Contributor: ACO Success—Driving Better Outcomes and Liberating Clinicians

I cannot imagine being anything other than a physician. The science of medicine, the people I care for, and my community keep my love for this profession alive. But the twin storms of the ongoing workforce crisis and the rising demand for care among our nation’s growing Medicare population have made it increasingly difficult to practice medicine the way I was trained.

Steven Reeves, MD, FACP

My patient population in Creston, Iowa, includes geriatric patients across our inpatient, long-term care (LTC), and skilled nursing facilities (SNFs). For many years, I’ve made it a point to see and follow through with all of my patients, no matter where they are.

As the years have gone by, this has become harder to do. Every year brings more patients, more follow-ups, and more administrative work, including additional calls and requests from our facilities for input. My working hours increased in tandem with demand, and in recent years, my home became the place I would use simply to fall asleep.

This is a common experience for the modern physician. There are only so many hours in a day, and we can only be in one place at once. As my workload grew heavier, hospital admissions became all too common among my patient population. Many of these were unnecessary. Few emergency departments understand how much care can be done within a nursing home. Then in 2019, my health system joined Signify Health’s Medicare Shared Savings Program accountable care organization (ACO) and real change began to happen. Now, we can facilitate data collection, improve analytics, and adopt workflow enhancements necessary to better manage our Medicare population.

Data became my liberator. Collaborating with my ACO team, I collected data points on admissions across our Medicare population and the associated costs of those stays. Understanding the importance of team-based care, I used that data to argue for a nurse practitioner (NP) dedicated exclusively to this patient population who could facilitate value-based care, deepen relationships with patients, and coordinate care across our facilities.

The difference has been substantial for me, for my patients, and for our organization, and the model can be implemented and scaled across any ACO or provider organization.

A Scalable Model for Delivering High-Value, Compassionate Care

The NP we hired 2 years ago is responsible for following patients at our long-term care and skilled nursing facilities and communicating daily with me and care coordinators across our sites of care regarding patient needs and progress.

One hire has made a world of difference for our population, shifting care from reactive treatment to proactive prevention. Whenever changes in a patient’s condition occur that may require intervention, our NP coordinates and manages care, ensuring quick treatment and avoiding unnecessary admission. Having a clinician dedicated to this population allows us to give patients who are admitted—and their families—the time and resources they need to make a successful transition from the hospital to the home, wherever home may be.

Importantly, this model has enabled our team to provide optimal care in the appropriate settings. Our NP is able to review and reconcile medications and perform transfusions and wound care within our LTCs and SNFs. Working in concert with me and other providers on our patients’ care teams, our NP is able to collaborate on treatment plans when patients are transferred.

The results have been staggering. After our first year, we broke even with our expanded costs of onboarding a new employee. The outcomes speak for themselves:

• 50% reduction in emergency department and hospital admissions
• Prescription medications decreased by an average of 3 to 4 per patient
• Greater satisfaction among patients and their families
• Significant reduction in the volume of phone calls and requests from patients and their families
• $3 million in population health revenue generated across our organization since joining Signify’s ACO
• $870,000 total in shared savings across our organization since joining the ACO

Our model can be scaled across any ACO; it is easy to envision 2 to 3 mid-level providers in this arrangement operating within the same format, in the same way. But it requires 3 essential principles:

1. Commitment: The complete commitment of a mid-level clinician is required to be able to succeed in this model. The amount of patient engagement and care coordination will not be sated with a qualified NP or physician assistant working a few half days a week.
2. Trust: Our success is due in no small part to the NP who serves this patient population. I trust her to communicate with me regularly as we manage our community, which consists of patients across 2 nursing homes and an assisted living facility.
3. Data: Sustaining this model requires the ability to quantify your data. How many patients is your team seeing? How many emergency department visits? How many hospitalizations? And, most importantly, what kind of impact is the model making?

Today, my schedule looks much different. I come into work at the same time, but I’m home by 5:30 pm. I visit our SNF patients whenever they’re admitted. But the most compelling impact of the team-based care model is that it has allowed me to re-introduce compassion into care while allowing our nurses to work at the top of their license.

This model allows patients and families to remain where they are. They don’t feel abandoned by their care teams. They understand what’s going on with their care at all times.

I would know: my own mother and mother-in-law are both patients in one of our nursing homes. Our NP oversees them.

Steven Reeves, MD, FACP, is a board-certified internist who works for Greater Regional Health in southwest Iowa. He started a solo internal medicine prac1ce in Creston, Iowa, going on to become employed by Greater Regional Health in 2007. He has since overseen the development and expansion of the Internal Medicine Department to now include 4 physicians and 3 advanced register nurse/physician assistant providers. He is also the physician representative for Greater Regional Health since it became part of an accountable care organization, first with Caravan Health and now with Signify.