Value-based care models come with high complexity and few guarantees. For healthcare organizations to do well and maximize returns, they must excel in everything from collaborating with other providers to integrating the systems required for reporting. Without a good roadmap for navigating this landscape, it’s easy for practices to wind up lost. Across the athenahealth network, healthcare organizations are using tools and technology to help them achieve their value-based care goals.

Here is one of them.

Since its founding in 2013, VillageMD has grown to become one of the country’s largest providers of value-based primary care, with services offered at 680 locations in 23 states. VillageMD has participated in a number of APMs, including CMS’s ACO Realizing Equity, Access, and Community Health (ACO REACH) program and various value-based contracts with commercial carriers.

“Our clinical model is centered on team-based care provided across multiple platforms, including office visits, virtual care, and the time and space between visits,” noted Clive Fields, M.D., co-founder of VillageMD. “We need an economic model that supports those cognitive and team-based programs, which is almost always a global capitation or risk-based payment, based not on the number of visits, but on the outcomes that we drive.”

To that end, VillageMD clinicians leverage the care management tools found in athenaOne.

“To have a proactive healthcare system, you have to be able to identify and reach out to those patients most at need,” he explained.

The athenahealth platform enables this by consolidating clinical data on individual patients in a system that’s easily accessible to all VillageMD providers.

Two EHR functionalities in particular — the care-gap worklist and the patient chart-embedded care plan — have been especially useful to providers, Dr. Fields said. Because care plans can be populated by care managers and seen by primary care physicians within their workflow, data-informed clinical decisions can now be made at the point of care. Visibility of care plan data among members of the care team is also crucial, Dr. Fields said.

“Without that core capability of multiple providers across time and space being able to access a single medical record within athena, I don’t think care management can actually be successful,” he said.

Citing statistics showing that less than 5 percent of the population accounts for half of healthcare spending in the United States, Dr. Fields noted that having a unified medical record has proven key to their success in value-based care: “It’s the one technology we need to have to know exactly where to allocate our resources.”