How care management can help primary care providers succeed with accountable care Insight Article Quality & Patient Experience Value-Based Operations Practice Efficiency Sign in to save Jennifer Bresnick Making the switch from fee-for-service to value-based care can be difficult for primary care providers, especially when they feel like they are already running flat-out just to keep up with daily financial and clinical demands. Joining an accountable care organization (ACO) is a promising way to overcome some of the biggest challenges of the transition. ACOs allow providers to work together to meet the goals of value-based care: lower costs, higher quality, and better outcomes for patients. But as Dr. Ryan Knopp of Stonecreek Family Physicians in Manhattan, Kansas has found out, not all ACOs are created equal. And it takes much more than the act of signing a contract to accrue shared savings in an accountable care arrangement. “Our first attempt at joining an ACO a few years ago was not very successful,” Knopp said. “We got no data, no feedback, no guidance, and definitely no financial results. If it hadn’t been written down on paper, I wouldn’t have known I was part of an ACO at all.” In order to maintain independence and ensure financial success, the ten physicians at Stonecreek needed to be more than just an ACO in name only. In 2017, they decided to try again, this time partnering with Aledade to zero in on practice-level improvements, chronic care management, and preventive care services. “Annual wellness visits (AWVs) for Medicare patients was the first initiative to tackle,” said Knopp. “We reworked our workflows to make those happen consistently and intentionally for our Medicare patients. Then we put in place the other important parts of care management, ED follow-up calls and transitional care management, by the end of the first year.” “To be completely honest, care management had been a foreign concept to us as an organization,” he admitted. “But once we hired our first care manager and care coordinator, we started to see how important it was and what an impact it made for our complex and vulnerable patients.” Patients with serious chronic conditions or multiple chronic diseases often require socioeconomic and mental health support in addition to clinical care, Knopp explained. Hiring a nurse with a background in social work to serve as a full-time care manager allowed Stonecreek to start caring for these patients much more holistically. By dedicating more resources to addressing these needs, Stonecreek has been able to achieve measurable results, such as reducing emergency department visits by 17 percent in its first performance year with Aledade. Securing engagement from staff members and patients is key for succeeding with new workflows and new patient care strategies, Knopp said. “Value-based care definitely requires a culture change, both for your practice and your patients,” he asserted. “There’s a learning curve for everyone. You’re always going to have some people who don’t think value-based care is going to work, so taking the time to educate your staff and communicate with your patients is very important. You can accomplish a lot when your staff believes in the work they’re doing.” Focusing on care management has been a core component of Stonecreek’s ability to accrue shared savings in its commercial and Medicare contracts while increasing patient satisfaction — all without putting undue stress on practice staff. “Now that we’re in our third year of doing this, AWVs and care management have become the new normal,” said Knopp. “When you hear a patient say that they really appreciate a call after they went to the ED, that they were so pleased that you know and care about their health, that’s an amazing motivator.” “And when these strategies translate into better performance on quality metrics, as we’ve seen here at Stonecreek, you’re also putting yourself on the path to shared savings, which certainly doesn’t hurt the pitch you make to your staff.” Knopp credits Stonecreek’s success to the combination of internal commitment and external support from Aledade. “If you want to succeed in the value-based world, you need to align yourself with an organization that has a vision and a roadmap for how this goes,” he said. “Working with a partner helps us make sure that we’re not spending time reinventing the wheel, and that we can learn from other practices just like us who have done this well. If you can pair that with the willingness to invest time and effort in care coordination, and if you believe in the model, then your time and effort are going to pay off.” To learn more about how Stonecreek Family Physicians secured success as an independent primary care practice, download the Aledade and MGMA webinar, “A Value-Based Care Roadmap for Independent Primary Care Physicians,” available on-demand by clicking here.