Advanced Primary Care Model for Medicare Beneficiaries

This document is a guide detailing the advanced primary care model implemented by Oak Street Health for Medicare beneficiaries. It outlines the organization's mission to provide high-quality integrated care, particularly in underserved communities, serving over 350,000 patients across 230 centers in 27 states. The model emphasizes prevention-based care, strong patient-provider relationships, and a multidisciplinary team approach, which includes primary care providers, behavioral health specialists, and community health workers. The guide presents statistics indicating a 44% reduction in hospital admissions compared to Medicare benchmarks, highlighting the effectiveness of this model. It also describes the patient demographics, noting that many patients face social determinants of health that impact their care. The document further explains the risk stratification model used to allocate resources effectively and ensure that patients receive appropriate care management based on their acuity level. Overall, the guide serves as a blueprint for improving primary care access and quality for vulnerable populations.