Learn more about emerging models of care established by the Affordable Care Act at AAPA’s Navigating Healthcare page.
After nearly two and a half years, Beth Grivett, PA-C, can see the positive effects of data sharing and coordinated care at Premier Physicians Medical Group, part of Monarch HealthCare’s Pioneer accountable care organization (ACO) in Southern California.
As a lead physician assistant (PA) within OptumHealth, Premier Physicians and Monarch’s parent company, Grivett works with a medical director to educate other clinicians on the many programs available to ACO participants.
She has been in this role since Monarch became a Pioneer ACO, and she has seen firsthand how access to data and coordination of care has improved patient care. This has been especially evident in the ACO’s signature program, the “Welcome to Medicare” visit.
Integrating the Welcome to Medicare program into clinical practice required a process-oriented, team-based approach, which Grivett helped manage. The ACO first had to learn how to bill for the visits and educate clinicians on the requirements of the visit. To aid in this, Premier Physicians developed its own branded forms with a preventative services checklist and other important patient education. The ACO also trained the scheduler on how to best explain the appointment with a patient and encourage them to schedule this appointment with one of the five PAs in the practice. This effort is paying off; patients reported feeling engaged in their preventative care and understood the goals of the visit. In particular, PAs have become especially adept at navigating these exams to benefit the individual patient. As a result, annual wellness visits are better managed, as patient information is already in the electronic medical record and PAs can focus on quality measures such as blood pressure control, body mass index and colonoscopies. Premier Physicians also developed a questionnaire that the patient fills out beforehand to address other quality measures—this information serves as a jumping-off point for the visit.
While the ACO primarily focuses on reducing hospital readmissions, its other major areas of focus are chronic disease management and patients with multiple comorbidities. Within the ACO’s centralized system, Grivett is able to access a patient’s billing data, which includes information such as other provider visits and any X-rays or diagnostic studies that have been conducted. This information allows Grivett to follow up with the patient and be able to coordinate care more easily than she would be able to for a traditional fee-for-service Medicare patient.
In a very innovative program, practices within the ACO have access to a predictive modeling system called IPRO, which aggregates patient data and selects the top 25 most “at-risk” patients per primary care provider, per week. In most practices, a PA will work with a medical assistant to assess each patient’s needs based on the indicators that have been flagged by the system.
“These are the patients who may end up in the hospital or have another bad outcome,” Grivett says. “The PAs take on the role of evaluating the patient’s chart to see what appropriate interventions are needed, be it changing a prescription medication, contacting the patient to have lab work repeated, having a pharmacist-nurse team visit the patient at home to intervene on medication management, or bringing the patient in for a visit.”
Grivett has an extensive support system on the administrative side of her position, so she is better able to focus on patient care while being a clinical leader. This support is vital, as the group—comprised of about 25 physicians and a dozen PAs and nurse practitioners—oversees the care of almost 2,000 ACO patients. Grivett sees the role of PAs in the ACO expanding—there are opportunities for PAs to coordinate care of patients discharged from the inpatient setting as well as increasing work on existing disease management programs.