Dr. Sindhu Gupta is a Board certified internist, operating her internal medicine practice in Bronx, New York, along with a physician assistant. But as a community provider participant in the Montefiore Medical Center Pioneer Accountable Care Organization (ACO), Dr. Gupta has many partners helping her to care for her patients. Through the ACO’s Health IT tools, she regularly receives data and alerts about her patients’ health status and to identify opportunities for follow-up to improve quality of care. “They notify me when patients are admitted to the hospital, and after discharge they follow up with the patients and send me the reports,” Dr. Gupta noted. The ACO also sends her notifications when patients need preventive care. “For example, I received a list of about 50 patients who had not received their pneumonia vaccine,” she said, which enabled her practice to contact those patients for an appointment.
In 2011, Montefiore was among 32 institutions nationwide selected to participate in the innovative Pioneer ACO Model. Under the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) designed and sponsored the program with the goal of providing Medicare beneficiaries with high-quality care while reducing expenditures through better care coordination. Community physicians like Dr. Gupta serve 60 percent of Montefiore Medicare patients, with the balance cared for by Montefiore’s employed physicians. In its first year of the three-year Pioneer ACO Model, Montefiore achieved a seven percent reduction in the cost of care through increased patient engagement, care coordination and preventive, patient-centered care. “Our first-year results indicate that actively engaging employed and community-based physicians in patients ’continuum of care can lead to better, more cost-effective care for our patients,” said Henry Chung, M.D., chief medical officer of Montefiore’s care management program and of the ACO. “In this system, everyone involved is accountable for guiding each patient toward the best treatments possible, with a goal of creating a healthier community.”
For Dr. Gupta, involvement in the ACO is one of the tangible ways she is using her electronic health record (EHR) to transform her practice and enhance patient care. On her journey to implement the EHR, she has the guidance and support of another set of partners: the team at NYC REACH, the New York region’s Regional Extension Center. “NYC REACH is very helpful, guiding us in what to do and what not to do,” she said. “For example, they taught me how to make order sets and templates that are very useful to me for things like the annual physical.” NYC REACH also provided guidance about how to use the EHR to pull lists of patients who need follow-up, for example, by identifying diabetic patients at specific blood pressure and A1C levels that warrant closer care management.