How Ilumed’s ACO REACH Model Improved Patient Care for This Primary Care Doctor

As a primary care provider (PCP), you go above and beyond for your patients, giving up your lunch break, working late and being on call around the clock. It’s not always a matter of working harder, but smarter—that's where ilumed’s ACO REACH model comes in. With ilumed, you have the financial stability you need to care for your patients the way you want with the added support you and your staff need to address the root causes of patients’ conditions. 

Dr. Vivek Dasondi in Galloway, New Jersey, has worked with ilumed for a year and half to transform his practice by serving patients outside the exam room. Here’s his story. 

Practicing as a Primary Care Doctor in the Medicare Fee-for-service Model Before ilumed 

Dr. Dasondi did fine in the Medicare fee-for-service model; however, his patient panel kept growing to make his finances work. “With insurance cutting back on your payments, you need to see more and more patients on a daily basis to make ends meet,” he said. 

But there was only so much he could do for patients in the exam room. He kept worrying about their lives at home. “A lot of patients have transportation issues, caregiving issues, medication problems, food problems,” Dr. Dasondi said. “There were a lot of social issues with patients which I didn’t know how to address.” Even when community services for things like transportation were available, they weren’t always easy to access or reliable. 

He felt like he was a step behind, racing to keep up with the patients in his office. There was no way he could help them in all the ways he wanted to. “It’s impossible to stay in touch with patients and how they’re doing clinically at home,” Dr. Dasondi said. “You could have hundreds of patients. It’s hard to reach them unless they call you or come to visit you.” 

Dr. Dasondi learned about ilumed and ACO REACH through Partners in Care, an accountable care organization. He found he and ilumed had the same goals to help Medicare beneficiaries improve their health and well-being. With ilumed by his side, Dr. Dasondi felt like he “would be heading in the right direction.” 

He had two main questions: 1. How can ilumed help him better take care of his patients at home? 2. How much can ilumed benefit his practice? Here’s how working with ilumed has helped Dr. Dasondi improve primary care delivery and financial stability. 

How ilumed’s ACO REACH Model Improves Medicare Patient Care for Primary Care Doctors 

With ilumed, Dr. Dasondi has a trusted, reliable extension of his staff to support his patients with their clinical and social needs. “ilumed is my extender,” Dr. Dasondi said. “They’re a bridge between me and my patients.” His patients have a dedicated source of support to help them manage their treatment, schedule appointments and transportation and get their social needs at home met. 

Reducing Hospitalizations and Hospital Readmissions Through Primary Care 

Before ilumed, Dr. Dasondi would only learn about his patients’ hospitalizations from them or a caregiver. He didn’t have the insight or communication with the hospital he wanted. “The hospital didn’t call,” he said. He practiced in an informational vacuum, reacting rather than responding to hospitalizations. 

“With ilumed, I get alerts on my phone if a patient visits the emergency room, gets admitted or discharged,” Dr. Dasondi said. Now, he has the data he needs to anticipate his patients’ needs and put a plan in place. “I can contact them to see what happened and review their chart and hospital records,” Dr. Dasondi said. “I can bring them into the office quickly. If they can’t come in, I at least call them to see if they’re having any issues after their hospitalization and confusion about changes in medication. I can answer questions on how to prevent recurrent hospitalization.” 

He helps his patients understand why the post-discharge follow-ups are so important to their overall health and well-being. “ilumed expects us to see patients within three to seven days of their hospital discharge,” said Dr. Dasondi. That proactive, immediate follow-up helps patients stay on track with their medications and treatments to  . 

As Dr. Dasondi said, “Hospitalization after hospitalization after hospitalization really adds up and takes a toll on you. It puts you in a cycle of fixing one thing and another going bad.” With ilumed, Dr. Dasondi can interrupt that cycle and set his patients up on a healthier trajectory. 

Addressing Social Determinants of Health (SDoH) with Primary Care Physicians 

As you know, health is determined by genetics as well as social and environmental factors. As an industry, healthcare has realized just how big a role those social and environmental elements play in overall health—social determinants of health (SDoH). That’s why the ACO REACH model aims to improve health equity. 

Before working with ilumed, Dr. Dasondi recognized the importance of what happens for his patients at home to their health, but he had no way of systematically finding out or addressing his patients’ needs. “Basically, we had no idea we should do that,” he said. Now with ilumed’s processes and intake forms, he and his staff can routinely ask patients about their needs at home and identify those patients who need more support. 

Dr. Dasondi now asks his patients what he can do for them to improve their situation at home, whether that’s helping them with transportation, food insecurity or medication refills. ilumed helped one patient in her late 80s who lived alone and had both mobility and transportation problems. She lost weight because she couldn’t shop for groceries, and she couldn’t get to and from the doctor. With ilumed, she had free rides to and from Dr. Dasondi and the help she needed to get food delivered. Dr. Dasondi said, “ilumed supplying transportation has made a big difference in patients’ lives.” 

Risk Stratification Targets the Most At-risk Patients with Proactive Primary Care  

Dr. Dasondi meets with ilumed’s team once a month to review his most at-risk patients for adverse events, who tend to have multiple chronic and/or complex conditions. “We keep a close eye on them,” he said. “ilumed’s case-management team or the social worker talk to them every week until we are satisfied they are safe at home.” 

He also works with ilumed to set up long-term case management and social needs support for those patients. These efforts help prevent future adverse events like medication errors or reactions from occurring. In turn, this helps to reduce the risk of patients having cognitive or mobility issues, which reduces falls and lowers avoidable hospital admissions. 

Prioritizing Preventive Patient Care for Medicare Beneficiaries with Primary Care Physicians 

ilumed's ACO REACH model asks PCPs to see their patients every 90 days (about once per quarter). This level of proactive, preventive care is the backbone of value-based care, and helps PCPs stay in tune with their patients’ changing needs. 

Dr. Dasondi knows he can adjust this as needed for his patients based on their health, seeing patients more or less frequently to best serve them. His patients appreciate this hands-on approach. “They don’t mind coming in every 90 days to see me,” he said. 

Improving Financial Stability for Medicare Primary Care Doctors 

With ilumed, the financial benefits to his practice are easy for Dr. Dasondi to see. “As a physician, I’m not a big accounting guy,” he said. “It’s easy to calculate with ilumed.”  

Dr. Dasondi has a monthly capitation rate with ilumed, which is above Medicare’s traditional fee-for-service rate. “It gives you a little security of having that money coming into your account every month,” he said. Over time, that positive cash flow adds up. 

He sees ilumed’s ACO REACH model as a win for him, his patients and the Centers for Medicare & Medicaid Services (CMS). He understands that more financial reward means more responsibility on his side. “I’m getting more financial reward to do my work the way I want so that my patients are taken care of,” he said. “I’m a good physician. I don’t mind taking on those responsibilities because that’s how I want to practice anyway.” In the end, when his patients are healthier and stay out of the hospital, Medicare saves money on avoidable hospitalizations. 

Dr. Dasondi’s Advice for New ACO REACH Primary Care Physicians 

Dr. Dasondi cautions PCPs that they might need to educate patients about ilumed and its benefits. Medicare patients are often the targets of scams. They are used to dodging calls and letters, especially when the promise sounds too good to be true. Educating his patients with ilumed brochures and letters made a big difference. “I personally encourage patients to accept ilumed phone calls,” Dr. Dasondi said.  

Now his patients know their ilumed social workers by name. They have a single point of contact to help them navigate the healthcare system and get their social needs met. They’ve created trusting, lasting bonds that change the healthcare experience for the better. 

ACO REACH—The Only Primary-care Model that Works 

Dr. Dasondi isn’t just an ACO REACH participant, he’s an advocate. “I’m happy with ilumed, and we’re hoping this bond continues to grow,” he said. He wants to see all patients, whether they are on Medicare or covered commercially, get the kind of support ilumed provides in the ACO REACH model. 

As people live longer and their healthcare needs become more complex, physicians need more financial, clinical and social support to give their patients a better quality of life. When “physicians are rewarded, we can improve patients’ lives,” Dr. Dasondi said. “The only way to do it is with ACO REACH.”  

If you’re ready to improve the way you deliver primary care by lowering hospital readmissions, addressing SDoH needs, targeting the most at-risk patients with proven interventions, prioritizing primary care and how you get compensated for the vital work you do, it’s time to consider ACO REACH and ilumed. Together, we can heal healthcare. Get in touch.