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

Transitions Leadership Group Maps Patient Moves through St. Vincent’s Network Continuum

Colleen SwedbergAs groundwork for participation in CMS’s Bundled Payments for Care Improvement initiative, St. Vincent’s Health Partners (SVHP) formed a cross-functional cross-boundary Transitions Leadership Group to map what happens to patients moving along their care journeys, explains Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration.

In this audio interview, Ms. Swedberg describes the structure and goals of the Transitions Leadership Group and some tools and protocols it developed to set standards for any post-acute provider wishing to join the SVHP network.

During a September 2015 webinar, Post-Acute Care Trends: Aligning Clinical Standards and Provider Demands in the Changing Landscape, now available for replay, Ms. Swedberg and Julia Portale, vice president of community services, Jewish Senior Services, share their organizations’ collaborative approaches to the evolving post-acute care market.


Length: 4:03 minutes

Road Shows, Report Cards Engage Providers in Top-Performing Medicare Pioneer ACO

Kelly ClementsPhysician engagement is one of three top challenges of the Medicare Pioneer ACO model, along with performance improvement and care management, explains Kelly Clements, Pioneer program director for Steward Health Care Network, which operates Promise, a top-performer in CMS’s Medicare Pioneer ACO program.

To drive engagement in its accountable care organization at the provider level, Steward offers a range of physician tools and supports, including road shows and report cards, which Ms. Clements describes in this audio interview.

During a June 2015 webinar, Medicare Pioneer ACO: Care Management, Quality Improvement and Data Integration Yields Substantial Performance Gains, now available for replay, Kelly Clements shares her organization’s Pioneer ACO Program experience over the first three Pioneer performance years and how Steward leverages this experience with other risk-based contracts, including the newly announced CMS Next Generation ACO Model.


Length: 4:09 minutes