Welcome to our newsletter—Rethinking Health Care! We hope these communications will serve to educate and engage you around the work of Trinsic and how we are working toward our mission of “transforming care together.”
CMO message from Amy Scanlan, MD.
Mike is a patient of mine. He has the worst case of diabetes I have seen in my 20+ years of practice. He has all the complications—neuropathy, nephropathy, cardiovascular disease, gastroparesis and retinopathy. He is on high doses of insulin and his disease is difficult to manage on a good day. Additionally, he has been intermittently unhoused. He has trouble getting a ride to the office to see me. He gets food stamps, but rarely has enough to eat, and his diet is nowhere near heart-healthy.
For many years, Mike struggled to stay on top of his life and his disease. He was in and out of the hospital, and often went to the ER with hypoglycemia. Even with his great medical team—endocrinology, neurology, cardiology and primary care—he struggled. Then, his insurance changed to a value-based plan. Suddenly, he had more access to help. An RN care manager helped him better understand his disease. She helped him manage his medications. She made sure he stayed on top of his preventative health care, such as vaccines and cancer screenings. A social worker helped him apply for housing aid. She connected him with Meals on Wheels. She helped get him transportation to his appointments. She encouraged him to ask me about a counselor.
It has been a year now since Mike started on his new plan. He has been in the hospital one time in that year. During the prior year, he had three hospitalizations, including a week-long stay in the ICU. This year he has been in the ER twice, versus six times during the previous year. He now has stable housing. He is eating better. His A1C went from 13 to 7.6, and he has a CGM.
I tell this story to show how value-based care truly affects patient lives. Value-based care is patient- centered care. Value-based contracts supply the resources that allow us to build teams of caregivers that wrap around patients. These teams fill the “in-between spaces” that doctors and clinic staff often cannot. They offer patients a lifeline in difficult times.
As we start to build Trinsic, our new Clinically Integrated Network, our most important measure of success will be our patients. Have we kept them healthier? Have we kept the costs of their care down? Have we made their health care journey easier for them? Value-based care IS patient-centered care. It will ask all of us to do things differently, but it will also allow all of us to go back to our medical roots, focusing on keeping patients as healthy—both clinically and financially—as we can.
Spotlight: Team-based care.
Many of the best practice programs and methodologies discussed in value-based care are well- understood, but the manner in which they are implemented often comes down to individual practices and what works best for them.
In this issue of Rethinking Health Care, we focus on the idea of “team-based care” and feature two of our practices that have successfully implemented it in a way that works best for them; and their patients.
Yampa Valley Medical Associates (YVMA) and Dr. Christopher Vialpando appear outwardly to be very different medical practices. YVMA is a small to mid-sized primary care practice that has, and is currently, participated in innovative primary care models supported by the Centers for Medicare and Medicaid (CMMI). Dr. Vialpando is a solo primary care provider beginning to scout the value-based landscape. Where YVMA and Dr. Vialpando are very much alike is that they are equally successful in value-based care and leverage a team-based model in their success.
YVMA has a large team dedicated to value-based care. Their care model includes care management, embedded behavioral health, pharmacy, and a dedicated quality improvement team. YVMA utilizes a whole-team approach and recruits help from all staff members who encounter the patient. Front desk team members identify patients who need Annual Wellness Visits scheduled. Clinical staff identify preventative care needs for patients. Providers engage in comprehensive, patient-focused visits. This is a well-educated, engaged, and empowered team striving to provide the best care for their patients.
Dr. Christopher Vialpando’s practice is an example of a “small but mighty” team. Every team member is instrumental in his success. The front desk and clinical staff work together to outreach patients to schedule Annual Wellness Visits and hospital follow-up appointments, ensuring patients are seen as soon as possible post discharge. They work hard to personally answer all phone calls from patients, and address concerns and emergencies as soon as possible. The medical assistant reviews charts before visits to identify care gaps, performs a monthly data review identifying patients needing outreach, and provides supplemental documentation to close care gaps. The medical biller contributes to the team’s success by reviewing documentation post-visit, identifying opportunities for hierarchical condition category (HCC) recapture to increase risk scores, and CPT II coding to further support care gap closure.
These two primary care practices are very different in composition. However, their utilization of their care teams, from front desk staff, to providers, to coders and billers, drives success in value-based care.