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

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

Healthcare Trends & Forecasts in 2014: Expect Surge in Commercial ACOs to Continue

Despite the migration of some Pioneer ACOs to CMS’s Medicare Shared Savings Program (MSSP), expect the surge in commercial accountable care organizations to continue in 2014, predicts Steven Valentine, president, The Camden Group. In this audio interview, Valentine suggests improvements to patient handoffs, an area in which ACOs have disappointed, in Valentine’s view, as well as expectations for the other much-modeled care delivery platform, the patient-centered medical home (PCMH).

In both the ACO and the PCMH, Valentine anticipates specialists will be critical parts of the solution, especially when it comes to emerging payment models, quality and performance.

Steven Valentine and Catherine Sreckovich, managing director, healthcare, Navigant, provided a roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2014 during an October 30, 2013 webinar, Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.


Length: 8:13 minutes

Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community

There’s education, there’s experience, and then there’s the ‘right stuff’ — the indefinable personality traits that earmark an individual as a change agent, collaborator and ambassador of case management, says Annette Watson, senior vice president of community transformation for Taconic IPA (TIPA), of TIPA’s requirements for the RN case managers it hires for its advanced patient-centered medical homes.

Then there are the not insignificant contributions of the RN case manager to accountable and patient-centered care, which Ms. Watson describes in this interview.

While staff-buy-in and communication continue to challenge the embedded case manager model, the participant in CMS Innovation Center’s Comprehensive Primary Care (CPC) initiative says reimbursement for embedded case management is less of an obstacle today than in the past, due to funding-friendly care models and pilots descending from healthcare reform.

Ms. Watson shared how TIPA has successfully embedded case managers in an open, multi-payor community during an October 9, 2013 webinar, Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community.


Length: 8:36 minutes

Performance Quality Measurement and Reporting for Accountable Care

When tracked within its electronic medical record, key interventions like transitional care coaching and an expanded Patient Health Questionnaire not only improve the care provided to John C. Lincoln ACO’s population but provide a clearer picture of the accountable care organization’s performance, note Karen Furbush, business consultant, and Heather Jelonek, chief operating officer of the John C. Lincoln Network ACO.

Additionally, the ACO’s Physician Advisory Network, made up of its leading physicians, tracks patterns and trends within the ACO and helps the care team to adhere to best practices in evidence-based medicine. Monthly webinars with the physician advisory network and its EMR specialists provide opportunities for evaluation and training in these best practices.
Karen Furbush and Heather Jelonek shared how the John C. Lincoln Network ACO has modified its reporting process, from workflow changes to customizations within its EMR to improve performance results during a July 17, 2013 webinar, Performance Quality Measurement and Reporting for Accountable Care, a 45-minute program sponsored by The Healthcare Intelligence Network.

Karen Furbush and Heather Jelonek



Length: 8:40 minutes