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.
As patients of Lehigh Valley Health Network (LVHN) began to utilize the features of its newly minted portal, LVHN and its physician providers soon recognized the added benefits of this interactive tool.
In this HealthSounds episode, LVHN’s Lindsay Altimare outlines seven ways the LVHN portal, the fastest growing portal on the Epic® platform, improves efficiency and quality for her organization.
During Patient Portal Roll-Out Strategy: Activating and Engaging Patients in Self-Care and Population Health, a November 2017 webinar now available for replay, Ms. Altimare, director of operations for the Lehigh Valley Physician Group, and Dr. Michael Sheinberg, medical director, medical informatics, Epic transformation, share LVHN’s initial portal roll-out strategy as well as the evolution of portal engagement and functionality since its 2015 launch.
The webinar provided key details on promotion strategies for portal launch, four LVHN portal platforms that allow patients to initiate self-service and their impact on physician practice workflow, LVHN metrics to measure patient engagement and portal success, new portal features slated to launch this year, and much more.
How 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.
How receptive are clinicians to being coached in patient engagement techniques? At PinnacleHealth, provider reaction to rollout of patient engagement coaching has followed a standard bell curve, notes Kathryn Shradley, PinnacleHealth’s director of population health.
In this HealthSounds episode, Ms. Shradley outlines the framework underscoring the engagement coach’s supportive and educational role while at providers’ elbows as well as ways the health system earned clinicians’ support for the initiative.
During A Two-Pronged Patient Engagement Strategy: Closing Gaps in Care and Coaching Clinicians, an August 2017 webinar now available for replay, Ms. Shradley describes her organization’s two-pronged approach to increase engagement rates across the health system, including details on the key patient survey data that helped to shape this program, three ways PinnacleHealth works to engage its more resistant patients, and more details on the essential role of the engagement coach for clinicians.
After 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.
Among 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.
Working to bridge the gap between hospital discharge and permanent supportive housing for homeless patients, the California-based Chronic Care Plus program found that 40 percent of client needs are related to social determinants, explains Paul Leon, CEO of the Illumination Foundation, a Chronic Care Plus joint venture partner. In this audio interview, Leon explains the need to not only house patients but also to connect them to a plethora of social services, including mental health appointments.
During Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients, a December 2016 webinar now available for replay, Mr. Leon shares the inside details of this recuperative care program that offers community-based stabilization for medically vulnerable chronically homeless patients, including program results and savings achieved.
Identifying 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.
Even when employing sophisticated predictive analytics to zero in on population health risk, healthcare organizations shouldn’t discount providers’ intuition, advises Luke Hansen, MD, vice president and chief medical officer, population health for AMITA Health.
With a future plan to adopt a risk prediction tool, AMITA currently creates chronic illness registries to track its high-cost patients. Listen as Dr. Hansen discusses the tradeoffs of mathematically intense risk predictors versus physicians’ guts.
During an August 2016 webinar, Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care Management Strategy, now available for replay, Dr. Hansen and Susan Wickey, AMITA Health vice president, quality and care management, share the key components of AMITA Health’s care management process, how the various care management teams work together and the impact the program is having on healthcare costs and utilization.
By focusing chiefly on moving high-risk patients down to the low-risk band, population health management programs are in danger of missing the “natural inertia” driving low-risk patients right back into that high-risk stratum, cautions Dr. Adrian Zai, clinical director of population informatics at Massachusetts General Hospital (MGH).
Dr. Zai describes why MGH, ranked the number one hospital in the nation by U.S. News & World Report,® advocates a multi-pronged approach addressing both low-risk and rising risk patients—a strategy that has improved MGH care quality and provider performance while reducing high-cost healthcare utilization.
During an August 2016 webinar, Targeting High-Risk and Rising-Risk Patients: A Multi-Pronged Strategy, now available for replay, Dr. Zai shares the key details behind his organization’s strategy and the results it has achieved.