How Texas Children’s Turned Child Diabetes Management into a Community Cause

Patients with diabetes are at a high risk for infections and substantial complications, including the risk of death from infections. Further, social determinants in these patients’ communities have a tremendous influence on their health.

Texas Children’s Hospital, ranked as one of the top four Best Children’s Hospitals by U.S. News & World Report, recognized that there were gaps in diabetes care coordination in the community—where the majority of a child’s diabetes management takes place. The hospital initiated a coordinated community response, aided with an analytics platform, which is setting the standard for community management of pediatric diabetes.

Results

  • 4 percent relative improvement in the percentage of patients with diabetes who received the influenza vaccine.
  • 3 percent relative improvement in pediatric provider diabetes knowledge.
  • 90 percent of patients now have individualized school packets developed and available in the EHR.
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Improving Population Health for Children with Diabetes

Diabetes is the most common chronic illness for children living in developed countries. Leaders at Texas Children’s Hospital wanted to take a more data-driven approach to population health management for children with diabetes. They created a Care Process Team (CPT) to pursue outcomes improvements related to diabetic ketoacidosis (DKA) since data from the EDW revealed that 64% of diabetes patients discharged had this life-threatening condition.

After the CPT achieved their initial goal of improving care for patients admitted to the hospital with DKA, they set out to implement larger improvements that would benefit the entire population of diabetes patients.

By empowering CPT members, leveraging data to drive decisions, and implementing new interventions effectively, the Diabetes CPT members have improved population health for patients with diabetes across all settings of care. Below are a few of the most significant results.

  • 44 percent relative decrease in LOS for patients with DKA.
  • 30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
  • 34.4 percent relative improvement in the percentage of patients with diabetes who receive the influenza vaccine.
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Improving Diabetic Care in the Ambulatory Environment

Diabetes is the most common life-threatening, chronic illness in children who live in developed countries. With effective management of diabetes, children with diabetes can live long, healthy, and active lives.

Texas Children’s Hospital believes that diabetes patients and their families are most successful in managing their disease if they receive standardized, family-centered, multidisciplinary care in both inpatient and outpatient settings.

Texas Children’s created a new Clinic Care Process Team (CPT) which developed a comprehensive approach to standardizing diabetes care by automating best practice alerts that help clinicians recognize the need for testing, so they order labs more quickly.

Within one month of implementation Texas Children’s saw measurable improvements:

  • Screening percentages for each test improved to >80 percent.
  • 28.2 percent relative improvement in the percentage of patients receiving recommended annual thyroid-stimulating hormone (TSH) testing, with current performance greater than 90 percent.
  • 23 percent relative improvement in the percentage of patients receiving recommended annual lipid testing, with current performance greater than 90 percent.
  • 54.1 percent relative improvement in the percentage of patients receiving annual retinal examinations, with current performance at 94 percent.
  • Patient satisfaction is on an upward trend.
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Care Management: A Critical Component of Effective Population Health Management

Unprecedented changes in the healthcare payment system have resulted in health organizations across the country investing in the pursuit of the Institute for Healthcare Improvement’s (IHI’s) Triple Aim to improve population health, improve patient experience and outcomes, and reduce costs per capita. Health organizations must develop effective population health management strategies, and they need the right data and analytics to inform their initiatives.

Once armed with the information to make data-driven decisions, leading healthcare providers are implementing care management programs, which have proven to be helpful mechanisms for achieving the Triple Aim. Many healthcare organizations have identified specific patient cohorts to monitor the impact of care management interventions on individual and population health outcomes.

Data-driven care management programs that target high-risk and rising-risk patients can achieve impressive results, including:

  • Up to 20 percent lower rates of hospitalization in mature care management programs.
  • Lower rates of emergency department utilization.
  • Decreased costs.
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Developing a Multilevel Approach to Improving Population Health

Heart attacks are the leading cause of death for both men and women in the United States, yet heart attacks are largely preventable through healthier lifestyles. Spurred on by this knowledge, New Ulm Medical Center, the Minneapolis Heart Institute Foundation, and the rural community of New Ulm, Minnesota, teamed up to create Hearts Beat Back: The Heart of New Ulm (HONU) Project. This population-based prevention demonstration project aims to reduce the number of heart attacks and heart disease risk factors among the New Ulm population.

Recognizing the complex web of personal, institutional, and societal factors that influence an individual’s heart-health behaviors, HONU leaders implemented a multilevel strategy spanning 10 years to improve the health of the entire population.

The HONU Project’s multilevel, data-driven approach has resulted in substantial changes in improving population health in New Ulm:

  • Significant improvements in blood pressure and cholesterol at the population level.
    • 86 percent of residents now have blood pressure within the recommended range.
    • 72 percent have LDL cholesterol within the recommended range.
  • Improvements are greater than changes seen in the national comparison population.

 

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How an IDS Standardized Care for Women While Increasing Market Share

One in three pregnant women give birth via cesarean section in the United States, which is more than double the rate the World Health Organization (WHO) recommends. And instead of decreasing, the overall C-section rate in Washington State increased 73 percent from 1996 to 2009. C-section rates are just one area of maternal care where our practice in the U.S. lags behind the science and knowledge of best practice. MultiCare Health System believes that all of its female patients should experience the same high-quality care across its integrated delivery system. The health of the next generation depends on it.

MultiCare recognized that it had to standardize care across its system to meet quality standards, improve its patients’ experiences and outcomes, and maintain its market share. The health system launched a Women’s Collaborative, the sole purpose of which was to improve clinical care and patient outcomes for women’s services systemwide.

By working with clinicians to implement standards of care, and using analytics to measure performance, the Women’s Collaborative achieved the following:

  • NTSV (low-risk, rst-time mother) C-section rate 9 percent less than the national average and already below the 2022 national goal of 23.9 percent
  • Six-point increase in market share for inpatient OB/GYN services
  • Improvements in care delivery:
    • 63 percent reduction in episiotomy rate
    • 
11 percent reduction in SSI rate for C-sections
    • 14 percent reduction in 3rd or 4th degree perineal laceration rate
    • Non medically indicated induction rate consistently less than a quarter of one percent
    • 6.7 percent reduction in the percentage of abdominal hysterectomies
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A Care Model to Support the Needs of Medically Complex Patients

People with disabilities face daunting challenges in accessing basic healthcare. As a result, they frequently use hospitals and emergency rooms, and are four times as likely to be hospitalized compared to the general population.

Allina Health has deployed an effective “primary care medical home” model that gives patients with disabilities the care and support they need outside of the hospital setting. Key strategies of the model include assigning dedicated care coordinators to each patient; strengthening care coordination across the continuum of services; and an analytics platform from Health Catalyst to target opportunities for improvements and savings.

Allina’s data-driven efforts to strengthen care of patients with disabilities have made a clear and meaningful impact; most importantly, on patient outcomes. They have achieved: 30% reduction in hospitalizations and 66% reduction in hospitalization days; 79% reduction in 30-day readmissions days; significantly improved access to care; and saved $4.5 million over a one-year period.

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Calculating the ROI of Diabetes Care Improvement

Texas Children’s Hospital has dedicated itself not only to successfully improving diabetes mellitus (DM) outcomes, but also to developing a framework for measuring the ROI of its performance improvement efforts. Texas Children’s tackled its DM initiative with a combination of technology investments and new organizational models, including an enterprise data warehouse (EDW) and analytics platform, a clinical care process team model for improving the quality and cost of care, and a diabetic care unit (DCU) staffed by a highly specialized, highly trained group of providers. Health system leaders also worked with the business school at Rice University to develop a model for measuring ROI that focused on easily quantifiable drivers. The results of this effort include substantially improved quality of care for DM patients, an increase in net revenue by a projected $232,000 annually, and an estimated ROI of 53 percent.

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Nationally Recognized Transitional Rehabilitation Program’s Strategies

Serving patients with special needs, such as traumatic injury or multiple high acuity co-morbidities, is a costly and complex endeavor. Allina Health’s Transitional Rehabilitation Program (TRP) tackled both of these realities head-on—resulting in cost savings while helping this vulnerable patient population achieve a higher quality of life.

Recognizing the need for high-quality data that could prove the TRP’s value to its patients and community, Allina implemented analytics that enabled it to track and report outcomes and costs, demonstrate value, and generate savings for the health system and the community.

The initiative has reaped wide-ranging results in patient improvements and cost savings including saving health systems and communities $3.2 million over a one-year period, 20 percent greater success than traditional skilled nursing facilities in discharging patients to home and community, 20 percent improvement in impairment in brain injury patients (MPAI-4), and 84 percent improvement in spinal cord independence measure (SCIM).

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Care Management Strategy Improves Lives of Stroke Patients

Stroke is a leading cause of hospitalizations among elderly often resulting in serious long-term disability, readmissions (up to 27% are readmitted to the hospital in year one), or secondary stroke. Allina Health’s Courage Kenny Rehabilitation Institute (CKRI) had deployed a successful care coordination model for other complicated, high-risk populations that it was confident would help stroke patients, as well.

CKRI created a holistic program for stroke patients that delivers comprehensive, seamless care across inpatient, outpatient and support services. A data warehouse and analytics platform merges data across the care continuum, and enables Allina to target high-risk stroke patients for coordinated care, track their progress and measure their outcomes.

Within a year, Allina was able to prove the value of this new care model for stroke by realizing $350,000 in cost savings and, most importantly, through actual lives saved and improved.

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One Healthcare System’s Effective Strategy to Improve Pneumonia Outcomes

MultiCare Health System, an IDS serving communities throughout Washington State, recently undertook an initiative to improve the care of, cost of, and experience for pneumonia patients. This initiative included the building of evidenced-based order sets (and driving their adoption), assigning a team of social workers called “personal health partners” to research and improve patient follow-up and communication, and deploying an analytics application to provide near real-time feedback on compliance and performance while offering a single view of patient-specific data across multiple visits and care settings, such as medication and readmission histories. Through these efforts, MultiCare has realized significant outcome improvements including reducing pneumonia readmissions by 23 percent, a 28 percent reduction in mortality rate, a 2 percent decrease in LOS, and a 6.4 percent reduction in average variable cost per patient.

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Achieve Reduced Heart Failure Readmission Rates: One Healthcare Organization’s Care Coordination Strategy

Heart failure (HF) sends more US adults over 65 to the hospital than any other cause—costing Medicare alone more than $17 billion annually—with readmissions significantly contributing to the issue. For large integrated networks like Allina Health, efforts to reduce readmissions for HF patients are challenged by the need for coordinated care and consolidated data across the care continuum. Allina implemented a multidisciplinary HF management program with a nurse care coordinator and nurse practitioners who assure patient engagement and provide a “bridge” between different points in the care continuum. These important people and processes are aided by access to data from an enterprise data warehouse that merges data across the health system and gives providers insight into HF care and performance metrics. The program has helped Allina achieve a 30-day HF readmission rate well below the national average —17 percent in 10 of 11 hospitals doing cardiac care.

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How Partners HealthCare is Leveraging Episode-Based Data to Improve Care Delivery

U.S. healthcare is shifting from procedure and visit approaches to a longitudinal view of patient care. The Centers for Medicare & Medicaid Services (CMS) is supporting this change with their “Bundled Payments for Care Improvement Initiative.” Under the initiative, healthcare organizations enter into payments arrangements with financial and performance accountability for 48 episodes of care. This requires health organizations to integrate data from a combination of sources in order to identify the bundles with the highest costs and the sources of variation. Learn how Partners HealthCare, an Integrated Healthcare Delivery System and ACO, successfully integrated hospital, provider, and claims information for the first time—and how they can now easily evaluate and compare clinical and financial performance for the 48 CMS episodes of care.

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Managing Half a Million Risk-Contracted Lives: Partners HealthCare Population Health Strategy

Population health management in a value-based model requires reengineering care delivery to provide higher quality of care at a lower cost. To address this challenge, organizations need to take a system-wide, strategic approach to defining their structures and processes. Learn how Partners Healthcare, an Integrated Healthcare Delivery System and ACO, developed and successfully implemented a strategic framework —guided by strong leadership and meticulous change management—for managing its half a million risk-contracted lives. The framework enables collaboration and aligns providers across the care continuum, using a unified set of performance targets for all contracts. The framework includes a robust analytics system that provides metrics to deliver the best patient care, while meeting the disparate requirements of multiple external contracts. Partners Healthcare has developed an internal performance framework that can serve as a population health management model for health systems throughout the United States.

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Patient Identification and Matching—An Essential Element of Using an Enterprise Data Warehouse to Manage Population Health

In a healthcare industry transitioning to value-based reimbursement and population health management (PHM), matching patients accurately to their care events across multiple sites of care and sources of information is becoming ever more important. Being able to accurately track utilization of services for a particular patient, patient population, or provider is fundamental to the strategies underlying effective population health management. Partners HealthCare developed an effective patient matching solution for more than 10.5 million patients achieving a 20 percent improvement in patient matching accuracy and a 96-99 percent high-risk patient matching rate. This has allowed the organization to accurately “flag” high risk patient populations and better manage risk under risk-based contracts.

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Sepsis Mortality and Length of Stay: One Hospital System’s Story

Sepsis, a serious complication that strikes quickly and is often fatal, is the single most expensive condition to treat in the hospital, in part because of the longer than average stay. To reduce sepsis mortality rates, which are between 20 and 50 percent, many hospitals have established evidence based bundles comprised of antibiotic administration, lactate level monitoring and other elements of care. However, without analytics, hospitals rely on manual processes to track sepsis rates and bundle compliance. Learn how Mission Health has streamlined surveillance by 75% while experiencing a 2.6% reduction in sepsis mortality rates and an 18% reduction in length of hospital stay.

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Using Advanced Analytics to Manage Population Health in Primary Care Clinics

The need to effectively manage the health of populations is largely driven by the fact that 5 percent of the population accounts for 50 percent of healthcare costs. Being able to identify these patients, provide high-quality care and reduce their utilization is a pressing goal for many of today’s primary care providers (PCPs). Learn how this healthcare organization used a healthcare enterprise data warehouse and analytics to better manage their individual patients and patient population, integrate regulatory and performance reporting, and allow PCPs to spend more time with patients and less time collecting data.

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How to Improve the Population Health of Women and Newborns: Exclusive Breast Milk Feeding

Several regulatory and licensing agencies are focused on Women and Newborn Population Health measures (Healthy People, 2020; the World Health Organization; and The Joint Commission (TJC)).  Beginning in January 1, 2014, TJC began requiring hospitals that delivered at least 1,100 infants annually to report their rates of exclusive breast milk feeding. The measure has also been incorporated into Meaningful Use requirements. This healthcare system, like many organizations, couldn’t accurately report their rates.  Learn how they used healthcare analytics to optimize their EMR data capture, reduce manual chart abstraction and increased their breast milk feeding rates by 21 percent.

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Community Care Physicians Deliver Effective Population Health Management with Clinical Analytics

Learn how Community Care Physicians used clinical analytics to drive a 75 percent reduction in patient navigator reporting and chart abstraction time. Now RNs can spend more time focused on quality improvements.  Patients also receive timely outreach for overdue treatment and upcoming reminders. View sample regulatory and patient level visualizations and learn how these graphical visuals — including clinic and provider comparison metrics — helped drive provider engagement.

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Other Content in Population Health

Posts

How Care Management Done Right Improves Patient Satisfaction and ROI

A comprehensive care management program organizes many moving parts into an efficient workflow and brings order to the complex, often messy, world of healthcare. Care coordination harmonizes the workflow of clinicians, patients, family, social workers, and therapists, to name a few. It facilitates medication reconciliation, care compliance, appointment scheduling, and communication with patients, as well as engagement between patients and the care team. Care coordination concentrates on the highest-utilization, highest-cost patients to produce better clinical, operational, and financial outcomes, the bottom line goals for healthcare systems involved in population health and value-based care.

This article details the benefits of, and barriers to, care management and coordination, their role in population health, and the technology that’s helping to automate this area of healthcare.

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Three Essential Systems for Effective Population Health Management

An effective population health management program must include three systems: Healthcare Analytics, Best Practice, and Adoption. Organizations with only one or two of these systems often display symptoms of weak and ineffective capability for population health management.  But when you have a analytics foundation based upon a data warehouse, combined with evidence-based practices contained in a best practice system, and the ability to deploy and implement systematic changes to healthcare processes, health systems are truly prepared to manage population of patients.

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Understanding Risk Stratification, Comorbidities, and the Future of Healthcare

Risk stratification is essential to effective population health management. To know which patients require what level of care, a platform for separating patients into high-risk, low-risk, and rising-risk is necessary. Several methods for stratifying a population by risk include: Hierarchical Condition Categories (HCCs), Adjusted Clinical Groups (ACG), Elder Risk Assessment (ERA), Chronic Comorbidity Count (CCC), Minnesota Tiering, and Charlson Comorbidity Measure. At Health Catalyst, we use an analytics application called the Risk Model Analyzer to stratify patients into risk categories. This becomes a powerful tool for filtering populations to find higher-risk patients.

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Improve Patient Engagement with Five Public Health-Inspired Principles

Patient engagement is critical as we move toward population health—as patients who engage in their own care by following medical recommendations and making healthy nutrition and lifestyle choices will have better outcomes and experiences.

There isn’t, however, a clear path to successful patient engagement. Fortunately, public health can lend several established principles that may help us better involve patients in their own care:

  1. Using systematic, population-level solutions that require less individual effort.
  2. Engaging patients on interpersonal and community levels as well as personal.
  3. Identifying root-cause, assessing and capitalizing on strengths, and engaging stakeholders.
  4. Using strategies from behavioral economics to help individuals make good choices.
  5. Anticipating failure and learning from it.
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The 6 Critical Components of Population Health

This article examines how to define population health through a review of the top analytics research firms. It lands on a single theme, but in the process it uncovers six common categories of IT capabilities required to successfully manage population health:

  1. Data Aggregation
  2. Patient Stratification
  3. Care Coordination
  4. Patient Engagement
  5. Performance Reporting
  6. Administrative/Business

These six strategic components define the population health ecosystem, and successful organizations must multitask across these domains, working with an enterprise data warehouse, if they hope to thrive in value-based healthcare and become true partners and assets in their respective communities.

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Product Demos & Literature

Community Care (Product Demo)

Using diabetes as an example, this 6-minute demo illustrates how the Health Catalyst framework and methodology lets you:

  • Measure compliance across user-defined and/or regulatory metrics
  • Compare provider-to-provider, provider-to-clinic, or clinic-to-clinic compliance
  • Use built in filtering to get to the precise information you need
  • Drill down to a detailed patient view to determine compliance and needed actions
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Webinars

KLAS: The Population Health Management Journey

As population health management goes mainstream, providers need robust, integrated software solutions to aggregate and analyze data, coordinate care, engage patients and clinicians, and provide full administrative and financial functionality. Population Health Management is a journey, and the number of approaches to population health are varied.

Join Bradley Hunter, Research Director over Population Health at KLAS as he addresses these key questions:

  1. How are providers looking to tackle population health?
  2. What are the challenges facing providers today?
  3. Which vendors are meeting the needs or are poised the meet the needs of providers in the future?
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Return on Engagement—the Fundamental Metric of Population Health Management

The fundamental question of the future for population health management is, “How much will it cost our system to achieve a unit of improvement in this patient’s outcome?” At Health Catalyst, we call that Return on Engagement (ROE), and we measure the numerator and denominator, analytically. Engaging patients in their own care is not just an altruistic gesture. It is an economic imperative for healthcare organizations who are at financial risk for achieving clinical outcomes and value based care contracts.

Join Dale Sanders and Russ Staheli as they share their observations about population health management from across the industry and how those observations are influencing the Health Catalyst product roadmap. Simply put, achieving optimal care for a population of patients begins with providing optimal care for a single patient, then repeating that over and over again for an entire community of patients. What public health is for infectious disease, population health is to chronic disease; the same concepts for engaging patients in their socio-economic context are applicable to both.

In the last half of this webinar, Russ will demonstrate Health Catalyst’s Care Management suite. The five applications in the suite are powered by the Health Catalyst Analytics Platform and were designed by synthesizing concepts from Customer Relationship Management and social networking applications— blending data collection, suggestive and predictive analytics, and decision support into a seamless software experience— and applying that to population health management, one patient at a time.

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Accountable Care Transformation: The 4 Building Blocks of Population Health Management (Webinar)

Unlike few can do, Dr. David Burton has simplified these complex topics into a simple construct of four population health management building blocks. By acquiring proficiency in each of these four dimensions, healthcare delivery systems can create an asset which can be marketed to various types of governmental and commercial payers, which sponsor health benefit plans and offer shared accountability contracts (i.e. accountable care) into which these population health management sponsors can enter.

The key learning points of the webinar include:

  • The four building blocks of population health management (provider network, population(s), quality/safety outcomes, and cost outcomes)
  • The central role patient registries play in success in population health management
  • Pragmatic tools and methodologies to help healthcare delivery systems become proficient in each of the four dimensions of the framework
  • A discussion of the categories of governmental and commercial sponsors of shared accountability solutions, including the potential impact of the shift from defined benefit to defined contribution health benefit programs
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Population Health Analytics: Improving Care One Patient at a Time

Population Health Analytics is about more than just identifying a group of patients. It involves helping physicians care for their patients as individuals, improving their own practice through evidence-based best practices, and enacting cultural change that results in better outcomes for entire populations. Population Health Analytics—with the capability to look at one patient at a time and one physician at a time—will enable providers and organizations to answer three important questions: 1) What best practices should I be doing with this population? 2) How well am I following these best practices with this population? And 3) How can I change to create better outcomes for this population? 

In addition to addressing these population health questions, please join Tom Burton, Co-Founder and Senior Vice President of Product Development, Health Catalyst, as he discusses Population Health Analytics and presents the Three Systems Model of Care Delivery. Tom will share Health Catalyst’s experiences and learning’s and why each system is essential to create long-term change and transform healthcare. 

Attendees of the webinar will:

  • Learn about the Three Systems Model of Care Delivery required for effective Population Health Analytics. Understand the issues that must be addressed at each stage in order to optimize care delivery.
  • Discover the role analytics play in enabling physicians to deliver better care to their patients leading to improved outcomes for an entire population of the patients.

In the future, healthcare executives with a solid Population Health Analytics system will be better prepared to deliver better outcomes and more efficient care. Both will be key for succeeding with payment models based on risk, value, and performance.

 

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The Path to Shared Savings With Population Health Management Applications (Webinar)

Eric Just, Vice President of Technology and Kathleen Merkley, Clinical Engagement Executive and Vice President at Health Catalyst, will demonstrate live several advanced applications built on a Late-Binding Health Catalyst data warehouse. Attendees will better understand how to:

  • Identify variability in care
  • Define accurate populations
  • Report on key health indicators across the continuum of care
  • Apply flexible models for risk stratification
  • Measure detailed process metrics spanning transitions of care for HF patients

Next generation health systems and Accountable Care Organizations will be paid based on an evolving model that rewards healthcare providers through ‘shared savings.’ Those savings must be achieved through systematic cost reductions while still improving quality of care. For most, this dual focus will prove to be the most critical and difficult part of realizing success.

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