Business challenge

Loudoun Medical Group sought to improve health outcomes for diabetic patients in the communities it serves with a comprehensive and standardized outreach approach across its 350 specialty and primary care providers. 


Using the IBM Phytel Outreach solution, LMG identified patients who needed care and efficiently communicated with automated health reminders that prompted patients to schedule appointments for necessary checkups.   


USD 192,000 in revenue

as more patients were seen by their providers and treated for their diabetes

Saved valuable staff time

completing patient scheduling calls in a day instead of a week

Quality Metrics Exceeded

with a scalable solution that helped close care gaps and improve quality

Business challenge story

Quality care for an entire population

In 2017, the Centers for Disease Control and Prevention (CDC) reported a startling statistic: more than 100 million adults in the US have diabetes or prediabetes, which often becomes diabetes within five years. With USD 245 billion in medical expenses and lost productivity, the cost of diabetes to the nation is significant. And as the seventh leading cause of death in the US, the emotional toll of the disease cannot be understated.

LMG, one of Virginia’s largest healthcare providers, is on the front line of care in a state that has more than 630,000 people with diabetes — nearly one in every ten people. As a value-based care provider, LMG focuses on patient outcomes — the whole health of a patient — rather than a traditional fee-for-services healthcare delivery model. Ushered in with the Affordable Care Act (ACA), value-based care is designed to reduce the enormous costs of chronic illnesses — such as diabetes — and, more importantly, provide better care and better outcomes for patients.

“Our goal was to identify and treat our chronic patients,” says Clara Nussbaum, Quality Assurance Director for LMG, “and also prevent disease states from starting or worsening.”

But with 120 locations and 350 primary and specialty physicians, patient data was held in 15 different electronic medical record (EMR) systems — or in some cases, paper filing systems with no electronic patient records at all. LMG knew that it was going to be impossible for staff members to not only contact every patient, but also follow up with appointment reminders. The organization needed an automated and scalable tool that would allow them to cast a wide net across its practices and EMRs to identify patients diagnosed with diabetes as well as those at risk for diabetes. 

Using IBM Phytel Outreach, Loudoun Medical Group was able to effectively contact our diabetic patients to get them the right care at the right time.

Clara Nussbaum, Quality Assurance Director, Loudoun Medical Group

Transformation story

Outreach, education and support

LMG’s multifaceted approach to diabetes management includes comprehensive care coordination, patient education, workshops and support for long-term success. The Phytel Outreach solution proved to be the perfect choice to help facilitate these efforts. With the ability to scale and ease of integration, LMG was able to assess and identify patients across all of its practices in need of treatment — whether they had been diagnosed with diabetes or prediabetes conditions. With the automation of the Phytel Outreach solution, LMG was able to free up staff time with tailored communications — directly from a patient’s physician — alerting them to schedule appointments for recommended follow-up care or preventive services. 

“It’s not an unknown number on the caller ID or even Loudoun Medical Group,” says Nussbaum. “It’s a patient getting a call from her physician and branded for that physician’s practice that says, ‘You are due for a physical, please call our office today and schedule your appointment.’”

As a value-based care provider, LMG follows a protocol of evidence-based guidelines for managing diabetes in the communities it serves. Designed to improve overall patient outcomes and reduce preventable health complications and the associated medical costs, value-based care rewards providers for delivering high-quality care with payment incentives based on positive patient outcomes. LMG has ten value-based contracts that deliver shared savings across its organization, providing it improves patient outcomes and the patient experience while driving down costs.

While the benefit to patients is clear, the transition to value-based care delivery doesn’t happen overnight. With new processes and protocols, and a comprehensive outreach effort to manage chronic diabetes in its community, buy-in from the 350 specialty and primary care providers was crucial. Nussbaum says that at the beginning of LMG’s value-based contract journey, the idea was almost an abstraction. But as the practices saw how value-based contracts supported their patients, they quickly realized how the Phytel Outreach solution could help save them time by automating once manual administrative tasks and help close care gaps.

“It’s time back,” says Nussbaum. “And that’s what doctors and nurses and office staff need.”

Results story

Healthier patients and scores for higher quality

LMG’s use of the Phytel Outreach solution led to extraordinary quantifiable benefits for diabetic patients. The scalable cloud-based solution not only led to quick adoption across the organization but also allowed LMG to cast a wide net across its practices to identify patients in need of care. Automated communications alerted patients of necessary appointments, freeing up staff to focus on patient interactions for better quality patient experiences. The automation capabilities of the Phytel Outreach solution drove remarkable efficiency — completing scheduling calls in one day instead of one week. Using the solution, LMG was able to identify and connect with diabetic patients in need of care to help ensure they saw their physicians and booked appointments for ongoing treatment, resulting in USD 192,000 in revenue.

Since the inception of its value-based contracts, LMG has consistently had high quality scores. And since the implementation of the Phytel Outreach solution, the organization has met or exceeded all of its quality metrics across all payer contracts, realizing shared savings for each one. Overall, the organization saved 3 percent over its previous year’s expenditures and received 44 percent of that savings back from Medicare.

Moving forward, LMG plans to use the IBM Phytel Coordinate solution for pre-visit planning and targeted campaigns to provide better management of chronic conditions and help prevent catastrophic events for its patients.

“Loudoun Medical Group is made up of people who live in Loudoun County,” says Nussbaum. “We’re serving our family members, our friends and other professionals. Using IBM Phytel Outreach, we were able to contact diabetic patients in our community and help them get the right care at the right time with the support they needed.”

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Loudoun Medical Group

Founded in 2000, LMG is one of the largest physician-owned healthcare providers in Virginia. With collaboration across its 350 multi-specialty and primary care providers and 120 locations, the organization delivers high-quality, coordinated patient-centered care that meets the unique needs of the communities it serves. LMG is an Accountable Care Organization and earned distinction with accreditation as a Patient-Centered Medical Home for primary care practices by the National Committee for Quality Assurance.

About IBM Watson Health

IBM Watson Health™ is a business unit of IBM that is dedicated to the development and implementation of cognitive and data-driven technologies to advance health. Watson Health technologies are tackling a wide range of the world's biggest health care challenges, including cancer, diabetes, drug development and more.

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