Thriving with Value: How a Team-Based Medical Group Transformed Workflows

Emerald Coast Medical Group (ECMG) first opened its doors to the city of Pensacola, Fla. more than 40 years ago. A staple of health care in the Pensacola community, ECMG utilizes a team-based approach to deliver high-quality, full-service primary care.

Jennifer Richardson, PA-C, has cared for patients at ECMG since 1999. She purchased the practice in 2021, and has served as its owner since, dedicated to continuing its mission.

"As part of that ownership, you're looking for ways to keep the doors open and to not only make it profitable for you, but also compensate your employees appropriately," Richardson said, adding that she then became interested in accountable care organizations (ACOs).

As an Advanced Practice Provider (APP)-owned medical group, ECMG was in a position to benefit from value-based care solutions and resources. Richardson's interest in joining an ACO - and in driving financial sustainability - became a reality.

New strategies can position practices for success.

In value-based care, patient attribution is an indicator that patients are pleased with their care and is a crucial part of ensuring clinicians are recognized for improving patient outcomes. Proper attribution means patients are receiving coordinated care and are assigned to the correct ACO. Prior to Aledade ACO participation, there wasn't an emphasis on attribution for ECMG. Maureen Padden, MD, joined ECMG's team in 2022 with a focus on helping them implement new workflows and smoothly transition to the value-based model.

"ECMG didn't have attribution workflows because they weren't in an ACO at that time," Dr. Padden said. "They struggled with whether they were going to survive or not. Recruiting new doctors and changing how we did business really helped."

After Dr. Padden came on board, she worked with ECMG to improve attribution and focused on continuing to provide care as a team. One of the first things they did was decide how to strategically message patients about seeing one of the doctors once a year for an annual wellness visit (AWV). ECMG also actively utilized the Aledade App's Wellness Worklist feature, which highlights patients that need primary care visits, to optimize scheduling.

"We work together collaboratively. We want our patients to build relationships with more than one person in the clinic," Dr. Padden said. "We started having all the chronic care management supervised, and used the Wellness Worklist to identify who hasn't seen a physician to get them in for their next appointment."

ACO resources, including technology for care coordination and financial success, provide the support clinicians need to excel in value-based care. APP-owned group practices, like ECMG, can greatly benefit from organized patient data and new funding opportunities.

After joining an Aledade ACO and successfully implementing new workflows, ECMG's hard work quickly produced positive results.

Improved patient outcomes and quality metrics are a joint effort.

With a continued team-based approach, ECMG is already excelling in AWV measures and has seen a substantial spike in patient attribution. In their first performance year alone, ECMG achieved outstanding quality metrics: 90% completion of patient AWVs, 95.5% patient follow-up after emergency department (ED) visits, 83% transitional care management (TCM) outreach and 77.2% blood pressure control.

"The assistance and education from Aledade for my front office staff and my management team has helped make sure that patients are being brought in and have an appointment scheduled," Richardson said. ECMG's attribution has grown significantly, and they anticipate further growth in this area as their ACO participation progresses and they continue to provide their patients with coordinated care.

With ACO technology and solutions, like the Aledade App, clinicians are easily able to view actionable patient data in one place. The App's unique Daily Huddle feature integrates patient data from multiple sources.

"The Wellness Worklist is the key to attribution and preventive care," Dr. Padden said. "Our staff is religious about checking the list from top to bottom and getting people scheduled for their AWVs. The Daily Huddle and the App really gives you a lot of information that we didn't used to have before, not just here, but anywhere, and there's no excuse now to not know."

ECMG's preventive care efforts extend beyond AWVs. Richardson has seen continued success with their chronic care management program, which prioritizes outreach to patients to minimize hospital readmission. "We run the program ourselves, and my team identifies patients that would be good candidates to enroll in our chronic care management plan," Richardson said. "It's mutually beneficial, both for the patient and financially for the practice."

Value-based care presents a growing opportunity for APP-owned practices.

ECMG's collaborative approach has positioned the team to learn from each other, build trusted relationships with patients and thrive in the value-based model.

"There is a vital role for advanced practitioners in family medicine and value-based care. I would much rather my patients be seen in my office by me or one of the other advanced practitioners instead of going to urgent care or the emergency room," Richardson said.

"As an APP, I take a lot of pride in what I do and how long I've been in family medicine. The mentoring relationship in family medicine is great with our physicians because we work side by side, elbow to elbow all day long."

Richardson said she looks forward to watching ECMG continue to grow and potentially add new physicians to the team.

"I heavily focus on quality of life for my providers, and I've been approached by a few physicians who want to get away from hospital systems," Richardson said. "I would love to be able to expand the practice and perhaps open a satellite clinic with the revenue we can generate."

Aledade is proud to work alongside and support practices like Emerald Coast Medical Group, who was recently selected as the best of the coast for Pensacola for medical practice and the community. Explore the great work ECMG is doing today: https://emeraldcoastmedgroup.com/