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.

It’s hard to stay healthy if you don’t have a place to call home.

That’s what we learned firsthand, when one of our patients came in for his annual wellness visit.

Thanks to Aledade, we’ve been doing a lot more of these AWVs. They give us a chance to have a conversation with our patients that’s not just about the test or procedure or illness they came in for that day. They help us see the full picture of the patient’s health. Thanks to Aledade’s care management trainings and real-time data and analytics from the Aledade app, we know which patients we need to see for an AWV, and how to work with them when they arrive.

Our patient that day was wheelchair bound, so we asked how his social situation was. Sometimes patients in a wheelchair can get to feeling a bit lonely. In the course of the conversation, though, this patient told us that he had recently lost his home. The waiting list for housing assistance stretched out for three years. In the meantime, the only place he could stay was a shed in his friend’s backyard.

As a care management team, we knew we had to do something.

Housing is such an important part of good health. The National Council on Health Care for the Homeless covers a few reasons for this. A clean, dry and safe environment supports good personal hygiene, the storage of medication, and safety from people and the weather. A private space lets a patient establish stable personal relationships, and have good social interactions with other people. Importantly for us as health care professionals, a patient with a place of their own is more likely to stick with a treatment plan, eat meals regularly, and show up on time for appointments. And housing reduces anxiety and the impact of stress-related illnesses.

Aledade’s practice transformation specialist Connie Perkins and I knew that a three-year wait was too long. So we spent countless hours on the phone with the state’s resources for homeless and disabled persons. Tooele is a rural community. We don’t have that many resources for housing, but after a lot of work and some persistence, we did it.

We were able to find housing for this patient in Wendover. Even though Wendover’s a two hour drive away from our town, the patient was thrilled to have a home of his own. He even started looking for work around his new place.

Thanks to an annual wellness visit – supported by the training, technology, and partnership of Aledade – we helped our patient get healthier, by finding a place to call his own.

In about two weeks, I’m joining the team at Aledade as Chief Administrative Officer – largely because three years ago, I went through a health scare.

It wasn’t me; it was my then 86-year-old father. And what started with a short-term crisis dragged out into a long-term battle with our dysfunctional health care system.

For two years, my dad bounced between doctors, hospitalists and specialists. We never got a clear picture of his health or the care he was getting. His doctors rarely talked to one another, rarely gave him much time and I couldn’t talk to them to understand it all.

At the same time, this was happening while I worked at the Centers for Medicare and Medicaid Services, tasked with running the entire Medicare program. I couldn’t help but put our situation into a broader context: if this frustrating and frightening ordeal could happen to my dad- a brilliant lawyer who was on the Law Review at Penn — and his son who ran the world’s largest insurer, what was it like for other families who didn’t have our resources and our knowledge of how to navigate this confusing health care system?

Fortunately, we were saved by a good quarterback – someone who could take a step back and look at the entire field of my father’s health. For an entire hour, a geriatrician sat with my father just to talk with him. He got a sense of his health conditions, what was giving him the most trouble, and the serpentine path he had taken to get help.

The doctor set up a care plan with him, and took a close look at his medications. When we focused on one drug in particular, my father pointed out that studies had shown it was relatively effective. “That’s true,” the doctor said, “until about 75 years of age.” My dad was taking medication that stopped being effective – and possibly became harmful to him — about ten years ago. In the end, we cleared out about half of my father’s prescriptions. It was as if a switch had been thrown. Over the next few months, my dad returned to the person we knew.

Value-based health care, directed by empowered, independent primary care physicians, is what my father and I needed then. Today, everyone agrees it’s what we all need now.

We need primary care physicians to be the stewards of care, guiding patients through this confusing health care system like the captains of a ship – always pointed to the north star of better health. We need a health care system that doesn’t focus on how many procedures or prescriptions patients get, but on how well their doctors keep them healthy. When those priorities are misaligned, that’s when our health care system doesn’t work. I know, because that’s what my father and I saw firsthand.

I’m joining Aledade because I know the team here is working with incredible physicians best situated to chart that path to value-based care. For years at CMS, I looked at the results and dove into the data – I saw that the future of health care will be led by primary care physicians with the autonomy to act in their patients’ best interests. I saw this potential for success across commercial plans, Medicare Advantage, and traditional Medicare – and Aledade’s covering all of these.

At Medicare, my focus was on the operational integrity of a program that provides insurance for more than 55 million Americans. I worked to ensure the program was run efficiently and responsibly for the taxpayers, and that we kept focused on our strategic goals of improving care and reducing costs. That’s what I’m most excited to do here at Aledade. My focus will be making sure the trains run on time – that our hardworking teams are valued and supported, and that we’re helping our partner practices along every step of this journey.

I’m also joining Aledade because there’s a unique mix of purpose and people in this place. I came from public service, and I wanted to join an organization with a mission that’s bigger than profits or short-term returns. Aledade lives its mission every single day.

I also was lucky to work at CMS with some of the most brilliant people in health policy who were also great colleagues. And I see those same qualities here at Aledade. Thanks to the hard work of so many people, Aledade partners with more than 200 primary care practices in 17 states to actively manage the care of nearly a quarter of a million patients. I can’t wait to be a part of the team that’s building the leading model for a health system that’s good for patients, good for doctors, and good for society.

Tucker

Two weeks ago, The New York Times showcased two Aledade partner practices in Kansas. I, like many of my colleagues, excitedly shared this piece with friends and family to explain what we do at Aledade, and how we have the power to impact health care. Are you curious about the people taking on this innovative problem solving?

Last month, the Aledade Fellows had a Friday afternoon happy hour, with Farzad, our CEO. He kicked off the summer celebration by asking, “What does it mean to be Aledadey?” Each fellow gave an answer, often supplying an anecdote with the value. After every answer, Farzad would dig deeper, “Why?” he would ask. “What it is it about this trait is Aledadey?”

Read what some other Aledade Fellows took away from this conversation on values:

Nicholas

As I looked around the room at my impassioned coworkers, I couldn’t help but think that this moment was really what Aledade was all about. The fact that the CEO cared enough to take the time out of his Friday evening to hear what group of recent college grads thought about company values is very unique to Aledade. It doesn’t matter what your role is, whether you’re a fellow or the CFO, if you have a well developed opinion or idea and articulate it, people are going to listen to you. Aledade is a place where you are judged on the quality of your ideas and the work that you do rather than on your title. This distinct culture inspires the kind of collaboration that has been instrumental to Aledade’s success.

One of the interesting points that Farzad made during this kitchen hangout happy hour was that each person at Aledade has a deck of playing cards – we each have a unique skillset to contribute. No one is an expert at everything. But as we get involved in new projects, we acquire new skills and expand our decks. A culture of continuous self-improvement is central to Aledade’s mission to improve primary care. In the short time I have been here, I have become better at data analysis, learned a new programming language, and participated in various projects both within and outside of my team. When I complete my fellowship and move on to pursue a medical education, I hope to bring my “Aledadiness” with me – that never ending desire to own what I do, share my passions with others, and find “scrappy” ways of continuously improving the world around me.

Selam

As we went around the room, we heard words like “scrappy”, “flexible”, and “collaborative” to describe our Aledade work culture. The Aledadey qualities list can go on and on but, simply put, it’s the supportive culture that encourages us to be innovative and always thinking outside of the box. At the core, Aledade gets it – invest and build something great, hire a talented, fun, and personable team that believe in the Aledade core values and success falls right into place.

Whether it’s through hangouts or staff retreats, the Aledadey culture constantly creates opportunities for togetherness that help close the gap between remote employees and HQ staff. Those relationships are key and contribute to the great work we do as a company. In my experience, the focus is more on doing something than being someone here at Aledade. Each day we are presented with new challenges and situations, which help us to stay focused and interested. Whether it’s being scrappy in Excel sheets or bringing Primary Care Providers and specialists together for meetings on referral processes, I know when I go home that I truly did something meaningful and important.

This happy hour itself contributes to being Aledadey. One example of Farzad’s that stuck with me was his advice on finding that one thing you’re good at, becoming an expert on that subject matter and using that as a growing point to learn around. I have never before felt that our leaders cared about our development, life outside of work, and general happiness with our roles more than the Aledade team. Individual success is celebrated as a team as much as team successes. The “work hard – play hard” attitude is very much alive in the Aledade world. While sticking to its core values, the empowering, Aledadey culture strives to deliver affordable, high-quality care across the country.

Molly

What are the things we do that make us Aledade?

As a recent graduate, it’s easy to answer this question with a litany of business clichés from the textbooks I read not so long ago. At Aledade we break down the silos, peel back the layers of the onion, think outside the box, move the needle, roll up our sleeves, get deep in the weeds and when that’s all said and done we stand back and look at the 30,000-foot view. Although there is some truth to the sentiments of many of these platitudes, they’re not what make us Aledade.

Google Hangout video calls allows our company culture to thrive across the country. Although this might sound like an exaggeration, these virtual interactions play a critical role in our daily operations. These calls provide more than just a channel for individuals across the country to speak to one another. They also allow us to understand the subtle nonverbal cues and facial expressions that often convey more than words, like seeing someone crack a smile when you slip a joke a presentation or noticing your coworker fail to hold back a yawn at 3pm and giving them knowing look. It’s these elements of human interaction that foster a sense of comradery and better enable us to openly discuss concerns, share ideas, and delve into the issues we face.

Another aspect of our culture is our shared understanding that working together is critical to our success. We believe in the importance of collaboration, respect and face to face conversations in relationship building so much, that each of our partner practices receives weekly in person practice transformation support.

Simply put, at Aledade, we still do business face to face.

Josh

Farzad posed a question to the gathering of Aledade fellows and summer interns: “What does it mean to be Aledadey?” We glanced at each other, uncertain of an answer, but sure that this adjective was not in any dictionary. As we reflected on our brief experiences at Aledade with its co-founder and CEO, it became evident that this short question did not have one finite answer.

I was anxious when I joined the team at Aledade as a summer intern. While I had developed an interest in working to improve health care from the perspective of government and policy, I did not know where to begin from the perspective of a start-up. Health care in America is complex, yet my team was undaunted. Quickly, I learned how Aledade is in the business of tackling systemic problems in health care, creating value for patient and provider alike.

In my first week, I confronted one of many challenges in Aledade’s mission to drive value in health care: I began working on a new initiative that focuses on improving the quality of care in the end of a patient’s life. With up to 25 percent of Medicare costs occurring in the last year of living and high levels of patient and family dissatisfaction – often due to excessive hospitalization – the motivation for making a change was clear and compelling. I was excited by the potential impact, but overwhelmed by the complexity of what seems to be some uncharted territory in value-based care: How do you realize gains for quality and value, and achieve these consistently at scale? Noticing my unease, Dr. Joshua Israel, the project lead, ended our first meeting with a smile: “I do not know, we will just have to figure all of that out together.”

This “can-do” approach in the face of complexity, uncertainty and high stakes serves as just one clue to respond to Farzad’s question. Being Aledadey is asking difficult questions and digging into the data and evidence to discover a solution. It is tackling complex problems and creating solutions that improve the lives of patients. Aledadey is the pathway to the brighter future of American health care.

Tucker

For me Aledadeiness is comprised of the people and their humility, integrity, and impatience for improvement. Humility is knowing we may try something and have unexpected results. A push here may not lead to a pull there. We are okay with re-charting a course, knowing we’ve learned something from it. This humility also promotes asking, asking for help from teammates or asking why. Data is important in everything we do, but isn’t always visible to an end user or to the patient who will end up coming in to see their doctor because of it. It’s knowing we would never use data that could shortchange a partner practice or put a patient at risk.

Finally, it’s a continuous improvement. Last summer, I worked on a relaunch of our website. This redesign was months in the making and included incredibly talented designers with feedback from every team. Before the new version was rolled out there was already a list of improvements for the next day and the next version.

For us, being Aledadey is being scrappy, and focusing on continuous improvement, collaboration, supporting your teammates, building relationships on face to face conversations, jumping into an unknown problem to discover an actionable solution, and people who demonstrate humility, integrity, and impatience for improvement.

There aren’t too many opportunities when you can get the present and the future of primary care in the same room. But that’s exactly what we found at the Louisiana Academy of Family Physicians’ Annual Conference.

Emma Lisec and Nadine Robin at the Aledade booth

On Wednesday afternoon, we arrived at the historic Roosevelt Hotel in downtown New Orleans – Nadine Robin, Aledade’s Southeast Executive Director, and me, Aledade’s Fellow for the Southeast. We were caffeinated, excited and ready to join a massive room full of displays from local hospitals, pharmaceutical companies, and specialty groups. We set up our booth, with Aledade’s slogan: “A New Model of Primary Care”, and we waited to see who would come through the doors.

Right on cue, as the conference’s main sessions took a break, the showcase room flooded with health care professionals from across Louisiana – independent doctors, curious hospital employees, even medical students from Louisiana State University. (Geaux Tigers!)

They dropped by a number of different booths, but kept lingering by ours, wondering what that “new model of primary care” actually meant. So Nadine explained: with MIPS, the new payment program created by the 2015 Medicare Access and CHIP Reauthorization Act (or “MACRA”), quality reporting was taking center stage.

Small, independent practices are the key to that focus on quality. As our CEO Farzad Mostashari has pointed out, small, physician-owned practices offer more personalization for patients. They have lower average costs per patient, fewer preventable hospital admissions, and lower readmission rates than larger, independent- and hospital-owned practices. In other words, they’re in the best position to succeed.

Nadine explained how Aledade helps their independent partner practices report these quality measures all while maintaining their independence. I noticed that a few physicians’ ears perked up at this – the prospect of having a helpful guide through MACRA and MIPS seemed to be integral to their practices staying independent.

I remember one doctor in particular who pulled us aside. He felt like his clinic was short-staffed, and the pressure to sell his practice was only growing. Nadine and I listened to him, and explained that the whole purpose of Aledade is to help small, independent physicians like his stay independent – and thrive. But to do that, we have to start with an honest relationship. We weren’t going to pressure him into joining Aledade if it wasn’t going to be in the best interest of his practice and his patients. We agreed to pull his QRUR report and follow up to see if a partnership with Aledade would be his best step.

We also spoke with some of the physicians of tomorrow. A few medical students from LSU dropped by our booth, wondering what an ACO was. To many of them, the idea of opening their own independent practice seemed out of reach. The concept of a comprehensive approach to primary care, one where the independent practice is in the center of a high value network, sounded promising. They asked us if they could reach out to us later to get a better understanding of an ACO and value-based care.

Nadine and Matt Wheeler presenting at LAFP

That Friday morning, Nadine and Matt Wheeler, one of our inspiring Office Administrators from Bossier Family Medicine in Bossier City, gave a presentation about the new world of alternative payment models. They laid out the idea of value-based care – that physicians should be empowered to provide quality care, and rewarded for helping their patients stay healthy.

They explained what an ACO is – basically a group of health care professionals committed to the health and well-being of a specific group of patients. And they explained why this future – better health care at lower cost – was inevitable. It’s good for doctors, good for patients and good for society.

Nadine with Dr. Jose Mata, a family medicine doctor in New Iberia, LA

Nadine and Matt weren’t the only ones making the case for value-based care. A number of Aledade’s partner physicians in Louisiana were there too – each of them explaining to other doctors why value-based care works.

This whole move to a better health care system isn’t being led by any single practice or any single company, like Aledade. It’s a partnership – a network of practices who want to keep their patients healthy, and organizations working to help those practices succeed. Value-based care is the best model for today’s primary care physicians here in Louisiana, and tomorrow’s too.

Are conversations between doctors and patients the key to good health care? How well do doctors and patients actually talk to one another? In a 1984 study, Howard Beckman and Robert Frankel surveyed 74 practices and recorded how doctors listened and interacted with their patients. 77 percent of the time, physicians prevented their patients from completing an opening statement by asking questions about a specific concern. On average, it happened 18 seconds after the patient began talking.

Beckman and Frankel’s study was conducted in 1984, but the results resonated in a larger study by Lawrence Dyche and Deborah Swiderski in 2005. Physicians in that study asked a question during a patient’s opening statement in 72 percent of the visits, on average in 23 seconds. A quarter of doctors did not solicit patient questions at all.

The average doctor spends between 13 and 15 minutes with a patient. In only 15 minutes, the doctor and patient are supposed to discuss a full patient history, treatment plan and questions. The question at the root of this problem is why do doctors feel the need to rush?

The current fee-for-service system does not reward doctors for having long, detailed conversations with their patients. It incentivizes them to provide more treatments, because payment depends on quantity of care rather than quality of care. Understandably, this system is infuriating to both doctors and patients. However, the fee-for-service system is not the only healthcare model available to doctors.

At Aledade, we focus on helping doctors do their jobs the way that they want to – so that they can listen longer, ask deeper questions, and get more complete answers from patients without needing to rush through diagnoses and treatment plans. As you may have seen in some of our success stories on our blog we do this in many ways, most often by helping our partner practices effectively conduct Annual Wellness Visits (AWVs), Chronic Care Management (CCM), and Transitional Care Management (TCM). These stories highlight how value-based care and a patient-centered approach improves the patient-provider relationship and improves health outcomes.

Communication is the cornerstone of patient care. A report by the Joint Commission, an organization accredits healthcare programs and organizations,  found that  “communication failure was at the root of over 70 percent of serious adverse health outcomes in hospitals.”  Aledade partner practices have learned the value of good communication between a doctor and a patient.

In 2015, Aledade’s ACOs decreased emergency department (ED) visit rates by 6 to 7 percent. The ED visit rate for the Medicare Fee-For-Service (FFS) population increased by 2.4 percent. Hospitalization rates decreased by 5 to 7 percent, while hospitalization rates for Medicare FFS populations increased by 2.4 percent. And Aledade’s ACOs decreased readmissions by 7 to 11 percent. Across Medicare FFS, readmissions increased by 8 to 9 percent.  

What could account for the difference? For starters, AWV, TCM, and CCM all help  practices catch problems earlier, and provide more consistent care. Annual Wellness Visits help to decrease ED visit rates by helping physicians identify high-risk patients and give them the tools they need to avoid a trip to the emergency room, saving on costly hospital bills. Transitional Care Management lowers readmission rates by helping patients stay out of the hospital when they’ve been discharged from the hospital.he Chronic Care Management program provides high risk patients with intensive ongoing care management support that decreases adverse health events, decreases readmissions and improves self-management skills.

If a provider has the space and time to listen to their patients, they can lay the foundation for mutually trusting and beneficial relationships. This trusting relationship is a key component in providing value-based care as it improves patient satisfaction and health outcomes. It all starts with a conversation, and it is more important than ever to really listen.

Sometimes, one of the most valuable members of the care management team isn’t in the practice at all.

For example, take a patient we enrolled in chronic care management in 2015. The patient was nearly 80, and living with a number of chronic conditions – starting with some pain in her ribs. We enrolled her in CCM so we could find the cause of this rib pain, control it, and hopefully help the patient stay independent.

Aledade teaches practices how to identify the patients who would benefit the most from the Chronic Care Management program. They encourage CCM for high-risk patients with multiple chronic conditions, high-risk factors, and poor symptom management. Most of all, they encourage practices to help patients improve their self-management skills, so they can live as independently as possible.

At the first appointment for our patient, I met one of her two daughters. We ran through all the preliminary steps, and set up a care plan. That’s when I learned that the patient lived with her other daughter. That daughter would be our point of contact.

From the beginning, this mom and her daughter called me with any needs they had. I helped the patient and her daughter set up studies, appointments with specialists, insurance referrals and communication with the patient’s primary care physician. I made sure that we had all of the communications and correspondence from specialists that we needed, and I kept the patient’s list of medications updated.

Aledade’s Care Management model emphasizes how important it is to have coordinated care, especially for high risk patients. They train practices on how to connect patients to the right care at the right time and for the right reason. Through this care coordination, we can close the gaps in care, making it simple and continuous for the patient.

In the process of our care management, I learned a lot about our patient.

But I was also learning a lot about her daughter. She was working three jobs at once – one full-time, and two part-time. Not to mention her fourth job as mom’s caregiver and main source of support. I knew how hard she was working. I could hear it in her calls and messages, which always came at the break of dawn or late into the evening. I made a point to respond to every single one.

Aledade’s Care Management holds the patient and their family at the center by emphasizing the importance of trusting relationships between the practice and our patients. The whole model encourages us to focus care around the patient’s needs and concerns.

One morning in June, my phone rang. It was the patient’s daughter – our care team MVP. I knew that they were on the search for an apartment that was just a single level, since it was getting tougher for mom to go up and down the stairs. Until then, every morning and every evening, the daughter would help her mom up the stairs and down – careful to avoid any falls, with all of the back and knee problems her mom had.

The night before, though, had been different. The daughter noticed it right away. She told me her mom had been “very winded” – much worse than normal. It took her a lot longer to recover from the walk. The daughter didn’t notice any chest pain or shortness of breath, but that morning, her mom was much more tired than usual.

I asked the daughter if they’d be able to come to the office that day. She said yes – she’d just need 30 minutes’ notice so she could leave work, pick up her mom and make the drive over.

Early that afternoon, our patient’s primary care doctor welcomed them in – the patient was diagnosed with new-onset congestive heart failure. We started her on a diuretic and scheduled an urgent follow-up with a cardiologist. By the end of it, we avoided what probably would have been a costly and frightening visit to the emergency room.

Aledade encourages care managers to proactively educate patients and caregivers on managing symptoms – not to wait until they become a problem. They advise practices to keep open lines of communication with their patients, so the patient can contact the practice as soon as a symptom becomes a concern. Quick and clear communication can help the practice and patient get the appropriate triage, ultimately reducing how often patients and their families have to visit the practice or a hospital.

There are a number of effective ways to do this. One way is to set up same-day appointments in the office. Another is to open a phone line for patients that’s available 24 hours a day, 7 days a week. Aledade always reminds us how important the relationship is between the practice and the patient.

Today, our patient’s follow-up is continuing. She’s getting better. And our care team all-star, her hardworking daughter, is our care management team’s key contact. Her mom is lucky to have her around. Our practice is, too.

Natanya 2

Natanya

At this week’s all-staff meeting, our CEO Farzad Mostashari repeated one phrase again and again. “At Aledade,” he said, “we’re thinking long term.”  

Our work at Aledade helps physicians, patients, and society today, but we’re always looking ahead three years, six years, and even more. A focus on the future resonates in our values and the work we do every day.  In fact, the Aledade Fellows program is born from this long-term thinking. By joining the Aledade team as recent graduates or current students, we have the opportunity to learn what it takes to be the value-based health care champions of the future.

Dr. Ezekiel Emanuel’s new book, Prescription for the Future is similarly forward-thinking. In it, he argues for a positive prognosis for the U.S. health care system – but a prognosis that relies on disseminating a variety of transformational practices to raise the quality and lower the cost of health care.  

At Aledade, we partner with practices to implement these high-value practices every day.  Chronic care management that cares for a whole patient. Wellness visits that take into account a patient’s experience outside the doctor’s office. Referral management that steers patients to high-value specialists. And transitional care management that eases a patient’s discharge from the hospital. These are all initiatives that Aledade undertakes today. They’re practices we’ll keep improving on with an eye toward the future.

What Prescription for the Future offers us, as young people involved in the transformative work that Dr. Emanuel describes, is an understanding of Aledade within the greater context of the movement toward a value-based health care system. His book reminds us that the work we do is integral to that  movement, and that we are not alone in looking to the future.

But I wasn’t the only fellow who learned some valuable lessons from Dr. Emanuel’s work. Below are some additional insights from three Aledade fellows:

 

MargotMargot

In chapter eight, Dr. Emanuel asks the question, “Is transformed healthcare transferable?” In other words, can we replicate high-value care success stories across the country?

He points to factors such as cultural, social, and economic histories as the primary barriers to transferring care. Considering these barriers, it seems to me an organization like Aledade is uniquely positioned to transfer high-value care to patients across the country. With a large network focused on collecting quality data, Aledade is equipped to identify successful ideas and scale them among its partner practices. Coupled with this, and equally essential, is Aledade’s emphasis on local physician leadership.

Our partner practices have the independence and flexibility to adopt successful ideas in ways that fit their communities. Care management in Mississippi is not the same care management performed in New York. Ultimately, practices are accountable for the care of their patients, and practices have the grassroots knowledge to transform care for their patients.

 

Doug Streat1 - Edit

Doug

At Aledade, as in health care in general, we have a tendency to use industry buzzwords to describe what we do. Phrases like “value-based” and “patient-centered (and, scarier yet, our alphabet soup of acronyms like ACO, AAPM, CCM) dominate our conversations. This isn’t necessarily bad—we love our work—but it can be hard to explain exactly what is that we do, and why we do it. Dr. Emanuel’s Prescription for the Future is as much a formula for transformation as it is a chronicle of stories that clearly explain the future we are working to achieve.

The future we envision is good for patients. It is one where patients like Miss Harris in chapter one don’t need six providers to manage their care or, if they do, receive seamless care coordination among these providers. The future we imagine is one where patients have ready access to community interventions, like Mr. Downs in chapter six did. The future we are creating is one where primary care providers are so readily available, that their patients don’t need to go to the ED as often.

The future is good for providers, too. The future we are striving for stands on strong technological infrastructure that supports, but does not replace, the work of medical providers, as discussed in chapter seven. The future we seek is one where primary care providers can create improved care and improved bottom line at the same time, as one of our partners in West Virginia, Julie DeTemple, reported to us when she spoke at our all-staff retreat this May.

These transformations, and the others Dr. Emanuel writes about, will help stabilize health care costs and improve practices at a systemic level. In so doing, we hope to build a future that is good for society, too.

 

KellyKelly

As a widely-contested health care reform proposal dominates national news coverage, reading Dr. Zeke Emmanuel’s “Prescription for the Future” was both uplifting and insightful. Each day since I started at Aledade, I have gained a deeper understanding of the United States’ health care system. But arguably the most important thing that I have taken away is a new perspective on the future of health care.

Working alongside a passionate team dedicated to value-based care, a team that is growing every day, has shown me that health care providers are constantly innovating to improve the quality of care delivered nationwide.

I found the chapter on “Transforming Physician Office Infrastructure” particularly interesting and enjoyed reading the section about measuring and releasing unblinded physician performance data. Dr. Emanuel’s explanation of the effectiveness in releasing this data lies in the principle of peer comparisons, from behavioral economics. Physicians, like all humans, are wired to avoid embarrassment in front of their peers, so releasing unblinded data on their performance motivates changes in underperformance. In one story that Dr. Emanuel features, a physician notes:

“As soon as the system started generating data, I remember my own thought was, ‘This is silly. I know I am going to do great on this performance review.’ And then I saw my data. Holy cow, not nearly as good as I thought. Knowing made me realize, ‘Hey we’ve got to be sharing this data.’ But more importantly made me ask, ‘Who is doing the best?’ I need to look at that person and say, ‘What are you doing? How do you do it so well?’” (p.83)

By looking at positive outliers in performance data and assessing what exactly these outliers do better, providers can deliver better care as individuals and practices. That’s why, at Aledade, we analyze and provide quality metric performance and cost data to our providers, both at the ACO and the practice level. We take this one step further by providing practice support through a field team that works directly with practices to decrease their total cost of care and achieve higher quality performance.

My favorite part about working at Aledade is hearing provider success stories, like the one above that Dr. Emanuel features, shared by our field team after implementing Aledade’s resources in our ACO practices. They prove to me that health care professionals around the country are already making incredible progress, and building the future of health care today.

 

Natanya

Natanya

It is not always easy to explain Aledade’s work, and our work as Aledade Fellows, to our family and friends. With healthcare news dominating the airwaves and Twitter feeds recently, it can be tough to make clear how Aledade fits into all of these changes.  

While the answers to these questions are complex, the goal of everyone involved in the value-based transformation is relatively simple: We want to see a future with lower health care costs and higher quality care. At Aledade, we achieve that by partnering with practices and physicians to make that transition from volume toward value.

After all, an alidade is a device used for determining direction. In our case, we’re aiming our sights on a future with better outcomes for patients, providers, and society. Prescription for the Future has given us a peek into where others are aiming their sights. After reading it, I believe we’re not the only ones thinking long term, and that when we converge on the future, it’s going to be bright.