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Understanding Population Health Management: A Diabetes Example

Michael Barton

Patient Safety Operations, SVP

Diabetes is one of several chronic health conditions at the root of U.S. healthcare challenges. To improve the quality of care and costs associated with diabetes, health systems, clinicians, and patients can benefit from taking a data-centric approach to diabetes management and leveraging population health tools.Managing individual cases of diabetes require actively involving patients in their care plan, enabling each patient to monitor and understand key data, such as A1c readings, and adjust lifestyle or other factors affecting overall health. Managing diabetes across larger populations, however, is best done through the use of a data and analytics platform that can aggregate data from multiple sources and provide actionable insights. Specifically, a data platform can identify patients who aren’t up to date on tests and those at high risk for other complications, uncover variations in diabetes care across an organization, and more.

The Right Way to Build Predictive Models for the Most Vulnerable Patient Populations

Predictive artificial intelligence (AI) models can help health systems manage population health initiatives by identifying the organization’s most vulnerable patient populations. With these patients identified, organizations can perform outreach and interventions to maximize the quality of patient care and further enhance the AI model's effectiveness.The most successful models leverage a mix of technology, data, and human intervention. However, assembling the appropriate resources can be challenging. Barriers include multiple technology solutions that don’t share information, hundreds of possible, often disparate, data points, and the need to appropriately allocate resources and plan the correct interventions. When it comes to predictive AI for population health, simple models may harness the most predictive power, which allows for more informed risk stratification and identifies opportunities for patient engagement.

The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement

Bobbi Brown, MBA

Senior Vice President

Jared Crapo

Senior Vice President, Integration

The shift from fee-for-service to value-based reimbursements has good and bad consequences for healthcare. While the shift will ultimately help health systems provide higher quality lower cost care, the transition may be financially disastrous for some. In addition, the shifting revenue mix from commercial payers to Medicare and Medicaid is creating its own set of challenges. There are, however, three keys to surviving the transition: 1) Effectively manage shared savings programs to maximize reimbursement. 2) Improve operating costs. 3) Increase patient volumes. With an analytics foundation, health systems will be able to meet and survive today’s healthcare challenges.

10 Motivational Interviewing Strategies for Deeper Patient Engagement in Care Management

KimSu Marder, RN, CCM

Lead Care Manager

Care management programs are most successful when patients are deeply engaged in their own care. Using the motivational interviewing technique, care managers work with patients to identify personal care goals and motivators to follow the care management program.Ten strategies guide the motivational interviewing process, each focusing on patient-centered insights (e.g., pros and cons to following care management and barriers to adherence). With mobile technology to support these interactions, motivational interviewing can become a seamless, and vital, part of the care management workflow.

Measuring the Value of Care Management: Five Tools to Show Impact

Kathleen Clary, BSN, MSN, DNP

Vice President of Care Management & Patient Engagement

To earn legitimacy and resources within a healthcare organization, care management programs need objective, data-driven ways to demonstrate their success. The value of care management isn’t always obvious; while these programs may, in fact, be responsible for improvements in critical metrics, such as reducing readmissions, C-suite leaders need visibility into care management’s impact and processes to understand precisely how they’re improving care and lowering costs at their organizations.Five analytics-driven technologies give healthcare leaders a comprehensive understanding of care management performance:1. The Patient Stratification Application2. The Patient Intake Tool3. The Care Coordination Application4. The Care Companion Application5. The Care Team Insights Tool

Four Population Health Management Strategies that Help Organizations Improve Outcomes

Holly Rimmasch

Chief Clinical Officer

Population health management (PHM) strategies help organizations achieve sustainable outcomes improvement by guiding transformation across the continuum of care, versus focusing improvement resources on limited populations and acute care. Because population health comprises the complete picture of individual and population health (health behaviors, clinical care social and economic factors, and the physical environment), health systems can use PHM strategies to ensure that improvement initiatives comprehensively impact healthcare delivery.Organizations can leverage four PHM strategies to achieve sustainable improvement:1. Data transformation2. Analytic transformation3. Payment transformation4. Care transformation

Care Management Analytics: Six Ways Data Drives Program Success

KimSu Marder, RN, CCM

Lead Care Manager

To succeed in improving outcomes and lowering costs, care management leaders must begin by selecting the patients most likely to benefit from their programs. To identify the right high-risk and rising-risk patients, care managers need data from across the continuum of care and tools to help them access that knowledge when they need it.Analytics-driven technology helps care managers identify patients for their programs and manage their care to improve outcomes and lower costs in six key ways:1. Identifies rising-risk patients.2. Uses a specific social determinant assessment to capture factors beyond claims data.3. Integrates EMR data to achieve quality measures.4. Identifies patients for palliative or hospice care.5. Identifies patients with chronic conditions.6. Increases patient engagement.

Identifying Vulnerable Patients and Why They Matter

KimSu Marder, RN, CCM

Lead Care Manager

The vulnerable individuals in a health system’s patient population are at risk of becoming some of the organization’s most complex and costly members. Because vulnerability can be determined by long-term health status and social determinants of health (versus acute episodes), managing risk for these patients relies on a whole-person approach to care. Fee-for-service reimbursement hasn’t incentivized this comprehensive approach to care, but, under value-based payment models, health systems are increasingly rewarded for care that keeps patients well.The first challenge in addressing the needs of vulnerable patients is identifying those patients. Analytics-driven technologies can help health systems understand who is vulnerable in their populations and take actions to control risk for these patients.

The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care

Will Caldwell, MD, MBA

Senior Vice President and Executive Advisor

Medicare patients make up the majority of health systems’ revenue; yet, organizations earn only a one percent profit while caring for this population. Despite historically low profit margins, Medicare can be lucrative for health systems, and through the Medicare Shared Savings Program, healthcare organizations can increase revenue with four tools:1. The ability to aggregate and analyze data.2. The ability to align financial incentives between payers and providers.3. The ability to engage patients in behavior or lifestyle modifications.4. The ability to garner support from clinicians and encourage them to lead the shift to VBC.As the shift from fee-for-service to value-based care continues, health systems can leverage MSSP to deliver the highest level of care while also increasing profit margins.

Value-Based Care: Four Key Competencies for Success

Jonas Varnum

Population Health Management Consultant

How prepared are healthcare organizations to enter into value-based care? Many may not be ready. While early value-based care adopters have focused on improving and measuring quality, they’ve often overlooked steps to bear the associated financial risk. Now that health systems can enter into alternative payment models and risk-based contracts, they need to ensure that cost is as much a priority as quality.Health systems can achieve sustainable value-based care success by optimizing the five core competencies of population health management:1. Governance that educates, engages, and energizes.2. Data transformation that addresses clinical, financial, and operational questions.3. Analytic transformation that aligns information and identifies populations.4. Payment transformation that drives long-term sustainability.5. Care transformation as a key intervention in value-based contracts.