Social Determinants of Health: Adapting Screenings for Different Populations

Amanda ParsonsAfter choosing two validated tools to assess social determinants of health (SDOH) in its largely Medicaid and otherwise government-insured patients, Montefiore Health System allowed each physician practice to determine its target population for screening.

In this podcast, Dr. Amanda Parsons, MBA, vice president of community and population health at Montefiore Health System, explains the various screening approaches taken by the physicians, and how that multi-site strategy figures into the health system’s overall plans for SDOH interventions.

During Assessing Social Determinants of Health: Collecting and Responding to Data in the Primary Care Setting, a June 2017 webinar now available for replay, Dr. Parsons provides insight into her organization’s evolution of SDOH screening into an EPIC®-supported process.


Length: 3:17 minutes

Michigan SNF Collaborative Sets Competition Aside to Improve Quality and Readmission Rates

Susan CraftTo hold the line on hospital readmissions, a tri-county, skilled nursing facility (SNF) collaborative in Michigan evaluates 130 participating SNFs by a host of quality metrics the SNFs enter into a common data portal.

In this podcast, Susan Craft of the Henry Ford Health System (HFHS), one of four collaborative founders, outlines a few SNF participation and reporting mandates that run the gamut from meeting attendance to LACE readmission risk scores.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvement, a May 2017 webinar now available for replay, Ms. Craft, director, care coordination, family caregiver program, HFHS Office of Clinical Quality & Safety, shared the key details behind this SNF collaborative, the program’s impact on readmission rates, and new readmission reduction targets derived from the program’s data analysis.


Length: 4:15 minutes

The Science Behind Care Transition Management: More Than Case Managers and Discharge Calls

Jennifer DragoAmong the myths surrounding care transitions management is the belief the intervention can be effectively executed pre-discharge or by phone only, explains Jennifer Drago, executive vice president of population health for Sun Health.

In this audio interview, Ms. Drago dispels this myth, outlining requirements for a professionally designed, evidence-based transitions of care program, and why inclusion of dedicated staff and home visits will enhance clinical outcomes and possibly save lives.

During A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay, Ms. Drago shared the key features of Sun Health’s care transitions program, which achieved the lowest readmissions rates in CMS’s recently concluded Community-Based Care Transitions Program.


Length: 2:34 minutes

CMS’ Physician QRUR Tables Highlight High-Value Referral Patterns for Medicare Population

William HoldingAmong other data, detail tables in a physician practice’s Quality Use and Resource Reports (QRURs) pinpoint specialist referral networks for Medicare beneficiaries, explains William Holding, consultant, PDA, Inc., which can help physician practices determine their highest value referral pathways.

In this audio interview, Holding explains the benefits of tapping CMS-generated QRUR reports to enhance performance under Merit-Based Incentive Payment Systems (MIPS), one of two payment paths for physician reimbursement under MACRA.

During Physician MACRA Preparation: Using QRUR and Other CMS Data To Maximize Your Performance, a January 2017 webinar now available for replay, Holding and colleague Nancy Lane, president of PDA, Inc., share the critical steps physician practices should take when analyzing their QRUR data, along with details on other CMS data points that can help practices improve MIPS performance.


Length: 3:07 minutes

Social Determinants of Health: Scenarios to Encourage the Sharing of Sensitive Information

Dr. Randy WilliamsIdentifying social determinants of health (SDH) requires providers to probe beyond the scope of clinical data. But how can health teams ensure that patients and health plan members provide valid data during SDH assessments? In this audio interview, Dr. Randall Williams, chief executive officer, Pharos Innovations, describes three scenarios to build trust and encourage individuals to share sensitive information during SDH interactions.

During Social Determinants and Population Health: Moving Beyond Clinical Data in a Value-Based Healthcare System, a December 2016 webinar now available for replay, Dr. Williams shares his insight on the opportunity available to providers to impact population health beyond traditional clinical factors.


Length: 3:16 minutes

Trends Shaping Healthcare in 2017: Employ Technology for Patient Engagement

Steven ValentineThe engagement of patients, particularly those with multiple chronic conditions, continues to challenge healthcare providers.

However, as Steven Valentine, vice president of advisory consulting services for Premier Inc., explains in this podcast, clinicians actually have a host of tools at their fingertips to engage patients—tools they must employ in order to succeed in value-based healthcare.

During Trends Shaping the Healthcare Industry in 2017: A Strategic Planning Session, a November 2016 webinar now available for replay, Steven Valentine provides a roadmap to the key issues, challenges and opportunities for healthcare organizations in 2017.


Length: 2:52 minutes

MACRA Prerequisite: Procure QRUR Performance Data to Maximize MIPS Success

Barry AllisonPrior to enrollment in MACRA’s Merit-Based Incentive Payment System (MIPS), physician practices should request their confidential Quality Use and Resource Report (QRUR) from the Centers for Medicare and Medicaid Services (CMS) for crucial performance feedback, advises Barry Allison, chief information officer, the Center for Primary Care.

In this podcast, Allison explains how to obtain a QRUR report, the origins of QRUR quality and cost data, and the benefits of leveraging QRUR feedback to improve the quality and efficiency of care delivered to attributed Medicare fee-for-service beneficiaries and ultimately prosper under MACRA’s multi-pronged approach.

During Physician Chronic Care Management Reimbursement: Setting MACRA’s MIPS Path for 2017, an October 2016 webinar now available for replay, Mr. Allison shares his organization’s chronic care management reimbursement strategy and how this is guiding their preparation for MIPS in the year ahead.


Length: 3:12 minutes

UT Southwestern ACO Home Health Narrow Network Reinforces Providers’ Home Care Accountability

Cathy BryanAfter UT Southwestern Accountable Care Network (UTSACN) discovered its home health spend was more than twice the national average, it applied data analytics to create a preferred home health network of 20 agencies (down from 1,200) that has saved more than $6 million in home health utilization in the first quarter of 2016 alone.

In this podcast, Cathy Bryan, director of care coordination at UTSACN, describes the provider reeducation process supporting the launch of this narrow network that has improved accountability, data sharing and communications related to home health utilization.

During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a September 2016 webinar now available for replay, Ms. Bryan shares how her organization’s care coordination model manages utilization while achieving its mission of bridging care gaps and enhancing health outcomes for approximately 250,000 covered lives.


Length: 3:21 minutes

UPMC RAVEN ECCPs ‘Driving Force’ in Reducing Long-Term Care Hospitalizations

April KaneUnder its partnership with CMS to improve quality of care in long-term care (LTC) facilities by reducing avoidable hospitalizations, the University of Pittsburgh Medical Center RAVEN project embeds clinical staff within eighteen nursing facilities. Here, April Kane, co-director of the RAVEN project, explains how the on-site presence of enhanced care and coordination providers (ECCPs) elevates the facility’s clinical capabilities, from goal development to advanced care planning.

During Hospital-Nursing Home Collaborations to Reduce Avoidable Admissions and Readmissions: A UPMC Case Study on Curbing Long-Term Care Hospitalizations, an August 2016 webinar now available for replay, April Kane shares the key details of the RAVEN program and how UPMC is preparing for Phase 2 of the program.


Length: 3:56 minutes