Reducing the Need for Hospital Visits: A Primary Care Doctor’s Story

Case managers made available through an accountable care organization (ACO) model work with family doctor to address unique needs of patients, reduce provider burnout

Published September 5, 2024

Helping patients stay out of the hospital has been one of the most positive outcomes of joining an Accountable Care Organization (ACO) for Dr. Shari Rozen, a primary care doctor in Pittsburgh, PA.

Dr. Rozen’s practice, Preferred Primary Care Physicians, is part of the ACO Realizing Equity, Access, and Community Health (ACO REACH) Model, a pilot program run by the Centers for Medicare and Medicaid Services (CMS) Innovation Center. In an ACO, doctors, hospitals and other health care professionals work together as a group to provide patients a high-quality, coordinated healthcare experience designed to improve health outcomes and manage costs.

REACH ACOs allow providers the flexibility to deliver personalized services to better support a patient’s individual needs, such as access to a registered dietician to help with disease prevention and nutrition management, help covering copays for those needing financial assistance, and in-home visits for individuals who may be homebound due to their chronic conditions.

For Rozen’s practice, being part of an ACO means she can hire social workers and chronic care case managers to support patients who may face difficulties following treatment plans.

“We can prescribe medicine, but if the patient can’t get it or can’t afford it, then it doesn’t matter,” said Rozen. “By addressing barriers to care in real time, we’re preventing leaks instead of plugging leaks.”

According to Rozen, social workers and case managers have been game changers because they ensure that patients follow up on doctor recommendations, and they help coordinate care between primary care physicians and specialists. This type of care coordination helps patients better manage their conditions and avoid the emergency department and unnecessary hospitalizations. 

For example, Rozen recalled one of her patients, a man in his 90s with heart failure who takes diuretic medications that made him dizzy and lightheaded.

“Years ago, he would have been in and out of the hospital, but he hasn’t had a hospitalization in several years,” said Rozen.

She explained that case managers, who are trained nurses, can monitor the man’s health and communicate with his sister, who is also his caregiver, when he has a health episode.

Another patient who has chronic obstructive pulmonary disease (COPD) told Dr. Rozen that, because of his access to case managers, he no longer feels like he must go to the emergency room every time he’s short of breath.

In addition to preventing hospitalizations and improving patients’ quality of life, the collaboration and support Rozen receives from providers in her ACO fills her with a personal sense of relief. She noted that when a patient recently received a valve replacement, the surgeon’s office was in touch with her the same day. Better communication between primary and specialty providers is a critical goal of ACOs. 

Additional support staff “takes a lot of stress off doctors and patients,” said Rozen, adding that preventing physician burnout improves quality of care and increases the availability of providers for patients. Areas with more primary care providers have better patient outcomes.

“We’re not trying to see as many patients as we can cram in a day,” said Rozen. “We’re slowing down, we’re keeping patients out of the hospital, we’re doing what we’re supposed to do – focusing on providing better care.”