Privia Health’s Diabetes Care Management Program


In an exclusive interview with Hospital & Healthcare Management, Ryan Graham, CPHIT, Vice President, Practice Operations & Value-Based Care, and Zia Khan, MD, Chief Medical Officer for Privia Medical Group — Georgia, provided insightful details about Privia Health’s innovative approach to diabetes care management. Here are the key highlights:

1. Can you provide more insight into the key findings of Privia Health’s data presented at the AMGA Annual Conference regarding diabetes care management programs?

The key findings from Privia Health’s data on diabetes care management, presented at the AMGA Annual Conference, highlighted significant insights and outcomes from their analysis of approximately 107,000 diabetic patients in their Accountable Care Organization. By categorizing patients into “Bundle Complete,” “Bundle Pass,” and “Bundle Incomplete” groups based on the Together2Goal reporting parameters, they discovered notable differences in healthcare utilization and costs. The “Bundle Incomplete” group had higher hospital and emergency department usage compared to the others, and the “Bundle Complete” group showed a substantial reduction in Risk Adjusted Per Member Per Month costs by $2,585 compared to the “Bundle Incomplete” group. The findings underscored the importance of regular primary care provider visits and consistent, accurate data reporting for effective diabetes management. These insights led to improved patient engagement, more reliable data through collaboration with lab vendors, and enhanced care outcomes by focusing on completing care bundles for diabetic patients.

2. How does Privia Health leverage AMGA’s “Together 2 Goal” initiative to improve diabetes care, and what specific strategies have contributed to the $1.4M savings in risk-adjusted total cost of care?

Privia Health has effectively utilized the AMGA’s “Together 2 Goal” initiative to enhance diabetes care management, leading to a substantial $1.4M in risk-adjusted total cost of care savings. The strategy involved using the initiative’s core track metrics to benchmark and identify gaps in care, particularly focusing on moving patients from “Bundle Incomplete” to “Bundle Complete,” which demonstrated significant savings and reduced healthcare utilization. Privia Health developed a detailed patient registry updated monthly, which helped in tracking individual and overall performance metrics. They differentiated tasks that could be handled by physicians from those manageable by support staff, enabling efficient patient scheduling and pre-visit preparations to ensure necessary diabetic screenings were completed. Additionally, fostering a competitive spirit through regular meetings and updates motivated physicians and care centers, driving improvements in care delivery and outcomes across their network.

3. The study suggests three essential changes to statewide diabetes management programs. Could you elaborate on how these changes can enhance the quality of diabetes care and drive value to practices?

In our study, we proposed three essential changes to enhance the efficacy of diabetes management programs: improved reporting, comprehensive training, and strong leadership engagement. These changes improved the quality of diabetes care and bring value to medical practices by integrating them into existing value-based care frameworks.

  1. Reporting: By developing accurate, timely, and actionable patient registry reports, practices can address various patient groups effectively. Administrative staff can increase office visits and screenings by engaging patients with incomplete care bundles, thereby generating additional revenue. Clinical staff can prepare for upcoming visits by ensuring all necessary tests are completed, reducing the physicians’ workflow burden. This allows physicians and advanced practice providers to focus on developing specific care plans for patients who have completed the care bundles but have not passed all measures.
  2. Training: National training sessions for physicians cover essential diabetes management aspects, including program overviews, electronic health record workflows, coding, documentation, and advanced treatment options like continuous glucose monitoring and medication management. This consistent education across the network supports physician competency and encourages active participation and feedback.
  3. Leadership Engagement: Prioritizing the diabetes management program at the leadership level ensures that the initiative is aligned with the organization’s goals, securing necessary resources and support. This alignment facilitates operational efficiency and enhances the overall effectiveness of the program.

Together, these changes can lead to better patient engagement, higher screening rates, improved medication adherence, reduced healthcare utilization, better Medicare Advantage star ratings, and lowered total costs of care, resulting in increased shared savings distributions to care centers. These improvements not only enhance patient outcomes but also drive significant value to practices within the network.

4. With PCPs providing the majority of care for diabetes patients, how does Privia Health support these providers in delivering high-quality care sustainably?

Privia Health supports primary care providers (PCPs) in delivering high-quality, sustainable diabetes care through a combination of comprehensive management services and value-based care incentives. Their core services include electronic health record (EHR) support, revenue cycle management, group purchasing options, and operational consulting, funded by a percentage of collections. Privia Health emphasizes rewarding PCPs by redistributing 60% of all earned incentive payments back to them, with the remainder reinvested in infrastructure and care process redesign.

The organization operates under a single Tax Identification Number (TIN), enhancing continuity of care and operational efficiency through shared EHR systems and additional support services such as credentialing, analytics, and coding education. They also foster a strong culture of accountability and engagement by organizing physicians into geographically aligned groups led by a physician leader.

Furthermore, we acknowledged the efforts of our care centers with awards recognizing exceptional management of diabetic patients, based on metrics like the number of attributed patients and completion rates of diabetes care bundles. This multifaceted approach helps PCPs deliver effective and efficient diabetes care while maintaining their independence within a supportive larger network

5. Could you share some examples of how Privia Health’s value-based care platforms have helped independent practices grow and improve patient outcomes?

Privia Health is uniquely positioned to help support autonomous practices succeed in value-based care. Our MSO services provide strong RCM and operational support allowing care centers to focus on the clinical needs of their patients. Our healthcare analytics team effectively turns mountains of data into actionable insights and our operations and population health teams are experts in change management, workflow optimization and all the nuances associated with successfully navigating VBC.

We have especially been pivotal in supporting independent physicians in their gradual transition from Fee for Service (FFS) to VBC reimbursement. Year-over-year, Privia Health physicians are seeing a larger percentage of their overall compensation come from VBC. Some practices view this transition as an opportunity to align schedules and spend a little extra time with each patient, while others have used this revenue as an opportunity to grow their practice by hiring additional physicians and advanced practice providers, adding new services, or opening new locations.

6. How does Privia Health use readily available EHR data to develop clear patient cohorts, create actionable patient registries, and build meaningful care paths for each patient cohort?

Privia Health effectively utilizes EHR data, combined with additional information from payer partners, ADT data from facilities, and third-party sources, to develop detailed patient registries and dashboards. These tools are crafted in collaboration with physician leaders to ensure they are both clinically relevant and impactful for value-based care (VBC) initiatives.

Key tools developed include the “Patient Roster Report,” which helps care centers manage patient care by providing comprehensive data such as last and next visit dates, care gaps, and risk flags for chronic conditions. This report aids in identifying patients who need specific interventions, like those overdue for annual wellness visits or those with high emergency department usage.

Additionally, Privia Health has developed “Privia Engage,” a real-time patient outreach tool that divides the patient population into worklists for annual wellness visits and hospital follow-ups, updated daily. This tool allows care center staff to efficiently manage, and schedule necessary follow-up care based on recent hospital discharges, ensuring timely patient engagement and continuity of care. These strategies collectively enable Privia Health to build meaningful care paths and manage their patient cohorts effectively.

7. What challenges do healthcare organizations typically face when implementing changes to diabetes management programs, and how does Privia Health overcome these challenges?

There are a few key challenges to implementing any clinical program:

  • Resistance to Change:  Independent physicians are already stretched thin helping patients, managing staff and running a business alongside the additional challenges associated with value-based care. Trying to add a clinical program to the mix requires strong physician leadership, a clear vision for what you are trying to accomplish and well-defined success metrics. However, healthcare organizations often attempt to define the “how” before they identify the “why,” which leads to confusion and discourages adoption from key stakeholders. Privia Health has done an excellent job of building a strong physician-led governance structure helping mitigate these issues and encouraging success by soliciting input and addressing concerns earlier in the program.
  • Lack of Resources:  Adequate resources like funding, staff and technology are necessary for sustaining changes to diabetes management programs. However, many healthcare organizations face constraints in these areas. Privia Health’s diabetes management program started as a small pilot servicing a couple of care centers, we scaled the program across the Georgia market and eventually across the entire national network once we perfected workflows and ensured data confidence. With each escalation of the program, we saw a corresponding allocation of resources across dozens of teams at Privia Health to support the program’s continued development.
  • Complexity of Care Coordination: Diabetes management requires coordination among multiple healthcare providers, including primary care physicians, endocrinologists, dietitians, and other specialists, which may lead to fragmented care and sub-optimal outcomes. Privia Health has always emphasized the importance of care coordination and team-based care, including the establishment of care teams, implementing care protocols, and leveraging technology to facilitate communication and collaboration among healthcare providers. Having all of our physicians on a shared EHR eliminates the need for passing charts back and forth to reconcile data, while a centralized care management team ensures high-risk patients don’t slip through the cracks as they transition between care sites.

8. In terms of patient engagement, what strategies does Privia Health employ to ensure that patients are actively involved in their diabetes care plans?

Privia Health leverages several strategies to ensure patients are actively involved in their care. Through shared decision-making, patients are empowered to actively participate in developing their personalized diabetes care plans and make informed decisions aligning with their own preferences, goals, lifestyle, and medical history.

When appropriate, we will also refer high-risk patients into our Chronic Care Management (CCM) program, where they are paired up with a nurse care manager who helps support the care plan put in place by the physician and assists in coordinating care for the patient. This removes barriers to adherence where they may exist and provides a resource to the patient when needed. Meanwhile, patients with a less complex medical history may be enrolled in a remote patient monitoring program where daily blood sugar readings are integrated into our EHR and out of range alerts are triaged to a team of care managers for outreach, improving medication adherence, reducing A1c and bolstering patient engagement. Both programs are supplemented by the availability of telehealth directly within our platform, making it convenient for physicians and APPs to conduct a virtual visit with a patient before modifying the care plan or prescribing additional treatments.

9. Can you discuss any specific success stories or case studies that highlight the tangible impact of Privia Health’s diabetes care management program on patient lives?

The following story was shared by Marcia Lee, RN – Manager, Nurse Care Management:

“Mrs. Smith had been struggling to manage her A1c for years and was not interested in engaging in her care. As we rolled out our diabetes management program, her PCP quickly identified her as a ‘Bundle Incomplete’ patient with no upcoming appointment and scheduled her for an office visit. During that first visit, the PCP checked her blood pressure, ran updated lab tests, and completed an in-office diabetic eye exam then spent time reviewing the results with Mrs. Smith and stressed the long-term impact of diabetes on her health. The PCP and patient agreed to enroll into our Chronic Care Management (CCM) program to provide additional touch points and ensure she always had a person to call when she had questions. The CCM team ensured Mrs. Smith was compliant with her care plan and continued to attend her quarterly office visits with the PCP. Over the course of the year Mrs. Smith worked to improve her medication adherence, which resulted in her A1c improving from 10.2% to 7.8% and her blood pressure dropped below 140/90. Additionally, she has seen a decrease in emergency department utilization and has provided glowing patient satisfaction feedback and positive online reviews.”

10. Looking ahead, what are Privia Health’s plans for further improving diabetes care and expanding its impact on healthcare delivery systems?

We plan to continue following in the spirit of the original “Together 2 Goal” bundle but will be updating the measures to use 2024 Healthcare Effectiveness Data and Information Set (HEDIS) certified measures conforming with current clinical best practices, align with our Medicare Advantage programs and follow a calendar year reporting period which allows for better month-over-month trending. Specifically, our new Privia Bundle will measure blood pressure control (140/90), HbA1c control (<8%), diabetes eye exam and kidney health evaluation.

We will also be rolling out an updated diabetes management dashboard significantly improving visibility across our entire organization with market, POD, care center and physician level performance and trending data. These enhancements help us create more targeted action plans to impact specific regions and patient populations as well as engage patients on a larger scale.

We are developing enhanced clinical decision alerts within our EHR system to notify physicians and care team members at the point of care when a patient is overdue or out of range for a bundle measure and allow them to order the appropriate test directly from the alert. We’re confident this will help reduce care center administrative work and eliminate the need for proactive chart preparation before each diabetic patient visit.

Upgrading our bundle measures to include the kidney health evaluation measure will power our chronic kidney disease (CKD) program. By improving kidney function testing and eGFR and albumin level screening rates, we can identify CKD earlier and work with our nephrologists to implement care plans designed to delay the progression of the disease. Our new CKD patient registry also identifies high-risk CKD patients in need of a referral to nephrology so we can proactively engage these patients instead of waiting for their next PCP appointment.

Lastly, we are working to integrate our Privia Behavioral Health practices into our value-based care efforts to provide whole person care by helping manage the impact chronic diseases like diabetes have on a patient’s mental health.

Author: Ryan Graham, CPHIT, Vice President, Practice Operations & Value-Based Care at Privia Health and Zia Khan, MD, Chief Medical Officer for Privia Medical Group — Georgia.

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