What does an integrated health care delivery system look like in a primary care setting?

In the heart of Texas, Austin Regional Clinic (ARC) is a multispecialty medical group bringing integrated health delivery, including both primary and specialty care, to half a million Texans, in 28 locations and 12 cities.

ARC differs from some other CAPP organizations in that it does not own hospitals and is focused exclusively on outpatient primary and specialty care. During the past four decades, ARC has forged a path for accountable care that elevates the standard of delivery in its community and gives patients the benefit of an integrated medical model — care coordination, connected technology, and preventive services to keep patients healthy.

This blog examines four aspects of the primary care model: innovation, care coordination, prevention, and collaboration with local employers.

From erecting tents in the parking and doing drive-up testing to provide care during COVID-19, ARC has proven its adaptability and creativity in serving its community.

During the pandemic, ARC was the only provider in the city that kept all of its patient care offices open. Its investment in telehealth enabled the staff to quickly convert to virtual patient visits when possible, protecting people (staff and patients) from potential infection while providing needed medical care. Physician leaders reviewed new information on the virus every day, and updated the entire team via remote communications and an online question and answer service. New findings were quickly incorporated into the electronic medical record to ensure that they were considered in patient care decisions. Recognizing their responsibility to the local hospitals, they reduced the number of patients using those hospital resources needed for patients with COVID-19. Over 75% of triage calls that would have usually been referred to the ER were escalated to doctors supporting a new high acuity triage line, and those patients were successfully treated in the clinic. To relieve phone lines for usual health care service, a COVID-19 scheduling and nurse hotline was quickly established and innovative artificial intelligence tools were added to the web site to easily answer patient questions about services, symptoms, and treatment.

The leadership of ARC drives innovation in technology, clinical best practices, and prevention as it has built a connected, patient-focused delivery system.

Another example of innovation is ARC’s participation in a pilot project using Apple watches to accurately record data during patient visits.

Sharing complete data through the EMR is the hallmark of connected care. Yet collecting this data can sometimes be cumbersome. For example, patients must share their physician’s attention with the tablet, as doctors manually do the input for the visit. Or a scribe joins the visit to record this information, freeing the physician to focus on the patient but adding an additional expense.

ARC is currently involved in a pilot program that truly automates this patient intake, utilizing the Apple Watch to record data from patient visits and directly populate the EMR. The physician wears the watch, and turns it on at the appropriate time in the visit. The watch then records the information shared by the patient, uses machine learning and artificial intelligence to analyzes the input, and populates the information correctly into the electronic medical record.

As more physicians discover this solution and as the results of the pilot are published, this innovation may soon be broadly adopted across a variety of health care settings, improving the collection of accurate patient data and enhancing the experience of  both the physician and the patient.

Care coordination is one of the cornerstones of accountable care. This service is especially important for patients who are at risk — those who have multiple conditions, a chronic illness, or complex treatment plans.

At ARC, patients with two or more chronic diseases like heart disease, diabetes, or high blood pressure have a care coordinator to help manage their treatment. These patients typically have multiple medications (six or more) and are seeing multiple specialists (three or more).  To identify these patients, ARC taps its own data warehouse and then claims information about the patient’s treatments.

In addition to improved care, this care coordination service is reducing unnecessary ER visits for those with chronic conditions. The ARC team promotes opportunities to get care in convenient settings like clinics that are open 365 days a year, or virtually, rather than resort to expensive trips to the ER.   This function also addresses the reasons why people come to the ER, and how being compliant with the treatment for conditions like hypertension can avoid symptoms such as headaches, which are a major reason why patients resort to the ER.

At ARC, the cost of the care coordinators is covered in one of two ways: payers fund the service as part of their contracts, or ARC provides the services through its risk-based contracts to more cost-effectively manage patient care. Like most CAPP groups, ARC has a significant number of patients under these risk-based contracts: about half of ARC’s 530,000 patients are under an MSSP (Medicare Shared Services Program) contract or other shared savings plan. Providing care coordination to these patients is another of the benefits of value-based payment. ARC has earned high scores in patient satisfaction such as a 4.8 Star average, and 93% overall satisfaction rating with Blue Cross Blue Shield patients, while generating more than $6.4 million in shared savings in 2019.

Improving care and outcomes for patients with chronic illnesses or who belong to specific populations (such as children with asthma) is another initiative ARC has pursued for the last decade. Using data to identify patients who fit into specific criteria is the first step, followed by monitoring and interventions to enhance compliance. Results in 2019 include:

• Pediatric HPV vaccination rates increased from 56% to 63%
• A1c control rates (for diabetic patients) improved to an all-time high of 63.8%
• A diabetes specialty project decreased A1c by an average of 3.1%
• Lipid management rate improved to 72.7%, from a baseline of 28%

Recognizing that prevention is the key to maintaining good health, ARC demonstrates innovation in this area as well. Recently the team initiated the use psychographics in how they reach out to patients, changing the language of communications based on five different types of health care personalities. The goal is to improve compliance, response and action for preventive, maintenance and rehabilitative services.

Technology is another tool deployed to improve patients’ health through prevention. Using predictive analytics, IT specialists analyze data to find out, for example, if a patient is missing a wellness exam, or foregoing important preventive screenings like colonoscopies and mammograms. Research shows that patients who keep their annual wellness appointments have better health. And preventive screenings are important to detect any illness and risk factors early on so treatment can begin right away.

ARC employs an entire department team that calls, texts and e-mails patients to come in for wellness checks and preventive screenings. If a patient has an appointment at the clinic, staff is prompted to talk to them about any pending screenings and get them scheduled at that moment. Staff reminds patients with an ongoing text campaign, March through October, for their annual well checks, vaccine and screenings.

The patient portal is another way in which ARC removes barriers to getting preventive oversight and needed care. Reminders are also sent via the patient portal, which then creates scheduling options so appointments can be made instantly. Currently, 21 percent of appointments are booked online, and 13 percent of patients complete their check-in paperwork online before their appointment. Sixty-two percent of patients are active on the patient portal.

ARC’s outreach is critically important in closing gaps in care. In 2019, more than 17,000 appointments for patients with identified care gaps were scheduled, and more than 7,000 care gaps were closed for patients with cervical, breast and colon cancer, and diabetic measures.

Recognizing the role that food and weight play in many chronic diseases and in overall health, ARC is pioneering the concept of “food as medicine.” Programs include dietitian services and a healthiness program to help people get off medications. Two weight loss programs plus direct counseling are offered, including a special focus on weight loss for adolescents and on orthopedic patients who need to lose weight before surgery. ARC’s experience is that the “food is medicine” approach helps patients control weight, insulin, hypertension, cardio issues, and provides better nutrition for all-around health.

Health care is local and collaboration with the area’s employers is a key initiative for ARC. Self-insured employers and payers know that those patients that have multiple conditions are most fragile and more costly. ARC’s ability to obtain rosters of the sickest patients and highest utilizers from their own data warehouse,  combined with claims data from payers, provides  insight into whether or not people are picking up their medications, if they go to the ER, and other facts about their behavior. The application of the CAPP principles like care coordination, connected technology, and a focus in prevention are then applied to improve medical outcomes.

ARC also supports local employers and their workforce with oversight of onsite health clinics and providing on-demand 24/7/365 telemedicine services to employees through their eMD Access platform. Remote access to medical advice is especially popular after hours, at remote worksites, when employees are traveling and with families with young children. ARC also collaborates with Crossover Health to provide referrals to specialists, hearing services and preventive care. Finally, ARC physicians and executives have partnered with brokers to educate employers on self-insurance.

Leveraging data and technology, re-engineering patient care to close gaps, and a relentless push for prevention demonstrate that a multispecialty medical group can succeed in defining and delivering truly integrated health care.