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

MACRA for Small Physician Practices: Don’t Let the Technology Intimidate You

Eric LevinRather than threatening to drop Medicare volumes or open a concierge practice, small and solo physician practices daunted by MACRA technology requirements should sit tight and avail themselves of current and promised education and training from CMS to support the transition, advises Eric Levin, director of strategic services, McKesson.

In this audio interview, Levin describes what’s at risk for practices that don’t engage in at least one physician reporting program and four benefits of tapping into MACRA technical assistance from CMS.

During a July 2016 webinar, The New Physician Quality Reporting: Positioning Your Practice for MACRA’s Merit-Based Incentive Program, now available for replay, Levin offers a brief MACRA overview and outlines 2016 focus areas for practices to help them avoid reimbursement penalties in 2017 based on the proposed rule.


Length: 4:00 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

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

Horizon BCBSNJ Episodes of Care: No-Risk Retrospective Model Paves Way for Value-Based Migration

Lili BrillsteinWhile it does not immediately eliminate fee for service, a retrospective upside-only payment model is helping to transform the spirit of the payor-provider relationship, notes Lili Brillstein, director of the Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) Episodes of Care (EOC) initiative where this methodology has been implemented.

Listen as Ms. Brillstein describes how Horizon’s application of retrospective methodology across all episodes expands the program’s reach and opportunities while fostering a no-risk environment conducive to collaboration.

During a March 2016 webinar, Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship, now available for replay, Ms. Brillstein shares details behind the health plan’s EOC program, from the episodes they have bundled to goals and results from the program.


Length: 4:12 minutes

Hearst Health Prize Winner CCNC: Care Transition Management Not ‘One-Size-Fits-All’

Carlos JacksonCommunity Care of North Carolina’s Transitional Care program was awarded the Hearst Health Prize this month not only for demonstrating how effective transitional care is for its 1.5 million Medicaid beneficiaries, but also for continually evaluating and modifying the intervention based on its findings.

In this broadcast, Carlos Jackson, CCNC’s director of program evaluation, shares one of CCNC’s more interesting findings, identifying the priority population for the intervention, and explains why the care transition management mindset must expand beyond reducing hospital readmissions.

During a March 2016 webinar, Measuring and Evaluating the Impact of Home Visits for Clinically Complex Patients, now available for replay, Carlos Jackson shares the details behind CCNC’s home visits program, a key aspect of the care transitions program, from how individuals are identified for the intervention to the impact it has on key performance metrics.


Length: 3:23 minutes

Novant Health Pharmacist Drug Therapy Management: Ideas to Assure Accurate Medication Lists

Novant HealthAn accurate medication list is square one for clinical pharmacists working to reconcile prescriptions and reduce readmissions among Novant Health’s highest-risk patients, explains Rebecca Bean, director of population health pharmacy for Novant Health. But maintaining a valid list can be problematic when the inventory is accessed by multiple healthcare providers.

Ms. Bean describes the challenges of maintaining an accurate medication list and suggests strategies for ensuring medication list integrity in this audio interview.

During a February 2016 webinar, Medication Management: Using Clinical Pharmacists to Complete Comprehensive Drug Therapy Management Post-Discharge in High-Risk Patients, now available for replay, Rebecca Bean shares her organization’s medication management approach and why a clinical pharmacist is key to the program’s success.


Length: 3:00 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