A 13-Point Protocol Helps Telephonic Care Coordinators Locate Medicaid Members for Early Engagement Initiative

=A Medicaid expansion program in Wisconsin is introducing many Medicaid beneficiaries reluctantly to managed care but with an early, effective introduction to its telephonic care coordinators, Independent Health Care Plan (iCare) is successfully engaging these new members.

In this HealthSounds episode, Lisa Holden, vice president of accountable care, iCare, shared iCare’s key strategy in engaging Medicaid members…a call to members within days of enrollment by a telephonic care coordinator…as well as details on how iCare holds the care coordinators accountable for finding difficult to locate members.

During Medicaid Member Engagement: A Telephonic Care Coordination Relationship-Building Strategy, a May 2018 webcast now available for rebroadcast, Ms. Holden shared how iCare has structured its care coordination team, including both telephonic and boots on the ground staff to find, engage and assess Medicaid members.

The webinar provided details on how the care coordinators helps Medicaid members overcome barriers to care; seven rising risk/acuity identification tools; readmission prevention initiatives for high-risk patients; three programs aimed at reducing high emergency department utilization; and details on a Follow-to-Home program for members who are homeless and much more.


Length: 4:26 minutes

Waiting on ACO Shared Savings? Here’s 3 Ways to Generate Population Health Revenue Now

=While shared savings could be several years in the future for fledgling accountable care organizations, there are shortcuts for physician practices in ACOs to generate population health revenue immediately, explains Tim Gronniger, senior vice president of development and strategy for Caravan Health.

In this HealthSounds episode, Gronniger outlines the rationale for using three Medicare billing codes—the annual wellness visit (AWV), chronic care management and advanced care planning—to create revenue that offsets ACO infrastructure costs.

During Generating Population Health Revenue: ACO Best Practices for Medicare Shared Savings and MIPS Success, a January 2018 webcast now available for rebroadcast, Tim Gronniger shared the key focus areas for its ACOs to achieve substantial financial and quality results while building a sustainable healthcare delivery model for the year ahead and beyond.

The webinar provided key details on the key cornerstones of Caravan Health’s ACO success, including staffing and patient engagement secrets; payoffs from detailed MACRA and MIPS reporting; the benefits of effort-based quality metrics over outcomes-based data; two critical 2018 strategies Caravan Health’s ACOs use to build on their success, and much more.


Length: 3:54 minutes

Motivational Interviewing Respectfully Dispels Social Determinant of Health Barriers

Cindy BuckelsHow can care teams encourage patients to open up about sensitive social determinant of health (SDOH) factors? By employing motivational interviewing to establish a respectful partnership, advises Cindy Buckels, TAV Health director of population health.

In this HealthSounds episode, Ms. Buckels explains why motivational interviewing is more effective than the usual “Chunk-Check-Change” approach in transforming patient ambivalence and effecting the kind of behavior change that improves health.

During Social Determinants of Health: Using Empathy Interviewing To Help Care Teams Understand Factors Impacting Patient Health, a September 2017 webinar now available for replay, Ms. Buckels shares key steps in identifying and removing SDOH barriers. Program highlights include the four core skills of empathy interviewing every care team should know; ideal workflows to identify high- and low-vulnerability patients; and reasons why crowdsourcing data around patients can reduce hospital readmissions and ED visits.


Length: 3:59 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

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

For Success in Accountable Care Models, Educate Providers on the Ground

Travis AnselWhether an ACO is assessing readiness for CMS’s Next Generation ACO model or is already a Medicare Shared Savings Program (MSSP) participant, face-to-face education of non-executive providers living the day-to-day ACO reality is critical to that accountable care organization’s viability, advises Travis Ansel, senior manager of strategic services for Healthcare Strategy Group.

Even within experienced MSSP ACOs, providers often don’t understand MSSP quality goals, the relationship of their actions to cost management or MSSP data requirements, noted Ansel.

In this broadcast, Ansel describes the two biggest barriers to success across all ACO models, and offers two tips to organizations wishing to prosper in the value-based care reimbursement world.

During an April 2016 webinar, Next Generation ACO: An Organizational Readiness Assessment, now available for replay, Ansel and colleague Walter Hankwitz, senior accountable care advisor at Healthcare Strategy Group, provide a value-based risk contract roadmap to determine organizational readiness for participation in the Next Generation ACO Model in particular and in risk-based contracts in general.


Length: 3:26 minutes

Data Analytics Drive Medicare Annual Wellness Visits, Boost Beneficiary Attribution, Retention

Elena TkachevBeyond facilitating business decisions and improving quality of care and patient experience, data analytics help Collaborative Health Systems (CHS) to close gaps in preventive care within its 24 accountable care organizations (ACOs), explains Elena Tkachev, CHS director of ACO analytics.

One key preventive metric for the largest U.S. sponsor of Medicare Shared Savings Programs (MSSPs) is the Medicare Annual Wellness Visit (AWV), which CHS has set as a core goal. In this audio interview, Ms. Tkachev describes the rationale behind this goal, how data analytics drives AWVs, and the dramatic correlation between AWVs and patient attribution.

During a January 2016 webinar, Data Analytics in Accountable Care: Strategies and Case Studies, now available for replay, Elena Tkachev shared her organization’s experience in using data analytics effectively to improve ACO results.


Length: 3:37 minutes

Next Generation Healthcare Nurse Navigators: The Advantages That Won Over ‘Solo Cowboy’ Practitioners

Robert FortiniWhen Bon Secours adapted Geisinger’s case management model six years ago and embedded nurse navigators within physician practices, there was reluctance and even resistance from some “solo cowboy” physician practitioners, recalls Robert Fortini, PNP, chief clinical officer for Bon Secours Medical Group. Today, providers are fiercely protective of the cadre of 70 nurse navigators, who do the “heavy lifting” of chronic care management.

In this audio interview, Fortini offers some lessons learned for organizations considering the embedded case management approach, including budgetary planning, calculations, and “icing-on-the-cake” outcomes for patients and hospitals.

During a January 2016 webinar, Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning, now available for replay, Fortini offered an inside look at Bon Secours’ experience with CMS’ chronic care management reimbursement in 2015 and how they leverage this experience for CMS’s newest billable event in 2016—advance care planning.


Length: 3:24 minutes

Is Technology the Answer to Patient Engagement? The Intermountain Healthcare Experience

Tammy RichardsTools such as smartphone apps and automated reminders are increasingly employed to engage patients in self-care. But if healthcare organizations aren’t careful to create a seamless care experience, technology could actually disengage patients, even the youngest ones, according to Tammy Richards, corporate director of patient and clinical engagement at Intermountain Healthcare. In this audio interview, Ms. Richards suggests some ways to incorporate meaningful technology while creating a connected health strategy to engage patients.

During an October 2015 webinar, A Patient Engagement Framework: Intermountain Healthcare’s Approach for a Value-Based System, now available for replay, Ms. Richards shares the six key tenets of Intermountain’s patient engagement strategy.


Length: 3:02 minutes

Memorial Hermann Immerses Care Managers in ‘Micro Culture’ of Physician Practices

Mary FolladoriHaving heard from physicians and payors alike about the challenges of engaging patients, the Memorial Hermann ACO crafted its care management program with the goal of drawing patients more fully into their care, explains Mary Folladori, RN, MSN, FACM, CMAC, system director of care management at the Memorial Hermann Physician Network and ACO.

In this podcast, Ms. Folladori shares some key program design elements from the 2014 top-performing Medicare Shared Savings Program (MSSP) ACO, including immersing care managers into the ‘micro cultures’ of the physician practice, the community and the members that they serve.

During a September 2015 webinar, Care Coordination in an ACO: Managing the Population Health Continuum from Wellness to End-of-Life, now available for replay, Ms. Folladori provided the inside details on its care coordination strategy and results.


Length: 2:57 minutes