MANCHESTER — Sitting in a power scooter less than four months after a partial amputation of his left leg, diabetes patient Don Willikens is already talking about the prosthesis he'll be getting and walking again.

Willikens, who will soon be 74 and lives alone, has the scooter, which is smaller than the traditional wheelchair he had, because someone noticed he was having difficulty getting around his Manchester apartment in it.

That someone who noticed — Dartmouth-Hitchcock care coordinator Diane Flint — is as close as it comes to putting a face on the new way of organizing medicine called by the bureaucratic sounding name of accountable care organization (ACO) or collaborative care organization.

As Willikens' care coordinator, Flint speaks with Willikens often, ensuring he has the medical, social and community services needed for independent living.

When the larger traditional wheelchair became a problem getting through doorways, Flint helped Willikens get the motorized scooter. Getting in and out of the wheelchair was also a fall hazard, said Flint, who is a registered nurse.

The new power scooter made it easier for him to get through his bathroom door and around the kitchen at his Greenview Drive apartment.

“Our goal is to keep him out of the hospital and out of the emergency room,” Flint said, during a visit to his apartment.

Willikens said he has received evening phone calls from Dartmouth-Hitchcock's Dr. Brian Binczewski to check on him.

Willikens, who is getting physical therapy, is diligent about checking his blood sugar three to four times a day.

His diabetic educator, Sandra Madden, is another member of the team caring for Willikens. Like Flint, she is also a registered nurse. A social worker also visits patients who are part of the accountable care organization at their homes.

Willikens is part of Dartmouth-Hitchcock's Pioneer ACO, which started Jan. 1, with Medicare, the federal health insurance program for the elderly. It's the first time Dartmouth-Hitchcock has been able to tell Medicare patients they are part of a Medicare ACO, but Dartmouth-Hitchcock was a national pioneer in developing the ACO for years before Medicare adopted the name for its latest iteration.

A national pioneer

“If you think of this as a journey, if I do my seven years in seven minutes story for Dartmouth-Hitchcock, we started back in around 2004 with the first CMS Physician Group Practice Demonstration Project, where we were one of 10 medical groups, multi-specialty medical groups, in the country,” Dr. Barbara Walters, medical director at Dartmouth-Hitchcock Health, said during an interview at her Bedford office. The Medicare Pioneer ACO project kicked off in January with 32 participants nationally.

“These Pioneer ACOs represent our nation's leaders in health systems innovation, providing highly coordinated care for patients at lower costs,” Centers for Medicare & Medicaid Services Acting Administrator Marilyn Tavenner said in announcing the rollout last December. “Dartmouth-Hitchcock has demonstrated significant experience in providing high-quality, coordinated care, and we are excited to partner with them,” Tavenner said.

The accountable care organization concept is expanding beyond Medicare. Dartmouth-Hitchcock now has some form of ACO with commercial insurers Anthem Blue Cross Blue Shield, Cigna and Harvard Pilgrim Healthcare.

Cigna and the Granite Healthcare Network launched an ACO in May, although Cigna calls it collaborative accountable care. (Granite Healthcare Network is made up of Concord Hospital, Elliot Health System, LRGHealthcare, Southern New Hampshire Health System and Wentworth-Douglass Hospital.)

Flint is currently a care coordinator for Dartmouth-Hitchcock patients enrolled in Medicare and Anthem health plans.

“We take their risk scores and we determine which patients could use care coordination,” she said.

Dr. Steven Paris, who is Dartmouth-Hitchcock's Manchester medical director, said a patient in the ACO model has multiple connections to Dartmouth-Hitchcock, including a doctor, a nurse and a care coordinator.

“That's the difference. He doesn't have one contact. He has a number of contacts that help him out in his care, and he's got some chronic issues,” he said.

Patients in the Medicare ACO retain their option to see physicians outside the network, and they can also opt out of having their personal medical records included in the database used to analyze the health progress of the group.

Yet, that kind of data is important to monitor and improve the health of a group. “We developed registries where we take a look at the patients, say all the diabetic patients,” Paris said. Instead of waiting for patients to come in on their own, the registry lets care coordinators and doctors see the patient's recent test results, determine how often they need to be seen and reach out to the patient to come in. Patients are encouraged to get their blood work done before coming in for an exam, so their doctor can discuss the results.

“That's what Dartmouth-Hitchcock has been doing for the last five years. We've been doing that,” Paris said.

Meeting patient needs

Dr. James N. Weinstein, CEO and president of Dartmouth-Hitchcock, said the concept of the accountable care organization primarily focuses on meeting the needs of the patient, not the institution.

“Most health care is reactive; patients show up at a hospital, and we have to react to what they have,” he said.

“What Dartmouth-Hitchcock wants to do is be proactive, help people stay healthy and know them well, so when they come to our systems of health care, we are already working together,” Weinstein said. “That's very different. What we call this at Dartmouth-Hitchcock is creating a sustainable health system.

“It's creating a sustainable health system where the patient partners with the health system to stay healthy in a proactive way. When you do become ill, your partner knows exactly what to do because they've been helping you to stay healthy, so they know you. We're aligned with our patients' wishes to stay healthy,” he said.

The payment model for ACOs has also changed from traditional fee-for-service, which rewards health care providers for doing more, with an outcome-based system that rewards health care providers for doing well.

“The system now is going to reward us for outcomes instead of reward us for doing,” Paris said. “This is a mechanism that they are going to be more reassured that they are getting the highest quality, but also being cost effective, which is important. If you have high quality that costs too much money, then it's not affordable either,” he said.

The ACO effectively blends quality outcomes with cost effectiveness, Paris said.

If there is a weak link in the way ACOs are structured, Paris said, it may be that patients don't have a financial incentive.

“The patients benefit because we're providing high-quality care. Their basic insurance program hasn't changed. They haven't gotten a benefit to participate,” he said.

“If we do well, Medicare does well, the patient does well because they get quality of care, but their benefits haven't changed. I think ultimately what we need is to complete the circle and have the patients involved.”

Lessons learned

Dartmouth-Hitchcock's first venture into Medicare was the Physician Practice Group demonstration project. Medicare compared the cost and quality of care, based on 23 quality measures, provided by Darmouth-Hitchcock to its patient group with a group of patients in the same area who didn't participate.

Physician Practice Groups, whose costs rose less than the average rise in costs, got to share the “savings” represented by the difference in their actual costs from average costs with the federal Centers for Medicare and Medicaid Services, Walters said.

Through that effort, Dartmouth-Hitchcock developed some care processes, redesigned some disease management programs and introduced a medical home model in its primary care departments.

Dartmouth-Hitchcock is working to make sure all its doctors understand best practices and the evidence for them for a variety of common diseases. The goal is to get “consistent, reliable care across the continuum for every patient, every time,“ Walters said.

The Dartmouth-Hitchcock system includes hundreds of physicians, specialists and other providers. Patients have access to specialists in almost every area of medicine, as well as research at Dartmouth Medical School.

“To me, the best model is the physicians working together in collaboration with some local hospitals because a lot of the cost is in the hospital, and collaboration with a tertiary center (a hospital that does teaching and research) because you need all parts of the system to be working together to do the most effective things in the right place, and our system has those pieces, which made it appropriate for us to participate in these programs,” Paris said.

Family support

Willikens had a partial amputation of his leg on May 6, resulting from a diabetic ulcer that wouldn't heal and spread to the bone. He has been treated for diabetes for about 16 years.

Although Willikens is separated from his wife of 40 years, Ingrid Willikens, they speak every day and remain friends. That kind of support is very important in recovering from surgery, said Flint, Willikens' care coordinator.

His sons, Ian and Donn, also share support roles, helping with the heavy lifting and grocery shopping.

Willikens said he lost 50 pounds since his leg problem developed and his prognosis is good. He was measured for his prosthesis Aug. 23.

“I'm getting the blood sugar under control,” he said. “I've tried to maintain a positive approach.”

Flint said Willikens' attitude is helpful to his recovery. “He's been through a lot,” she said. Although he has been included in the Medicare Pioneer Accountable Organization since the beginning of the year, Willikens said he didn't notice any change in his care.

“It's been excellent all the way,” he said.