Managing Population Health in Northeast Georgia: One Medical Group's Experience

September 21, 2013
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Northeast Georgia Physicians Group’s experiences with care management offer insights into the emerging world
Managing Population Health in Northeast Georgia: One Medical Group's Experience

Northeast Georgia Physicians Group (NGPG), based in Gainesville, Georgia, a suburb of Atlanta, encompasses 200 providers, of whom 140 are physicians and 60 are mid-level practitioners, and serves patients in 45 locations in 13 counties in mostly-rural northeastern Georgia. Most of the NGPG primary care physicians practice in very small groups or in solo practices, while the NGPG specialists practice in groups of 10-15 doctors.

Early in 2012, the CEO of Northeast Georgia Health System, the parent company of NGPG, informed NGPG leaders that they needed to get all their primary care sites recognized as patient-centered medical homes by the end of the year. As a result, the medical group needed to be able to scale its care management process quickly to meet the PCMG requirements of the national Committee on Quality Assurance (NCQA). NGPG chose the x-based Phytel as a technology platform that could facilitate population health management activity, and could also integrate with the organization’s electronic health record (EHR). Among the tools implemented by the group is a module that combines an electronic patient registry with automated messaging to patients who have preventive and chronic care gaps. Triggered by nationally recognized clinical protocols, the messages urge patients to make appointments with their providers.

Recently, Antonio Rios, M.D., NGPG’s chief physician executive, and Marlene McIntyre, NGPG’s director of quality and patient safety, spoke with HCI Editor-in-Chief Mark Hagland regarding the progress that they and their colleagues have made in moving forward on population health management activities. Below are excerpts from that interview.

Your physicians practice in smaller-group settings for the most part, correct?

Antonio Rios, M.D.: In the case of the primary care practices, some are practicing in solo practices. Our biggest primary care practice has five providers. As for the specialty practices, sometimes 10-15 physicians are practicing in the same building

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Antonio Rios, M.D.

Marlene McIntyre, R.N.: We’re spread across 13 counties, mostly rural, in northeast Georgia. So while a five-physician practice might sound small in a place like Atlanta, a five-physician practice is actually pretty big in a place like Dawsonville.


Marlene McIntyre, R.N.

Tell me about your journey around population health. Are you also involved in some version of accountable care development?

Rios: We’re not necessarily presuming the accountable care journey. We realized a few years ago that we needed to redesign how we deliver care, and the medical home started to become a more prominent issue, and we definitely saw that as a goal for our group to pursue aggressively. And Marlene led three of our practices through NCQA certification through the patient-centered medical home. And because of that, we heard about a Centers for Medicare & Medicaid Improvement grant, through TransforMed. TransforMed is a division of the American Academy of Family Physicians.

McIntyre: They’ve become experts in care management. We’re not looking to establish an MSSP [Medicare Shared Savings Program] ACO, but we’ve definitely started going down the path of transforming care, to deliver better care for patients and to align ourselves well to better succeed in this era of healthcare reform and accountable care.

We’re a part of the Patient-Centered Medical Neighborhood grant; it is in effect for over three years for just over $21 million, and we’re one of 15 community centers participating in this process. It equates to a little over $2 million for us. We kicked off in January. We’re one of the 15 communities encompassing 90 practices, and eight community practices, of which seven belong to us, are participating, in our region.

So what are you doing, in the context of that program?

Marlene: We’re developing these practices into highly effective PCMHs. That means changing how we deliver care, as well as automating a lot of processes through technology. That requires us to identify care gaps for patients when they come into the office, as well as, a pilot around our diabetics—we’re using the Phytel population health technology, and we’re able to use some of their risk stratification tools to identify our most poorly controlled diabetics and work with them.

Those initiatives both began in January?

Rios: The three practices involved in the pilots already had the criteria for a media home, so we’ve been working with those for close to two years, and that involves the diabetic initiative, as well as open access, sharing of information, revisit planning, etc.

You’re speaking of three of the seven practices that belong to you among the eight community practices involved in the Patient-Centered Medical Neighborhood grant, correct?

Rios: Yes, three of seven. We started the process earlier with those three practices.

Are all seven participating practices now NCQA-certified?

McIntyre: No, and those three were certified under the 2008 standards, and NCQA rewrote those standards in 2011. Our three practices were certified in 2011 under the old standards. So we’ve currently submitted our applications for all of the 22 practices in our primary care network certified under NCQA. And seven of our practices are in the CMMI grant.

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