improving the patient experience and lowering health care costs.”

All of this starts with a question: “What information from would be most helpful when making a recert determination?”

By focusing on this question, we’ve developed a form for home health agencies. We found home health agencies were eager to provide the necessary information, as were the PCPs. This summary, and the conversations that came with it, are still in the early stages. However, we expect that more communication will identify the most necessary recerts.

Better home health care means patients get the right, high quality care. We work with our home health partners to transition patients from skilled nursing facilities, nursing homes, and hospitals safely and sooner when possible. Home health also helps to proactively keep high risk patients safely out of the hospital. This requires close partnerships with home health agencies, and the communication to paint a full picture of the patient’s health. Armed with this, Aledade’s partner practices can ensure their patients get coordinated care in the right place at the right time.

The 2016 results are in and Aledade Accountable Care Organization (ACO) practices saved Medicare more than $9.3 million! The Aledade West Virginia ACO not only reduced costs 5% below the Medicare benchmark, but also received a shared savings check. In 2015, we brought together a unique group of 11 independent primary care practices that understood the importance of collaborating on improving health. Together, our partner practices have created a strong network that have reduced unnecessary hospital visits and kept patients safely at home, managed high-risk patients through a robust care management program, and provided better coordination of patient care with specialists and other providers in the medical neighborhood. We are very proud of our partner practices’ incredible progress and dedication in these key initiatives that have helped improve patient outcomes. “Teamwork and quality are always a winning combination. None of us are as smart as all of us together, and that is why we joined the ACO, said Dr. Jonathan Lilly, a Vice Chair of the West Virginia ACO. “We’re so proud of the ACO’s work in improving care and reducing costs in West Virginia.”

At Aledade, we know the value data offers to primary care physicians (PCPs) in helping them to deliver high-quality, coordinated care. We believed that if doctors receive practice workflow support, technology, and analytics, they are in a better position to deliver the highest-quality care while reducing unnecessary costs. In West Virginia, our physicians get a real time report when their patients show up at the hospital. With this knowledge they have been able to coordinate with hospital providers and support patients coming out of post-acute setting, reducing hospital readmissions, unnecessary days spent in ERs and the number of days patients spend in skilled nursing facilities. Dr. Ghali Bacha, an ACO member, said, “By joining the ACO and utilizing Aledade’s technology and support, our practice has significantly reduced our patients’ unnecessary emergency department visits and hospitalizations in 2016. Helping our patients get the right care in the right place at the right time has been a major accomplishment.”

Aledade equips PCPs with direct practice support and tools to utilize data to deliver high-quality, coordinated care. Taking data from multiple sources helps doctors keep patients healthier and out of the ER, makes it easier to prioritize their time and their practice’s time for patients who benefit the most from programs like Transitional Care Management (TCM), Chronic Care Management (CCM), and Annual Wellness Visits (AWVs). By implementing care management programs in our practices, both providers and patients have seen significant benefit. In a recent blog, ACO partner physician, Dr. Beckett talked about how improving patient information and care coordination with the local hospitals has made a real difference. He shared a success story about “the patient who previously went to the ED up to twice a week has now gone six weeks without returning.” While this is only one exceptional example of success, this is fortunately a trend we are seeing across all our West Virginia practices and plan to continue to share future success stories.

As Aledade West Virginia ACO’s Medical Director, Dr. Tom Bowden put it, joining the ACO “helped better foster our relationships with patients and other health care providers and helped form that bridge to other doctors and hospitals.” And we have done just that. Practices have worked with local specialists in improving communication to make the patient experience as seamless as possible. Kanawha County specialists have worked closely with our PCPs on referral management to better coordinate and manage patient care. Whether, it’s meeting in person to strategize referral processes or getting systems aligned virtually to get real time data on their patients, the dedication to improving care coordination has driven unnecessary spending down and quality of care up.

In our first performance year, we have established a strong network of providers who have been able to remain independent by driving down costs all the while improving quality of care for their patients. The ACO strives to get every person the right care at the right time in the right place. The proof is in the numbers. 368 fewer West Virginians needed to be admitted to the hospital, 136 of those were readmissions that were prevented by reducing complications. Over 400 West Virginians ended up in their physician office instead of the emergency room. They spent 566 more days at home instead of in a skilled nursing facility and saw their primary care physician 10% more often to help make all this happen. In 2016, the ACO achieved a total savings of $3,197,252, with shared savings of $1,566,654. With continued dedication and hard work on ACO initiatives, we are moving in the right direction for bigger and better things this year and the coming year. We are excited for the future of our ACO in helping create a better health care system and better care for West Virginians.