The Aledade App uses proprietary technology to offer actionable insights for independent primary care providers participating in Aledade ACOs.  With access to integrated data, patient prioritization tools, and care management features, the App supports better outcomes for patients and higher-value care.

 

Independent primary care providers are increasingly joining accountable care organizations (ACOs) to deliver high-quality care for patients and support long-term financial sustainability for their practices.

ACOs are based on the idea that more coordinated, proactive, and comprehensive care can keep patients in better health, resulting in fewer avoidable, expensive events such as hospitalizations and unnecessary ED use.

By empowering primary care practices to become “quarterbacks” of patient care, ACOs aim to improve outcomes, reduce spending, and earn incentives. In order to achieve these goals, ACO participants need timely and actionable insights into their patients’ current diagnoses, clinical risks, and healthcare utilization patterns.  

This information must be meaningfully integrated into provider workflows so clinicians can close gaps in care, help patients manage their chronic conditions, and conduct outreach around transitions of care.

“It’s not really possible to manage patients well in an ACO if you don’t know who they are, what their needs are, and whether or not those needs are being met,” says Angie Walker, office manager at The Randy Walker Family Clinic, a member of the Aledade Arkansas ACO.  

For practices in Aledade ACOs across the country, the Aledade App delivers this information directly into the workflow, equipping physicians, nurses, care managers, billing staff, and executives with crucial data for informed decision-making.  

Leveraging the App in conjunction with Aledade’s hands-on practice transformation support and policy expertise can accelerate success with value-based care. 

“You really will see the results if you have the right tools at your disposal and use them efficiently to improve the way you care for your patients,” Walker added.  “The Aledade App is an important part of that for our practice and our ACO.”

Integrated data from the ACO and beyond

Data integration and interoperability are huge challenges in healthcare.  There are hundreds of different electronic health records (EHRs) and other health IT systems in use across the industry, and not all of them can share data in a standardized and easy-to-use format. 

Most independent primary care practices don’t have an in-house data integration team to ensure that every provider can access all the necessary information about each patient.  With the Aledade App, they don’t have to.

The App combines data from EHRs, hospital event notifications, labs and pharmacies, and insights from practice-generated and payer claims into a single solution.  Aledade works with more than 20 local health information exchange (HIE) partners across 27 states to ensure that ACO members can view up-to-date data about patients and their activities in the community.

“The technical connections of health information exchange would have been a very tough nut for us to crack on our own,” commented Timothy Rimmer, CEO of PMA Medical Specialists in Pennsylvania.  

“From a knowledge standpoint and a cost standpoint, it’s a lot to expect from any one provider organization, which is why it’s such a huge benefit to have Aledade’s data connections supplementing what we are already doing and helping us take it to the next level.”

The App’s integrated view of the patient’s medical record and recent clinical utilization can enable improvements in care coordination, transitional care management, and preventive care delivery, all of which combine to boost a practice’s ability to achieve their value-based care goals.   

In 2018, for example, PMA’s ACO reduced emergency department visits by 17 percent and slashed inpatient hospitalizations by 21 percent, saving Medicare $15.5 million in the process.

Intuitive access to prioritized patient information

Primary care practices need to stay one step ahead of the health issues that lead to poor outcomes.  The ability to personalize care for patients depends on access to data when and where it’s needed.

The Aledade App enables customized care not only for patients who walk through the practice’s doors, but importantly, for patients who are not coming in despite their needs. The Aledade App’s Daily Huddle brings actionable insights right to the point of care so that the care team can leverage timely information to impact the visit.  The detailed, prioritized worklists highlight patients in need of intervention and display necessary information in a meaningful way so that the entire care team can collaborate around action items and care planning.

The Daily Huddle offers insights into recent specialist utilization, hospital and ED events, and gaps in preventive or routine care.  New COVID-19 functionalities also generate a vulnerability risk score to keep appropriate patients healthy at home.

Using proprietary technology, the App is able to generate lists of high-priority patients so that care managers and administrative staff can conduct outreach, schedule appointments, and connect patients with the right services.  Providers can also view and modify diagnosis suggestions to appropriately capture patient acuity so that nothing falls through the cracks.

More than 80 percent of Aledade ACO members use the App daily to manage their patients.

“The Aledade App gives us insight into our high-priority patients so that we can connect with them for the care they need,” said Kristie Bennardi, CEO of Keystone Rural Health Consortia, a community health center (CHC) in New York.  “You simply have to utilize data for those purposes.  It’s a critical part of making sure value-based care really works, and that’s what Aledade provides for us.”

Keystone Rural Health uses data from the Aledade App to identify individuals in need of Medicare Annual Wellness Visits (AWVs), transitional care management (TCM), and other preventive care, ensuring the CHC meets its quality benchmarks – and that patients can make more engaged, informed decisions about their health. 

“If you can identify patients who can be served appropriately in the primary care environment without referring them to other providers, you’re going to see less duplication of services, better insight into the coordination of care, speedier access to care, and fewer avoidable ED and hospital visits,” Bennardi said.

Simplified, coordinated workflows lead to high-value results

ACOs are held to high standards of patient care and responsible spending.  Administrative efficiency, clinical quality, and coordination throughout the practice are key for continuous improvement.

From the exam room to the billing office, the Aledade App makes it easier for entire care teams to collaborate without duplicating effort or letting important tasks slip by.

In Eustis, Florida, for example, solo physician Dr. Sharon Nickell-Olm relies on the Aledade App to keep her practice operating at the top of its game.

Nickell-Olm and her team use the wellness worklist in the App to make certain their patients are getting their Medicare AWVs, an important opportunity for patients and providers to build strong relationships, set goals, and review concerns.

With the App, they can see if high-priority patients are already scheduled for a visit and add the AWV to the existing appointment.  This saves time for the patient and the practice.

Once a patient is scheduled for their AWV, the practice’s two licensed practical nurses (LPNs) use the Daily Huddle feature to conduct pre-visit planning. They review the patient’s recent specialist visits and any hospital events as well as clinical risks, diagnoses, and preventive care needs. 

On the day of the appointment, Nickell-Olm receives a printout of the Daily Huddle to inform her clinical conversations with each patient.

Thanks to these patient prioritization tools, 95 percent of Nickell-Olm’s high-priority patients were current with their AWVs through the fall of 2019.

Across the Aledade Florida Central ACO, providers leveraged similar data-driven strategies to earn a 96 percent quality score in the MSSP and generate $3.4 million in Medicare savings.

“It’s not easy keeping up with all of the changes happening to healthcare,” said Dr. Sharon Nickell-Olm, a solo physician in Eustis, Florida.

“I needed guidance and support to navigate value-based care, and that is exactly what Aledade provides,” she continued. “The App has helped us make the most of time and resources. It’s hard to overstate how important that is for us.” 

Access to the right technology can make the difference between a successful ACO and a group that falls short of its targets.  With the Aledade App, ACO participants get the tools they need to achieve their goals of keeping patients healthy and enhancing the value of primary care.