This document summarizes a presentation on population health management. It defines population health management as focusing on keeping patient populations as healthy as possible to reduce costly medical interventions. It identifies key aspects of population health management including defining targeted populations using data, establishing an effective governance structure, using technology to accomplish goals, and integrating care through community partnerships. The document provides examples of how organizations can implement population health management strategies.
Webinar: Transforming Operational Throughput – The Journey Toward Value-Based...Huron Consulting Group
At the 2014 Children’s Hospital Association Annual Leadership Conference, Huron Healthcare and Texas Children’s Hospital (TCH) presented an educational session on the journey toward value-based care.
In the presentation, Huron Healthcare managing director, Larry Burnett, TCH Senior Vice President, Tabitha Rice, and TCH Assistant Vice President of nursing, Jackie Ward, shared valuable insights from their work together at TCH. Focusing on insights and results from TCH’s engagement with Huron Healthcare, the presentation includes:
• Opportunities and results at TCH in areas including care management, care progression, patient placement, and care variation.
• Keys to driving results, successful change, and integrated care delivery
• Steps for a sustainable approach
Achieving Asset Optimization: A Strategic Approach To Aligning Assets With Mi...Huron Consulting Group
Huron Healthcare managing director Curt Whelan and Advisory Council member Jamie Orlikoff present new tools, processes, frameworks, and data points to enable healthcare executives to strategically align their assets to their mission and market needs. This resource, from the 2014 ACHE Congress on Healthcare Leadership, utilizes recent statistics and the presenters’ years of experience to advise on how to implement a strategic framework shift, leverage board support, and avoid asset rationalization in favor of asset optimization.
Wendy Jolley-Kabi, MPA, President & CEO, Global Health Action shares the results of a CCIH survey on CCIH member involvement in Health Systems Strengthening activities.
The University of Kansas, in an effort to find efficiencies and free up money to invest in academic programs, is undertaking 11 different change initiatives simultaneously. See a summary.
Webinar: Transforming Operational Throughput – The Journey Toward Value-Based...Huron Consulting Group
At the 2014 Children’s Hospital Association Annual Leadership Conference, Huron Healthcare and Texas Children’s Hospital (TCH) presented an educational session on the journey toward value-based care.
In the presentation, Huron Healthcare managing director, Larry Burnett, TCH Senior Vice President, Tabitha Rice, and TCH Assistant Vice President of nursing, Jackie Ward, shared valuable insights from their work together at TCH. Focusing on insights and results from TCH’s engagement with Huron Healthcare, the presentation includes:
• Opportunities and results at TCH in areas including care management, care progression, patient placement, and care variation.
• Keys to driving results, successful change, and integrated care delivery
• Steps for a sustainable approach
Achieving Asset Optimization: A Strategic Approach To Aligning Assets With Mi...Huron Consulting Group
Huron Healthcare managing director Curt Whelan and Advisory Council member Jamie Orlikoff present new tools, processes, frameworks, and data points to enable healthcare executives to strategically align their assets to their mission and market needs. This resource, from the 2014 ACHE Congress on Healthcare Leadership, utilizes recent statistics and the presenters’ years of experience to advise on how to implement a strategic framework shift, leverage board support, and avoid asset rationalization in favor of asset optimization.
Wendy Jolley-Kabi, MPA, President & CEO, Global Health Action shares the results of a CCIH survey on CCIH member involvement in Health Systems Strengthening activities.
The University of Kansas, in an effort to find efficiencies and free up money to invest in academic programs, is undertaking 11 different change initiatives simultaneously. See a summary.
Top 3 Strategic Initiatives for Sustainable Results in Healthcare in Middle EastSTELIOS PIGADIOTIS
This research paper offers insights in three areas:
1. Current Challenges in GCC/Middle East Healthcare sector
2. Future Drivers for Healthcare Excellence
3. Future Strategic Initiatives for Sustainable Results
Healthcare transition in GCC: Current Painful Realities & Proposed Strategic ...STELIOS PIGADIOTIS
Goals of research effort
1. Hands on analysis of GCC and specifically UAE healthcare market.
2. Proposed 2016 strategies for CEOs in GCC healthcare ecosystem
Evaluating the priority setting processes used across the Cochrane Collaborationmonalisa2n
A workshop in Cochrane Colloquium, Freiburg, Germany Oct 2008 on Ensuring relevance and building enthusiasm for Cochrane reviews:
determining appropriate methods for identifying priority topics for future Cochrane reviews
Introducing the Inclusion Scorecard for Population HealthImpact4Health, LLC
This presentation introduces a health equity playbook that can be adopted by healthcare systems eager to serve the needs of diverse communities through a systematic strategy that brings together key leaders across the hospital system. It will describe how the Inclusion Scorecard is structured, how it is implemented and provide examples of the different internal and community facing activities that need to be addressed. For a customized overview, see the last slide for additional contact information.
HFG Health Governance Presentation at 2015 USAID Global Health Mini-UniversityHFG Project
Presentation titled "Governance in the Third Dimension: Science Fiction or Science Fact," given by HFG at 2015 USAID Global Health Mini-University on March 2, 2015.
Session Description: Strengthening health governance can significantly improve the effectiveness and sustainability of reforms and, in turn, achieve better health system performance. Yet despite its importance, health governance investments are often overlooked. Health governance is frequently misunderstood by governments and the global health community, because governance in practice (vs. theory) is poorly defined and difficult to operationalize.
In this session, participants will learn how Haiti has defined and is addressing dimensions of governance for health financing and human resource reforms. Participants will apply these dimensions of health governance to work/activities that they are involved in, and consider how addressing these dimensions can strengthen health governance in their countries and enhance the impact of health financing, human resource, and service delivery reforms.
Meaningful Use and the Path to Population Health and Quality in a Transformin...Phytel
The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health management. Most physician practices will need supplemental information technology that automates the basic tasks of identifying, contacting, and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.
Population Health Management: Where are YOU?Phytel
This presentation explains how population health is fundamental to value-based delivery models, including key principles and definitions of PHM, as well as how to assess your organization’s “population health readiness.”
Top 3 Strategic Initiatives for Sustainable Results in Healthcare in Middle EastSTELIOS PIGADIOTIS
This research paper offers insights in three areas:
1. Current Challenges in GCC/Middle East Healthcare sector
2. Future Drivers for Healthcare Excellence
3. Future Strategic Initiatives for Sustainable Results
Healthcare transition in GCC: Current Painful Realities & Proposed Strategic ...STELIOS PIGADIOTIS
Goals of research effort
1. Hands on analysis of GCC and specifically UAE healthcare market.
2. Proposed 2016 strategies for CEOs in GCC healthcare ecosystem
Evaluating the priority setting processes used across the Cochrane Collaborationmonalisa2n
A workshop in Cochrane Colloquium, Freiburg, Germany Oct 2008 on Ensuring relevance and building enthusiasm for Cochrane reviews:
determining appropriate methods for identifying priority topics for future Cochrane reviews
Introducing the Inclusion Scorecard for Population HealthImpact4Health, LLC
This presentation introduces a health equity playbook that can be adopted by healthcare systems eager to serve the needs of diverse communities through a systematic strategy that brings together key leaders across the hospital system. It will describe how the Inclusion Scorecard is structured, how it is implemented and provide examples of the different internal and community facing activities that need to be addressed. For a customized overview, see the last slide for additional contact information.
HFG Health Governance Presentation at 2015 USAID Global Health Mini-UniversityHFG Project
Presentation titled "Governance in the Third Dimension: Science Fiction or Science Fact," given by HFG at 2015 USAID Global Health Mini-University on March 2, 2015.
Session Description: Strengthening health governance can significantly improve the effectiveness and sustainability of reforms and, in turn, achieve better health system performance. Yet despite its importance, health governance investments are often overlooked. Health governance is frequently misunderstood by governments and the global health community, because governance in practice (vs. theory) is poorly defined and difficult to operationalize.
In this session, participants will learn how Haiti has defined and is addressing dimensions of governance for health financing and human resource reforms. Participants will apply these dimensions of health governance to work/activities that they are involved in, and consider how addressing these dimensions can strengthen health governance in their countries and enhance the impact of health financing, human resource, and service delivery reforms.
Meaningful Use and the Path to Population Health and Quality in a Transformin...Phytel
The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health management. Most physician practices will need supplemental information technology that automates the basic tasks of identifying, contacting, and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.
Population Health Management: Where are YOU?Phytel
This presentation explains how population health is fundamental to value-based delivery models, including key principles and definitions of PHM, as well as how to assess your organization’s “population health readiness.”
New Technologies Are Required To Automate Expanded Physician Workflow. To create a sustainable healthcare system that provides affordable, high-quality healthcare to all, we will have to adopt a population health management (PHM) approach. While the transition to PHM will be difficult for providers and patients alike, the change could be facilitated and accelerated through the use of health information technology, self management tools, and automated reminders that are persistent in changing behaviors.
The patient-centered medical home (PCMH), an approach designed to rebuild primary care and improve care coordination, has become a major focus of healthcare reform. Thousands of physicians are already participating in medical home pilot projects across the country. Now is the time for practices to investigate the information technology tools that will help them medical home certification requirements.
Provider Based Patient Engagement - An Essential Strategy for Population HealthPhytel
As the healthcare industry starts to re-engineer care delivery to accommodate new reimbursement models, providers on the front lines of change recognize the need for population health management and for increasing patients’ engagement in their own care. These two approaches are inextricably bound together, because it is impossible to manage the health of a population without getting patients more involved in self-management and the modification of their own risk factors. This paper discusses the fundamentals of patient engagement and shows how automation tools and web-based care management can facilitate this key process.
Scaling the PCMH Delivery Model with AutomationPhytel
The patient-centered medical home continues to make progress. Much remains to be learned about the most effective techniques for building and maintaining a PCMH. But three conclusions can already be drawn from the pilots that have already been done:
1) Successful medical homes will have to perform population health management;
2) They will need a variety of health IT tools to do that and to coordinate care effectively; and
3) They will have to gain the cooperation of the other providers in their medical neighborhoods.
Major changes in practice workflow and work roles must accompany the proper use of information technology. In the end, practices must be completely reengineered to provide effective, patient-centered medical homes—and the environment in which they operate must also change to permit seamless care coordination. But all of this change can be less painful and lead to more productive results if practices use the right combination of technologies to scale population health management.
In January 2013, Catholic Health Initiatives began a multi-phase journey to develop a population health management solution across all of its regions. This presentation will describe the strategies the health system pursued for: creating a clinically integrated network as a first step in managing the health of populations and integrating care across the patient experience; aligning hospitals and physician groups to create successful clinical models; creating a data platform to share clinical measures and benchmarks; and ultimately becoming a risk-bearing shared savings ACO. Participants will hear real-world examples of best practices for how to meet FTC regulations, create an effective governance structure to manage performance, and align financial incentives. Learn how one of the nation's largest hospital systems developed a system-wide population health management solution in order to achieve the necessary transformation from fee-for-service to fee-for-value.
Accountable Care Organizations and The Medicare Shared Savings ProgramPhytel
Population Health Management, Enabled by Information Technology, Will Be Critical To Success. In 2012, the Centers for Medicare and Medicaid Services (CMS) will launch a shared-savings program with accountable care organizations (ACOs). ACOs that meet specified quality goals will be able to split with CMS any savings that surpass a minimum level. The challenge facing ACOs is choosing the right information technologies so they can track the health status of and the care provided to every one of their patients to produce significant savings or meet the quality benchmarks of CMS
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
CFO Strategies for Balancing Fee-for-Service and ValuePhytel
Moving from fee-for-service to value-based care is not easy. However, leading health systems are all following a similar blueprint that enables the move to value-based care.
Download this whitepaper to learn how:
- Bon Secours Richmond - Closed 75,801 gaps in care within 12 months, generating $7 million in revenue for chronic & preventive care, while improving quality.
- Northeast Georgia Medical Center - Decreased HbA1C levels across uncontrolled diabetes by an average of 1.6 points within 120 days.
- Riverside Medical Center - Reduced unnecessary readmissions by 40% by using automation to reach and assess patients post discharge.
- Prevea Health - Increased care management productivity by 150% by automatically identifying high risk patients, and automating patient engagement.
Gain insights from data analytics and take action! Learn why everyone is making a big deal about big data in healthcare and how data analytics creates action.
Population Health Approach for Diabetic Patients with Poor A1c ControlPhytel
New clinical research from The American Journal of Managed Care is available on the benefits of a population health approach for diabetes care. The peer-reviewed findings underline the importance of proactive health management for all patients, not just those with already high A1c levels.
Patient Centered Medical Homes are providing a pathway for healthcare delivery organizations pursuing value-based initiatives. As reimbursement models continue to transition at an accelerated pace, PCMH practices are well-positioned to achieve clinical targets and qualify for the associated financial incentives.
CHernandez DNP Essentials & Organization Systems Leadership.pptxCamilleHernandez24
A history of the DNP Essentials and leadership responsibilities, addressing the role in cost containment, DNP practice roles related to finance related Competency II (AACN, 2006).
Describes how the DNP improves nursing practice through communication and interprofessional collaboration.
Identifies the fiscal responsibility of the professional practice and the ability to impact global practice
Practical considerations in enabling new models of care, pop up uni, 10am, 3 ...NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
As new payment models emerge that emphasize value over volume, providers are being compelled to look more closely at how to motivate patients—especially those with multiple chronic conditions—to actively manage their care, make better decisions and change behaviors. This editorial webinar will explore the relationships between engagement and improved health outcomes, greater patient satisfaction and better resource utilization. Our panel of experts will share proven strategies for building patients' confidence, disseminating self-management tools and making the best use of your care team.
Best Practices for Enabling HIE and Incorporating Capabilities into EHR Workf...Justin Campbell
Health Information Exchange (HIE) allows health care providers to access and share a patient’s medical information securely and electronically, providing a unified view of patient data across health care organizations. HIE enhances clinicians’ workflow and their ability to connect, coordinate, and collaborate on patient care quickly and easily. However, health care organizations frequently struggle with last-mile connectivity from their clinical system of record to the receiving system and incorporating HIE capabilities into EHR workflows. This session will provide a framework for successful HIE onboarding including data access, conformance testing & validation, as well as share strategies for implementing HIE capabilities at the point of care. This session will also introduce the concept of Patient Centered Data Home and illustrate how the exchange of information utilizing the PCDH model is a cost-effective, scalable solution to assuring real-time clinical data is available whenever and wherever care occurs to improve the quality of care.
2017 Physician Strategies Webinar Series - Physician Relations StructureEndeavor Management
Acquire insight into how to develop a more strategic and operational approach that can grow your organization’s physician referral base in a continually evolving accountable care environment.
Planning, Launching, and Sustaining Accreditation-worthy Postgraduate NP Resi...CHC Connecticut
Planning, Launching, and Sustaining Accreditation-worthy Postgraduate NP Residency Training Programs
Presented by CHC. Inc. and the Weitzman Institute
January 9, 2019 3:00pm (EST)
Planning, Launching, and Sustaining Accreditation-worthy Postgraduate NP Resi...CHC Connecticut
Planning, Launching, and Sustaining Accreditation-worthy Postgraduate NP Residency Training Programs
Presented by CHC. Inc. and the Weitzman Institute
January 9, 2019 3:00pm (EST)
The HIMSS mHealth Physician Task Force's How-to-Guide will help both clinicians and C-suite executives identify which mobile tools are needed and worth investing in.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
Network physicians, hospitals, and other care continuum providers work collaboratively in active clinical process improvement programs across service lines and specialties to define, establish, implement, monitor, evaluate and periodically update the processes of:
- Evidence-based medicine
- Beneficiary engagement
- Care coordination
- Conservation of healthcare resources
- Clinical data reporting
As members of the body of Christ, what is our role in fostering collaboration to increase patient access and higher quality care? Barbara Campbell, RPh, CCN, Executive Director, ReLink Global Health-The Dalton Foundation explores the experiences of establishing the Haiti Health Network, a collaboration of more than 500 healthcare providers.
North highland himss_hardwiringclinicalfinancialperformance_041315North Highland
North Highland's Ricardo Martinez and Donna Houlne's presentation on "Hardwiring Clinical and Financial Performance Through Patient-Centered, Physician-Directed Transformation"
NHS Improving Quality was invited to take part in a recently held event that celebrated the work that is being done in partnership between the Pennine Acute Hospitals NHS Trust and AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP).
Gillian Phazey, Learning and Organisational Development Manager at Pennine Acute Hospitals NHS Trust explains:
'The Learning and Organisational Development and Governance teams at the Pennine Acute Hospitals NHS Trust have been working collaboratively with AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP) to support staff in developing knowledge and skills in this topic. The programme has been specifically designed to support colleagues wanting to gain an introduction to the fundamentals and concepts of quality improvement. So far, two cohorts of staff, from clinical and non-clinical areas of the Trust have completed the programme, and have completed quality improvement projects in their own work area to apply their knowledge. On 17th July a celebration event was held for cohort 2 where staff presented their work in poster or presentation form, the aim of which is to share and spread learning across the Trust. Projects were wide ranging, from introducing new processes to reduce complaints and drug errors, to improving patient experience by implementing new tools and techniques. The day was a great success with the Chief Executive and Chief Nurse in attendance. The Trust is highly supportive of this approach in equipping staff with these important techniques, and the programme supports not only our internal quality agenda and objectives, but more widely responds to the recommendations of the Berwick report. The next cohort is starting in September this year.'
Fiona Thow, Patient Safety Collaborative Delivery Lead at NHS Improving Quality delivered a keynote speech, (link to presentation slides) providing a national perspective on the plans for improving patient safety and took the opportunity to introduce the national safety collaboratives. She also highlighted the need for organisations and individuals to think differently about safety for both patients and staff.
1. 1.800.4BEACON │ BeaconPartners.com
BOSTON · CLEVELAND · SAN FRANCISCO · TORONTO
Thank You
Presented by:
Wendy Vincent, National Practice Director, Strategic Advisory Services
HFMA Dixie Institute
February 19, 2015
Population Health Management:
What it Means For You and Your
Organization
2. Heading – Ariel 40
Define Population Health Management
Identify targeted populations
Create effective governance structure
Use technology to accomplish goals
Establish realistic benchmarks
Integrate care approach through
community partnerships
2
Objectives
4. Storm Factors
Affordable Care Act: As of April 2014 – 8 Million Americans have
signed up for healthcare, shocking the system as they present to
PCP’s1
Rapid Baby Boomers, everyday 10,000 people turn 65
Reduction in Primary Care Physicians
Increase in prescription drugs, contributing to higher costs and more
advanced treatments resulting in longer life expectancy
1) Familiar Physician, Dr. Peter Jackson
5. Heading – Ariel 40Top Concerns of Health Care Systems
5
1. What is the business model for population health?
2. Have I assembled the right network components?
3. Do we understand our patients as consumers?
4. What investments can we can make to help us with both
fee-for-service and value-based incentives?
http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/At-the-Helm/2014/05/Four-challenges-every-leadership-team-is-talking-
about?WT.mc_id=Email|Daily+Briefing|Blog|HCAB|Jul-14-2014|||||
6. Why Is It So Important Now?
Healthcare Payment Reform
• End of fee for service
• Value-based purchasing
• ACOs and PCMHs
Reporting On Clinical Quality Is Retrospective
Care Coordination – what do we need to do right now to produce the
best outcome for a single, particular patient
Population Health – focuses on the future, what can we and should we
do in the future to produce better outcomes, higher quality and lower
costs
Technology
• Broad EHR adoption
• mHealth
• Analytical tools
8. Heading – Ariel 40Population Health
8
“The use of a variety of
individual, organizational and
cultural interventions to help
improve the illness and injury
burden and the health care use
behavior of defined populations.”
Dr. Michael Hillman,
Marshfield Clinic
“The health outcomes of a group
of individuals, including the
distribution of such outcomes
within the group”
American Journal of Public Health
9. Heading – Ariel 40PHM Defined
9
Population Health describes the health outcomes of a group of
individuals, including the distribution of such outcomes within the
group. Population health outcomes are the product of multiple
determinants of health, including medical care, public health,
genetics, behaviors, social factors, and environmental factors.
Goal: Keep patient population as healthy as possible and reduce the
need for costly interventions such as ED visits, hospitalizations,
imagine tests, and procedures.
To support PCMH & ACOs, many organizations will need to start
implementing PHM to keep patient population healthier and reduce
costs.
11. Heading – Ariel 40Patient Centered Medical Home
Engaged leadership
Quality improvement strategy
Empanelment
Patient-centered interactions
Organized, evidence-based
care
Care coordination
Enhanced access
Continuous, team-based
health relationships
12. ACOs
• Healthcare organizations are formulating
Clinically Integrated Networks (CINs)
• Network of Providers belong to ACO
• Physician metrics/scorecards are established
• Targets/Projections/Actuals – Shared Savings
• Population Health Management Systems are on
the rise for real time data
13. ACOs
Complete & timely information about their patients and the
services they are receiving
Technology and skills for population management and
coordination of care
Adequate resources for patient education and self
management
A culture of teamwork
Coordinated relationships with specialists and other providers
Ability to measure and report on the quality of care
Infrastructure skills for the management of financial risk
Commitment by leadership to improving value as a top priority
16. Challenges to Overcome
Technology Alignment with Business:
• Are we collecting the right data?
• Once we get it, what does it mean?
• How can we effectively use data?
Organizational Strategy:
• My organization doesn’t have a clear strategy
• Our areas are like silos with their own information
Process Changes:
• Each department has their own plan; roles and process
changes are needed towards a new optimal state but where do
we start?
Lower costs:
• How can overall costs for defined Populations be reduced?
18. Heading – Ariel 40Identifying Targeted Populations
18
What’s the best way to use our resources?
• Identify high risk
Readmissions
Repeat ED visits
LOS
• Specific diagnoses
Diabetes
Congestive heart failure
High blood pressure
Asthma
• Geographic/population areas
• Community Health Needs Assessment
22. Heading – Ariel 40Organizational Considerations
22
What are your resources across the continuum of care?
• Case managers
• Transition of care program
• DSRIP efforts
• PCMH development
• Care coordination
• Community resources
24. Heading – Ariel 40Governance Key to Success
24
Leadership endorsement of new staffing models and roles
Define specific roles and responsibilities
How will you
communicate
efforts?
How will you
ensure care and
resources are
centered around
the patient?
How will you
involve the
community?
How will you
integrate efforts
into the continuum
of care?
25. Heading – Ariel 40Key Considerations
25
Who will review and analyze data?
Avoid redundancy and overlapping efforts
Avoid silos
What committees do you already
have in place?
• Quality committee
• Ambulatory care committees
• Policy and procedure committees
• Credentialing committees
What has or hasn’t worked well in the past?
27. Heading – Ariel 40Effectively Using Technology
27
Automate workflows for appropriate utilization of
resources
Connect care team in coordinating patient care
HIE
Communicate via a portal
• Patients
• Physicians
• Affiliates and community resources
Track and report data in timely manner
Use appropriate metrics to evaluate the program
29. Heading – Ariel 40Primary Care
29
Registry member
Portal for EMR management
Push alerts for recalls and
immunizations or upcoming
needs for blood testing
Self-scheduling online
Diabetes management
30. Heading – Ariel 40Care Management/Coordination
30 Screenshot from Caradigm Care Management Tool
31. Heading – Ariel 40Care Gaps
31
Screenshot from Caradigm Care Management Module
33. Heading – Ariel 40Establishing Benchmarks
33
Gather data
• EMR
• Claims data
Input critical
• Staff
• Patients
• Providers
Evaluation techniques
• Timely data
• LACE index
• PHM tool
Set realistic targets
Where are you NOW
compared to your
benchmarks?
38. Heading – Ariel 40Key Takeaways
38
Develop PHM strategy and program
Use data to define your populations (internal and external)
Ensure your strategy aligns with organizational goals
Create a governance structure to drive change and
accountability (new roles)
Engage in Risk Model Programs (ACOs and MSSPs)
Develop care coordination programs through new optimal
workflows (Re-admission programs, PCMHs)
Use technology to automate processes
Create an outreach approach to integrate care throughout
the community
40. Heading – Ariel 40Questions?
40
Wendy Vincent, RN, is an accomplished healthcare executive with 30 years of
professional experience across all areas of healthcare. She has served in both
executive and senior leadership positions with academic medical centers and large
Integrated Delivery Networks. Wendy understands the unique opportunities and
challenges associated with optimizing people, process, and technology. She has
been successful with helping organizations identify areas to improve care quality,
increase operational efficiencies, and optimize revenue. Wendy is a strategic thinker
and planner with strong problem-solving and organizational skills. She is accustomed
to building relationships at all levels of leadership and staff. She holds a Bachelor of
Science in Nursing with graduate work in Nursing Education. She is actively involved
in nursing, clinical, and IT professional societies.
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BOSTON · CLEVELAND · SAN FRANCISCO · TORONTO
Thank You
For more information
please contact
Thank You
wendy.vincent@BeaconPartners.com
Wendy Vincent
Editor's Notes
Chart 2: Total Accountable Care Organizations by Sponsoring Entity; Source: Leavitt Partners Center for Accountable Care Intelligence
http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/