Innovations in health care delivery do not simply spread across the system on their own. They require significant investments in time, resources, and strategic thinking to push forward. Aledade is a health care company that works with independent primary care practices to form and operate accountable care organizations (ACOs). Currently, we work with 287 primary care practices across 17 states that care for more than a million patients. As our network continues to grow, we are constantly searching for the most innovative and effective ways to scale initiatives across large numbers of practices.

The key to successful diffusion of innovation includes: determining a sustainable financial model; adaptation to the local environment by partnering with an early adopter or champion; standardized training, including in-person and distance learning; and technology that facilitates appropriate workflows and aids in decision making. In this post, we describe how we applied these diffusion principles to adopt optimal chronic care management across our five initial partner practices in the Aledade Louisiana ACO, a participant of the Medicare Shared Savings Program since 2016.

Chronic care management focuses on managing and supporting patients with multiple chronic diseases, high use of services, and high expenses. Doctors and care management teams create personalized care plans for patients; interventions focus on care coordination, self-management, addressing barriers, and facilitating access to community services.

Identifying A Bright Spot

As we began implementing this care management model across the Louisiana ACO, we started by learning how one local practice had adopted it successfully. Lafayette Internal Medicine Clinic (LIMC) was one of the first in the ACO to adopt the chronic care management program and had done so quite effectively. To better understand how this practice adapted general chronic care management principles and tailored them to its own local environment, we gathered insights from both its lead physician for the program, as well as its lead nurse care manager.

Here is what we found:

  • LIMC adopted a model of care that is focused on building a relationship with its patients and gaining trust.
  • It has two chronic care managers who are nurses and were selected because they exhibited integrity, a commitment to patient care, creativity, and strong interpersonal skills.
  • LIMC focuses on caring for the whole person, instead of the sole condition for which the patient typically comes to the office. It addresses a patient’s social needs and home environment as well as his or her clinical needs.
  • The care managers connect patients to resources, educate them on their conditions, and support them with self-management skills and home monitoring.
  • The care managers also focus on educating patients on how to appropriately use health services and to seek care in the practice first, instead of going directly to the emergency department (ED).
  • The providers at LIMC are committed to supporting the nurse care managers. They make themselves available for collaboration and additional education. They hold team meetings with the care managers to review patient issues and their goals for care. They also provide in-service training programs for their nurses to offer additional education on chronic conditions that may be less familiar.

Today, LIMC patients view the practice as their primary place of care; they call the practice before seeking care elsewhere. According to the physicians at LIMC, they have drastically reduced the number of avoidable visits to the ED. Where they used to track anywhere from six to 10 patients in the hospital at a time, today, there are at most one to two. They have even noticed stretches of time when not a single one of their patients is in the hospital.

Charting The Path To Success

Their success left us with a question: How could we ensure that more practices achieve these results? Using LIMC’s insight, we started to gather as much information as we could—we picked up the phone and hit the road to meet these practices on their playing field.

We started by reaching out to other local providers. In ACO board meetings and meetings with medical directors, we presented the providers in other practices with LIMC’s model and shared our perspective on the value of care management. Our data spoke volumes.

Yet each practice’s needs are different. So, with field staff, we went out to other primary care partners in the ACO, sharing best practice insights and designing a workflow tailored to each practice’s unique situation. We initially focused on practices of similar size and resources as LIMC, as the care management model would be more easily replicated in those practices.

We provided practice-specific, in-person and virtual trainings on chronic care management requirements and guidance on how to implement an effective workflow, focused on proactively and comprehensively supporting high-risk patients. We used tools and resources from our care management team at Aledade’s headquarters in Bethesda, Maryland. We helped practices hire the ideal care management staff and helped that new staff get started in their new roles.

LIMC significantly supported these efforts. It regularly hosted new care managers from other ACO practices and allowed them to spend the day shadowing its care management team. It shared care plan templates, electronic health record templates, and other valuable tools with the new care managers to help set them up for success.

As more practices established a solid care management infrastructure, they supported the ACO-wide adoption of chronic care management by spreading the word about their processes and the value they have seen from the program. The ACO’s medical director, whose practice was also an early adopter of chronic care management, took the time to visit new practices and tell them about how the program works.

As we began to tackle chronic care management implementation in the ACO’s newer practices—many being smaller in size and with limited resources—we recognized that the key was to keep information flowing among the network of practices. Whether it was new tools and resources, creative ideas within the practices, or feedback on what was most helpful to address implementation barriers, we shared this information not only with our headquarters team but also amongst the other practices in the ACO. A constant flow of information to and from practices, through an online learning community as well as group meetings, helped us navigate each practice’s path to a successful care management program.

Paving The Path

Once we had experience building care management programs with a variety of practices, we started to look at how we could standardize these efforts. At headquarters, that meant developing a full training program and regimen. It meant leaning on that apprenticeship model of “see one, do one, teach one.”

Our team in Bethesda started by building a common space to come together—a group training forum, a virtual space where nurses could share best practices and learn from one another. Into this forum went content and tools, tailored to the needs of our ACOs, and targeted to areas that held the greatest opportunity to decrease costs—so our partner practices could take the next step and adopt these innovations on their own.

In the case of the Louisiana ACO, that meant taking a closer look at home health expenses and transitions of care among hospitals, postacute facilities, and home. We knew that these transitions, often a time of vulnerability and uncertainty for patients, were an opportunity to better engage patients with their primary care practice and improve coordination. To help our practices best support these patients, we developed training content and tools for care managers around sharing and receiving information with postacute facilities, coordinating postdischarge follow-up visits, and educating patients on medication management and addressing their home needs.

While these customized trainings were quite effective with helping care managers become more confident in their role and understand the chronic care management processes, we also wanted the ability to provide refresher trainings on core care management competencies without disrupting the regular flow of the practices. Through practice feedback, we learned quickly that short video modules on care management workflows were perfect for self-paced learning. A combination of in-person chronic care management “boot camps” along with monthly virtual training sessions gave our care managers support along their journey. In addition, a shared online messaging board allowed the care managers to share ideas and network in between trainings. In this way, each care manager had the chance to teach each other about what approaches worked best and how they navigated challenges in adopting chronic care management.

It is important to note that we were not dictating innovations and new processes to these practices or assuming that any one way was the only way. Instead, we were sharing lessons, coming together, and solving problems as a community. Due to that community-based approach, the final, standardized approach we adopted for chronic care management made sense for a variety of practices. And under a “see one, do one, teach one” model, each practice could understand this approach in detail, implement the program themselves, and then share learnings with others to help spread adoption throughout their ACO communities.

Supercharging The Change With Technology

Once we knew the direction we were headed, our technology helped us take these changes to a new level.

Through Aledade’s population health technology, we use a stratification algorithm incorporating claims and billing data to identify high-risk factors and list patients in each practice who were most appropriate for chronic care management. This helped the practices proactively target their interventions to the patients with high needs.

This technology also uses admission and discharge data, through connections with local hospitals and other health care facilities, to help our care management teams find patients who are transitioning between sites of care. They can see which patients have undergone a recent hospitalization or visit to the ED, which means they are able to reach out in a timely manner and schedule a follow-up visit and educate the patients on how to contact them with any questions or changes in symptoms.

Moving forward, we are working to expand this technology further. We anticipate a population health application that won’t simply identify which patients to target, but one that will help practices manage those patients in a seamless and standardized way—one that will enable care managers to provide the right care, at the right time, to the right patients through every twist and turn in their interaction with the health care system.

In detail, this means adopting key features such as care reminders, time tracking, assigning complexity level to cases, and other suggested interventions and resources, thus ensuring consistency in workflows and care models across all of the practices. It gives us the ability to monitor productivity and effective implementation—creating the data we need for ongoing evaluation and finding the patients who could benefit the most from an intervention.

We envision technology not as a single solution to the problem but as a tool to empower these care management teams to stay one step ahead of their patients’ conditions and give them the best care possible.

Conclusion

The diffusion of innovation in health care doesn’t happen on its own. As we learned in Louisiana, it takes strong support for early adopters and gleaning from their experiences to tailor workflows as implementation efforts are spread to other practices. It also takes a collaborative learning environment, inclusive of both online and in-person forums, and standardized training content that can be tailored to the unique needs of each practice.

With local leaders, a dedicated team in the field, support from a growing national value-based care network, and comprehensive population health technology that helps practices target and effectively manage high-cost and transitioning patients, innovative care can bring about amazing results for doctors, nurses, and most of all, patients. Thanks to the work of our team in Louisiana, through multiple layers of learning, tweaking, and standardization—we brought effective care management from a single practice in Lafayette to a total of 15 and counting.

Authors’ Note

Charisse Hunter, Nadine Robin, and Erin Flowers are all employees of Aledade, Inc.