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

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

Connected Care Management: Do Mathematical Risk Predictors Trump Provider Intuition?

Dr. Luke HansenEven 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.


Length: 3:04 minutes

Population Health Management: Don’t Ignore Natural Inertia Driving Low-Risk Populations

Dr. Adrian ZaiBy 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.


Length: 4:08 minutes

Behavioral Health Patient Engagement: Change Talk Highly Predictive of Behavior Change

Mia CroyleIncreasingly in motivational interviewing (MI) research, change talk—anything a patient or client says that counts as an argument for change—is a reliable sign they’re ready to make a change, notes Mia Croyle with the University of Wisconsin School of Medicine and Public Health.

Here, Ms. Croyle shares some of the latest thinking regarding change talk: how motivational interviewing practitioners might interpret change talk in interactions with clients, particularly those with behavioral health diagnoses, as well as how to elicit more change talk during an MI session.

During a June 2016 webinar, Behavioral Health Patient Engagement: Using Motivational Interviewing Techniques and Strategies To Improve Outcomes, now available for replay, Ms. Croyle shares key learnings from patient engagement initiatives targeted at patients with behavioral health conditions.


Length: 3:40 minutes

Healthcare Drivers for 2016: Why Data is a Health Plan’s Strongest Asset

Paul KeckleyThe future for health plans is not so much in plan design or call centers but in how they leverage their storehouses of healthcare data, advises Paul Keckley, managing director of Navigant. In this audio interview, Keckley talks about infomediation—the mining of membership data to determine factors influencing population health—and its influence on payor valuation, its role in shared risk arrangements, and why health plans’ ’embedded Intel’ uniquely positions them for success.

During a November 2015 webinar, Trends Shaping the Healthcare Industry in 2016: A Strategic Planning Session, now available for replay, Keckley and Laura Jacobs, executive vice president of GE Healthcare Camden Group, provided a roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2016.


Length: 2:40 minutes

Care Coordinators Boost Physician Practice Potential for Humana Value-Based Rewards

Chip HowardThe use of a care coordinator boosts the quality of care a physician practice provides and thus its potential for earning incentives in Humana’s Physician Quality Rewards program, explains Chip Howard, Humana’s vice president of payment innovation in the provider development center of excellence.

Here, Howard describes the value Humana places on the care coordination function, and describes the support and training available to physician practices at each level of the three-tiered rewards program, a hallmark of Humana’s Accountable Care Continuum.

Chip Howard will share how Humana’s program supports physicians’ transition from volume to value and helps them become successful population health managers during a December 16, 2014 webinar, Physician Quality Rewards for Population Health Management, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 7:22 minutes

3 Key Benefits to Prudent Sharing of Physician Performance Data

There are three key benefits to prudent sharing of performance data among physicians, notes Cynthia Kilroy, senior vice president of provider strategy and business development at Optum, who suggests a four-step systematic approach for data dissemination that moves companies away from simply creating “metrics in a box.” Besides the electronic health record, she recommends three other data sources to mine for provider performance metrics.

Cynthia Kilroy explored the key structure, issues and challenges in these evolving reimbursement models during a January 29, 2014 webinar, Accountable Care Reimbursement Models: Moving from Productivity to Population-Based Incentives, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 6:04 minutes