Team-Based Care Under Risk-Bearing Contracting

If you were a new patient coming into a Fairview Health Services clinic today, you would see a team of caregivers, says CEO Mark Eustis.

“You’ll see the primary care physician, but you’d also see the RN and the medical assistant. You might see behavioral specialists, and if you have complicated conditions, you would see a health coach.” Care coordinators are also hard at work looking at populations and evaluating when the patient receives care, “knowing things that happen with the patient so we can act on it immediately.”

That immediacy of action is critical to success under risk-bearing contracting, he says. In some ways it’s providing more access to the right kinds of services that also happen to be in a less costly setting, says Eustis.

“Our patients are really responding to the care model,” he says. “Going to the ED 12 times a year isn’t the best way to access care. In this community, the general assistance population is used to going to the ED for care. We’re not trying to take it away—you have that right—but that’s not really advancing your care in a positive way.”

Because of data-mining techniques that have been refined at Fairview, Eustis says for the first time, “our physicians now appreciate where their high-risk patients actually are. They can stratify the population. This 20% of patients are really the ones we need to spend extra time with.

“You might think a physician understands the individual patient well, but the treadmill runs patients through every 15 minutes. And it’s been great for other members of care team, because now they’re actually participating.”