Every day, physicians are evaluated by a myriad of sources. Think of all the websites with provider ratings: Health Grades, Angie’s List, and even Yelp. These sites ask patients to review the quality of care provided by healthcare providers, and yet give no control to those who are being reviewed. Now, consider insurance companies and other payers who may provide scorecards based on patient metrics. As physicians, we may see a patient four times out of the year for 15 minutes, but we have no control over how they spend the other 8,759 hours of the year.

Also, take into consideration that no physician gets a perfect score across all of these scorecards. In today’s medicine, anything short of perfection is a “ding.” The reality is that dings are part of the new value-based world, and it’s important that we recognize them for what they are—opportunities for improvement rather than points of frustration.

Let’s face it, medical providers do not like to be judged. Many of us, as physicians, have succeeded in our professions due to our hard work and dedication. But, more importantly, our pursuit of excellence is what sets us apart. Perfection is the gold standard and anything less will not suffice. We believe that our patients’ lives depend upon it.

When we see scorecards produced by a payer and see that we do not meet or exceed all measures, many of us find this as being insufficient in the care we provide. As a medical director for Aledade, my conversation with primary care physicians in our national accountable care organization (ACO) network generally go like this:

The Over-Utilization Ding: Frequent Emergency Department (ED) Visits
“You mean to tell me I’m getting dinged for that guy? There is no way I can keep him out of the emergency room. He loves going there.”

The opportunity for over utilizers “frequent flyers” is to have them utilize you more. Less ED visits are a step in the right direction, so rather than trying to “fix” or “make perfect” one frequent flyer, we will instead attempt to reduce a few visits among all of your frequent flyers. We do this by helping practices expand same day access, teach patients to call the physician first, and add robust care management that targets patients who “love” the ED.

The Over-Budget Ding: Costs More Than Expected
“So what you’re saying is that I am getting dinged for his liver transplant? How am I supposed to control his costs? I am just his primary care physician.”
The opportunity for high cost patients is to start thinking ahead. Ask yourself the “surprise question” are the high costs due to a specific medical condition, like cancer? Would it surprise you if the patient died in the next six to 12 months? If the answer is no, has the patient or family received an end-of-life conversation? If this is not an end-of-life situation, is chronic care management appropriate? Are the costs episodic? If so, there might not be much that you can do besides embrace the ding.

The Quality Measure Ding: Failure to Meet a Seemingly Arbitrary Content Management System Defined By Quality Measures that Make No Sense Clinically
“You mean to tell me I’m getting dinged by a patient with diabetes, who refuses to take my medical advice? I am going to dismiss that patient from my practice so I never get dinged again.”

This particular ding can provide the opportunity to improve quality measure performance for an entire population. Can the measure be addressed across the entire population? Are you leveraging standing orders? Are you seeing poorly controlled patients more frequently until they reach a specific goal? Do you recognize the opportunity to improve your risk coding for these complex patients?

It’s time to rethink the ding. It can feel frustrating to have someone tell you that you are not doing your job well, but embrace the ding and let it be your call to action. Keep providing the best quality care to your patients, always with positive outcomes in mind. If you get dinged, then you will know where you need to get better. Focus on providing better care at affordable costs.

Four years ago, enticed by the vision of a better healthcare system in the hands of empowered and elevated primary care providers, I joined my longtime mentors, Farzad Mostashari, MD and Mat Kendall, on our third collective adventure – Aledade.

Since that fateful day, I’ve served in a handful of roles – teacher, learner, confidante, road warrior, doctor, and mediator. I could write of the way our incredible mission has motivated me, kept me centered and determined, driven me to keep learning. I could explain the feeling I get when one of our Aledade physicians relays to me an a-hah moment, having realized that the Annual Wellness Visit they just conducted just saved a patient’s life, simply by opening up a conversation about the patient’s circumstances and risk factors. I could tell of the pride and exhilaration born of gaining momentum, of extending our reach to new patients across the country.

Instead, I want to share the story of Aledade’s four years through its people.

Year One introduced me to our Chief Technology Officer Edwin Miller, fabled builder of Electronic Health Record systems and incredible humanist, who literally feels the pain of our providers in a way I never thought possible. He shares his passion for working on old cars with his son and has quietly amassed the most incredible t-shirt collection I have ever seen. Edwin taught me what it means to serve our providers, to put their needs first, to dive in and do whatever is necessary to reach our goals.

In that first year, Edwin and I both got to meet Becky Jaffe, one of our original Delaware family physicians, a tireless advocate for the independent primary care provider, and the doctor I would choose for myself or any one of my family members. Becky and our indomitable physician partners in Delaware, Maryland, Arkansas, and Staten Island pushed us to be better and helped us build this incredible rocket ship without an instruction manual (and while flying it). Our first Delaware Practice Transformation Specialist, Robin Senft, taught me that you can accomplish anything with a smile – and a homemade, hand decorated cake pop.

In our second year, we blossomed. I was lucky to get to know so many new members of the Aledade team as our company grew, including Christine Dang-Vu, Golden State Warriors’ number one fan and tenacious, brilliant practice advocate and implementation strategist (and executor). A veritable One-Woman Band, Christine exemplified for me the discipline and work ethic necessary to move the needle in this complex ecosystem.

Our third year introduced me to the miracle of motherhood and the challenges of being a working mom. My daughter Nina became the light of my life on October 21, 2016, and even after an extended maternity leave, I was just not ready to suffer being away from her. My Aledade family rose up around me and held my hand, gracious, gentle and patient. Countless colleagues – friends – counselled and supported me and helped me see that there was a balance and serenity to be gained through persistence, self-love and incremental progress. My eyes were opened to so many awe-inspiring examples of Aledade parents – Candice Cortes, Spring Lane, Joe Neumann, to name a few – who have navigated this complex and often heart-wrenching dance. I can’t imagine going back to a time without Candice’s incredible EHR and practice workflow knowledge, Spring’s enthusiasm, can-do-it attitude and results-orientation, or Joe’s quiet progress behind the scenes to get us the data we need to promote practice change.

In our fourth year, our ranks continued to swell with the most inspiring individuals, personally and professionally. We count among us Peace Corps volunteers, foster parents, mountain climbers, church leaders, yoga instructors, acupuncturists, chefs, world travelers, and rodeo athletes. Every day, my colleagues carry our core values of Grit, Service and Inclusion to their communities. I am so proud and grateful to work alongside this incredible team and I cannot wait to see where, and to whom, Aledade’s fifth year takes us.

As a primary care physician in a small, independent practice, my focus has always been on doing what is best for my patients and community. Over the past twenty years, I’ve continued to come back to this idea. My practice, Scott Family Physicians, has become a trusted, connected part of the community. Being an independent physician offers many benefits to my patients.  One example is the freedom to have open scheduling in my practice, allowing patients to set same day appointments, instead of an expensive, unnecessary visit to the ER. It also allows me to serve my community as the high school football team’s doctor every Friday in the fall.

But, running an independent primary care practice also comes with challenges and tough decisions. As the shift to value-based care gained traction, it became clear that this new model was a great way for primary care practices to be rewarded for the attentive, personal care we provide our patients.

That’s why, two years ago, I decided to join the Aledade Accountable Care Organization (ACO) with other local Acadiana primary care physicians. I knew what this meant for my practice, as the transformation to value-based care is an investment of time, staff, and finances, but was confident that we could succeed with our partner independent physicians in the ACO and with Aledade.

And, I am proud to say, now as the Medical Director of the Aledade Louisiana ACOs with over 30 of the highest quality primary care practices in Louisiana, my practice’s decision to embrace value-based care is showing returns in a big way.

Through the Aledade ACO, our group of local, independent primary care practices partnered with one of the largest payers in Louisiana, Blue Cross and Blue Shield of Louisiana. In our first year providing value-based care to our patients covered by Blue Cross in its value program, Quality Blue, we saw great results. Not only did our patients receive better quality care, our ACO achieved significant savings.

Through our clinical initiatives, population health management, and increased ability to access and share data, we reduced our patients’ total cost of care by 8 percent. But, more importantly, we kept them healthier. Our ACO kept patients out of the hospital and ER, reducing admittances from 65 to 57 per 1,000 patients. By focusing on chronic disease management, we helped increase our patients’ rate of control of diabetes (up 13 percent) and hypertension (up 20 percent) significantly. Through improved visibility into our patient population, we could proactively reach out to high-risk patients, identify patients in need of a PCP visit, and conduct more preventive care – such as mammograms, which we saw rise 5 percent across the ACO.

For my fellow physicians and I in the ACO, this is a sign of our hard work paying off. Many of our practices had been delivering this kind of care for years, but in Aledade’s ACO model we now have the technology, access to data, and ability to participate in value programs, like Blue Cross’ Quality Blue program, to see the benefits and results for our patients and practice. For my practice this means we kept our patients healthier and the savings we achieved let me breathe easier as a small business owner. The savings we shared in, can be the difference between keeping clinic doors open and remaining independent or having to close a practice.

Growing up in the Appalachian Culture of rural southwest Virginia was challenging, but until I began working with Aledade, I did not realize that my community and circumstances were unique. As a child, I did not aspire to be a nurse. I presumed I would follow the same path as my mom. She worked as a seamstress in our local sewing factories, which were essentially sweatshops. She did not graduate from high school, she was widowed at an early age and she had two children to raise. We knew we were poor but we couldn’t escape the circumstances because it was all we knew.

Survival was hard work, ingenuity, and poverty “smarts”. We knew how to stretch a meager income, grow our own food, and treat ailments, injuries, and illness naturally. Our house was always in need of repairs. A leaky roof with buckets and pots strategically stationed to catch the water, no air conditioning and only a wood stove for heat. Our clothes were hand me downs therefore I never was stylish in the 70s and 80s designs. We didn’t have an indoor bathroom until I was 16, I never had my hair cut in a salon, rarely did I even get to go inside a grocery store, and the nearest mall or shopping centers were, in my mind, lightyears away, although it was a mere 35 miles. Our car was lucky to make it 5 miles before it puttered out or we didn’t have money for gas. This is what I knew, who I was and, to me, everything was normal in this environment.

The Appalachian Culture is difficult to leave because of the deep sense of place and pride. I was fortunate to have a mother who emphasized education. Without my education, I may have remained poverty stricken. Thankfully, I was led to a career in nursing through a choice I made to attend the high school vocational-technical school. Once I started nursing, I couldn’t stop. I started as a licensed practical nurse and eventually became a master’s prepared registered nurse.

I began my nursing career in 1988. Since then, I have seen incredible changes in health care. In those 30 years, I have worked in hospitals, home health, school nursing, community health, management and quality/patient safety. In November 2015, I stepped out of my box and accepted a Practice Transformation Specialist position with Aledade. Initially after joining the Aledade team, I felt intimidated by the “city folk”, the city, and the impressive educational and career backgrounds of our team. I thought, what does this country girl from southwest Virginia have to offer? As I soon found out, Aledade impacts the health care of my community and I play an integral role.

I always remember my mom telling me “you don’t go to the doctor unless it’s broke or you’re dying”. This mindset was driven by the lack of health insurance with the lack of adequate finances, poor health literacy, and a health care system built on the premise of reactive instead of proactive care. The history of medical care was based on treating illness and injury and lacked public health maintenance. It wasn’t until 2002 that the Institute of Medicine issued a report entitled “Who Will Keep the Public Healthy?” which concluded that public health professionals must develop a plan that identifies the impact of multiple determinates affecting health and address health for the 21st century.

Amazingly, it was just a few short years ago that we realized the need to change health care to improve the health of our people through prevention. Aledade wants to change health care across the nation and we are making a huge impact by working with our primary care providers to help them gain control of the health of their patients. Our team at Aledade HQ provides me data to help the providers in my community identify patients who have health risks and proactively address ways to prevent disease or injury. Aledade’s cutting edge technology gives providers insight to the patient’s medical care from all care transitions and sources including specialists, pharmacies, and hospitals. We also help them navigate end of life for patients who need quality instead of quantity of life planning.

I lost my mom suddenly 4 years ago. She was a smoker and had uncontrolled hypertension. She died unexpectedly of a massive heart attack at the age of 63. As I look back on her medical care now, I think about what I would have given for her provider to have been working with Aledade. Aledade would have worked with her doctor’s practice to implement Annual Wellness Visits to determine her risk factors and addressed smoking cessation, exercise, EKGs, diet and cholesterol control. Her provider would have been able to see, in the pharmacy data that Aledade provides, that she was not getting her blood pressure medicine filled consistently. Her hospitalizations for accelerated hypertension would have been evaluated through transitional care visits and a chronic care manager would have helped her if she couldn’t afford her medication but didn’t want to tell people because of her pride. This provider would have been equipped to proactively address her impending heart attack by educating her on the symptoms of a myocardial infarction. She would have known that the left arm pain she was having was not from overuse of carrying in wood to keep her fire going. If Aledade could have been there sooner, my mom could potentially still be here enjoying her grandson’s ballgames and watching him grow.

This is why I work for Aledade. I am part of a shift in health care delivery in our nation but most importantly, I can personally impact my community and my family. My mom always gave me this advice….”an ounce of prevention is worth a pound of cure.” She was so right.

Recently, I had dinner with some of my fellow family physicians and, typical for our group, our conversation ranged broadly. After discussing our favorite basketball teams’ odds of making the final four, we wound up talking about one of the biggest buzzes in health care today: the shift to value-based payment.

The conversation is moving beyond the fact of change to the pace of change acceleration.

Medicare is making this move because value-based care is improving patient outcomes. Increasing preventive medicine services, lowering hospitalizations and readmissions, and performing fewer unnecessary procedures means better medicine for both patients and their healthcare teams. The move to a value-based system is also saving money; in 2016, Medicare accountable care organizations (ACOs) generated more than $652 million in total savings. The private sector is not far behind, with a large coalition of health systems and insurers starting similar initiatives.

For primary care physicians, the implications of this shift are becoming clear. We understand the basic concept of value-based care: rewarding physicians for quality outcomes instead of volume. We are learning that providing value-based care empowers us to put the patients’ health first. A significant question remains: how can independent primary care doctors operate in this new environment?

While many of us feel we have the skills to be strong champions in leading this change, we lack the large-scale tools, regulatory fluency, and dollars to do so without sacrificing the qualities that make our practices our own. Negotiating with an insurance company or digesting volumes of government regulations aren’t skills often taught in medical school. Spending time learning those things in the midst of adopting new technology systems, adhering to regulatory requirements, and overhauling the practice payment structure distracts physicians from doing the job we love most: taking care of our patients.

The solution for independent practices may come from an unexpected direction: through innovative partnerships that don’t require geographic co-location or practice-based infrastructure. Three years ago, my practice made the decision to partner with an organization that believes patients must be at the center of value-based care, and that physicians are happiest and best utilized when providing that care to patients. I have served as the medical director for a Kansas-based ACO with Aledade, Inc. for three years.

I have seen the Aledade model provide support for the business, technological, administrative, and regulatory work of the ACO without placing a burden on my practice. The partnership allows each party to focus on what they know best: the practice takes care of the patient population and Aledade takes care of the infrastructure. The success of each partner is dependent on the other, which aligns priorities and goals across the organization.

Value-based care is the future of health care. From independent practices to large systems, we must adopt innovative strategies to accelerate the pace of change. Our physicians need it, our patients deserve it, and our healthcare system depends on it.

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.

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.