blog icon

Helping to Make Value-Based Care Personal in the Mississippi Delta Region

by Robbyn Johnson, Senior Practice Transformation Specialist

For this small-town, southern Mississippi gal, it is hard to believe that I work for a nationwide company based in Bethesda, Maryland filled with talented people from all over the country. I have never, in my 35+ year career, worked for a company that is so invested in what they are doing—and in their employees.

I was born in New Orleans and spent the first 3 months of my life in the Baptist Children’s Village orphanage there. I was quickly snatched up by the two most loving parents a girl could ever ask for. I landed in the rural Delta town of Cleveland, Mississippi where the land is flatter than a pancake and the people, music, and food all blend together to make it a very unique place to live.

At an early age, my parents instilled in me a desire to serve others who are less fortunate and taught me what selfless love and service meant. My mother volunteered to teach inmates how to read at Parchman State Prison, and my father taught Bible study to the male prisoners there once a week.

They weren’t the only ones who went above and beyond in their devotion to others.  One time, in the middle of the night, our family physician made a house call to check on my high fever.  I can still see his black leather ‘doctor’ bag, straight out of Norman Rockwell, and hear his calming, reassuring voice. 

I like to compare what we do at Aledade to that memory. Value-based care means going the extra mile for your patients and really wrapping your arms around them. That’s the family medicine I remember from my childhood and long for as an adult. It is a great privilege to get to do work day in and day out that transforms practices from the fee-for-service mentality back to providing care that brings value and better health.

As a Practice Transformation Specialist, my job is to help physicians achieve the goals of bringing value and better health to their patients.  I do this by creating workflows to implement preventive-based annual wellness visits, timely hospital and emergency department follow-ups, and better coordination of each patient’s overall care. I’m so fortunate to be able to travel back to my Delta roots every week to practices that have embraced value-based care.

Much of the Delta has changed, but there is still a lot that hasn’t. The poverty level is extreme. Mississippi is ranked first in the country in obesity, which only compounds the chronic conditions that most of these patients have. 

Education is so important when it comes to these patients’ health. The practices I work with are able to use Aledade’s tools to help teach these patients how to better take care of their chronic conditions. The support from our team in Bethesda is mind-blowing when it comes to educating our Care Managers on how to take care of these patients.

The Care Managers can use data from the Aledade App to see which patients need to be engaged first and what health issues they might be dealing with. This App also allows them to see a current snapshot of their patient’s healthcare via our Daily Huddle, which is full of pertinent information on one page. For example, a physician can see what specialists their patients are seeing, any recent hospitalizations, and which preventive services are recommended for them, such as colonoscopies and mammograms.  

I also love that the staff at Headquarters are continuously working to make the information more useful and seek input from us out in the field to improve the data and how it’s presented. I could not do my job without the tireless effort and constant support from these dedicated co-workers. Getting to teach practices about value-based care, which mirrors my up-bringing, and working for Aledade is a win-win!