Best Practice in Managing Patients with Multiple Chronic Conditions Learning Collaborative. Participating Group Projects Overview: Common Themes
|
|
- Randolph Evans
- 5 years ago
- Views:
Transcription
1 Best Practice in Managing Patients with Multiple Chronic Conditions Learning Collaborative Participating Group Projects Overview: Common Themes
2 Advocate Medical Group Affinity Medical Group Arch Health Partners Columbia-St. Mary s Medical Group Crystal Run Medical Group Dartmouth-Hitchcock Medical Group Essentia Health Fletcher Allen Health Care Geisinger Health System HealthPartners Medical Group Intermountain Healthcare Mercy Clinics, Inc. Mercy Medical Group Novant Medical Group Primed Physicians Riverside Medical Group Sentara Medical Group Sharp Rees-Stealy Medical Group The Polyclinic ThedaCare University of Pittsburg Medical Group University of Utah Medical Group Wenatchee Valley Medical Group
3 What Do You Look Like? Populations Served: Small to Large From Rural to Urban Areas Deliver health care to approximately 13.6 million patients across the country
4 MPMCC Groups by Organization Type 16% Academic Practices 5% IPAs 26% Group Practices 53% Integrated Delivery Systems
5 MPMCC Groups by Number of Physicians 10% <50 MDs 70% > 150 MDs 20% MDs
6 Proposed Framework for Complex Chronic Care Care Processes Redesign Performance Improvement Care Coordination & Transitions Patient Registries Medication Reconciliation Pre and Post Visit Plan Performance Measurement & Transparency Test Tracking & Reporting Patient Self- Management Support Health Coaching Systematic Improvement Plan Creating and Implementation of Standardized Processes Organizational Infrastructure Leadership Commitment Aligned Incentives Strategic Alliances IT Infrastructure
7 Group Pre-work Chronic Care Goals and Objectives Chronic Care Intervention and Population Baseline Self Efficacy Improvement Interventions Measures Used Payment Reform Challenges or Obstacles Outcomes and Successes Future Steps Lessons Learned Questions
8 High Level Common Theme Care Delivery System Changes Mission New scope (24/7/365) Structure (Redesign) Team Composition New Responsibilities New Dependencies Integration of Previously Separate Silos Process New Functions Measurement Best Practice / Standardization New Accountabilities Improvement / Optimization
9 Delivery System Redesign PCMH IOPC Transitions of Care Special Needs Populations Expanded Venues of Care Common processes Coordination of care Navigators Health Coaches Medication Reconciliation Adherence Mental Health integration Range of Activities
10 Chronic Care Goals and Objectives Virtually all groups, with varying differences in emphasis of each of the elements, have incorporated the three element of the IHI Triple Aim into their chronic care objectives: Improve the health of the population Enhance the patient experience of care (quality, access, rehabilitation) Reduce or at least control the per capita cost of care
11 Chronic Care Objectives Population Condition specific outcomes: DM, depression, COPD, CHF public reporting Patient Experience Continuum of care/coordination Reduce errors/defects, EBM Transitions Functional status Cost Reduce ER use, hospitalization Reduce errors/defects
12 Populations / Conditions Disease based: DM, CFH, HTN, Depression, COPD, CAD, Asthma Special populations: elderly, high needs, Medicare Advantage Special situations: transitions of care
13 Use of Standards External National (NQF, NCQA) Local (state, regional) Internal
14 Improvements Intervention Access Registries Chronic Care Model Complex case management for high risk patients (IOPC) AVS Pre-visit planning Group visits Home visits Medication reconciliation Care coordination with specialist Health coaches ARNP in SNF IP case management Post ER / Post IP d/c F/U Multi-disciplinary, teams Referral management Patient education Create new tools Align incentives PDSA cycle LEAN Standard workflows Worksheets (checklists) Lower thresholds for initiation of treatment (Rx) EMR tools Embed care coordinators in primary care practices Add PharmD, ARNP, RN navigators
15 Challenges Culture Engagement / momentum Resources Conflicting priorities Communication Collaboration across organization Internal alignment External dependencies Standardization Business case (external reimbursement) MD engagement Patient engagement Hiring right people Data
16 Successes Leadership (local and senior) Support from above Clear vision Defining the problem Motivated providers Shared learning Collaboration Communication / Trust Staff MD feedback Patient feedback Data Celebrate success Business case
17 Questions Set priorities Timing of progress Communication Maintain top support What measures matter What chronic conditions / pts should we focus on Developing a business case Incentives and shared savings models How to best measure value Risk stratification Measuring cost of care Track referrals Change culture Staff changes MD incentive Role of centralization Patient self management Patient engagement
18
Patient Centered Medical Home The next generation in patient care
Patient Centered Medical Home The next generation in patient care Provider Training Module I OBJECTIVE To explain... What Patient Centered Medical Home is How it works Why it s important Where to begin
More informationManaging Risk Through Population Health Initiatives
Managing Risk Through Health Initiatives Vicki DeBaca, DNS, RN Vice President, Health & Provider Services Sharp Rees-Stealy Medical Centers 1 Sharp Rees-Stealy Medical Centers San Diego s Multi-Specialty
More informationUNITED STATES HEALTH CARE REFORM: EARLY LESSONS FROM ACCOUNTABLE CARE ORGANIZATIONS
UNITED STATES HEALTH CARE REFORM: EARLY LESSONS FROM ACCOUNTABLE CARE ORGANIZATIONS Stephen M. Shortell, Ph.D., M.P.H, M.B.A. Blue Cross of California Distinguished Professor of Health Policy and Management
More informationPost Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator
Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator Janet Tomcavage, RN, MSN VP Health Services, Geisinger Health Plan Danville, PA February 3, 2012 Patient-centered primary care
More informationManaging Patients with Multiple Chronic Conditions
Best Practices Managing Patients with Multiple Chronic Conditions Dartmouth-Hitchcock Physicians Case Study Organization Profile Headquartered in Bedford, New Hampshire, Dartmouth-Hitchcock is a large
More informationClinical Integration and P4P: Using Pay for Performance to Build Clinical Integration within a Physician-Hospital IPA
Clinical Integration and P4P: Using Pay for Performance to Build Clinical Integration within a Physician-Hospital IPA March 9, 2010 Presented by: Michael Edbauer, DO, Vice President, Medical Affairs CIPA
More informationImproving Medicaid Chronic Disease Care and Controlling Costs. The Case for Medical Homes and Community Networks
Improving Medicaid Chronic Disease Care and Controlling Costs The Case for Medical Homes and Community Networks L. Allen Dobson,Jr. MD FAAFP Chair -Board of Directors NC Community Care Networks, Inc HOME
More informationPatient Centered Medical Home: Transforming Primary Care in Massachusetts
Patient Centered Medical Home: Transforming Primary Care in Massachusetts Judith Steinberg, MD, MPH Deputy Chief Medical Officer Commonwealth Medicine UMass Medical School Agenda Overview of Patient Centered
More informationCare Management in the Patient Centered Medical Home. Self Study Module
Care Management in the Patient Centered Medical Home Self Study Module Objectives Describe the goals of care management Identify elements of successful care management Recognize the 5 step Care Management
More informationBundled Payments to Align Providers and Increase Value to Patients
Bundled Payments to Align Providers and Increase Value to Patients Stephanie Calcasola, MSN, RN-BC Director of Quality and Medical Management Baystate Health Baystate Medical Center Baystate Health Is
More informationQuality, Cost and Business Intelligence in Healthcare
Quality, Cost and Business Intelligence in Healthcare Maitri Vaidya Population Health Executive DBA, MHA, CPHQ May 2016 Where are we going? IHI Triple Aim Improve the patient experience of care Lower
More informationFrom Reactive to Proactive: Creating a Population Management Platform
Session D9 / E9 From Reactive to Proactive: Creating a Population Management Platform Richard Gitomer, MD Director, Brigham and Women s Primary Care Center of Excellence Vice Chair, Primary Care, Dept.
More informationModels of Accountable Care
Models of Accountable Care Medical Home, Episodes and ACOs Making it work Elliott Fisher, MD, MPH Director, Population Health and Policy The Dartmouth Institute for Health Policy and Clinical Practice
More informationPopulation Health and the Accelerating Leap to Outcomes-Based Reimbursement. Craig J. Wilson
Population Health and the Accelerating Leap to Outcomes-Based Reimbursement Craig J. Wilson Agenda / Goals Define Population Health Management Review emerging reimbursement landscape eg MACRA Review why
More informationCREATING A NATIONAL CAMPAIGN TO IMPROVE HYPERTENSION CONTROL. Improving chronic care: It takes a team
F I N D I N G S T R E N G T H Improving chronic care: It takes a team CREATING A NATIONAL CAMPAIGN TO IMPROVE HYPERTENSION CONTROL Jerry Penso, MD, MBA, chief medical and quality officer American Medical
More informationStrategy Guide Specialty Care Practice Assessment
Practice Transformation Network Strategy Guide Specialty Care Practice Assessment 1/20/2017 1 Strategy Guide: Specialty Care PAT 2.2 Contents: Demographics Tab: 3 Question 1: Aims... 3 Question 2: Aims...
More informationACOs: Transforming Systems with New Payment Models & Community Integration
ACOs: Transforming Systems with New Payment Models & Community Integration Sunnah Kim PNP (Moderator), American Academy of Pediatrics Herbert Druilhet, RN, DNP, FNP-BC Lafayette General Medical Doctors
More information7/7/17. Value and Quality in Health Care. Kevin Shah, MD MBA. Overview of Quality. Define. Measure. Improve
Value and Quality in Health Care Kevin Shah, MD MBA 1 Overview of Quality Define Measure 2 1 Define Health care reform is transitioning financing from volume to value based reimbursement Today Fee for
More informationGuide to Population Health Management
Guide to Population Health Management presented by the Healthcare Intelligence Network Note: This is an authorized excerpt from the Guide to Population Health Management. To download the entire guide,
More informationAccountable Care Organizations Creating A Culture Of Engaged Physicians
Accountable Care Organizations Creating A Culture Of Engaged Physicians Judith Miller, VP Medical Services & CI Advocate Physician Partners August 14, 2014 1 Sites Of Care Advocate Health Care 13 Hospitals
More informationAdirondack Medical Home Pilot Overview. Dennis Weaver MD MBA November 2, 2010
Adirondack Medical Home Pilot Overview Dennis Weaver MD MBA November 2, 2010 Critical Success Factors Lessons Learned Partnership among all stakeholders is essential Must define common goals and timelines
More informationPopulation Health or Single-payer The future is in our hands. Robert J. Margolis, MD
Population Health or Single-payer The future is in our hands Robert J. Margolis, MD Today s problems Interim steps Population health Alternatives Conclusions Outline $3,000,000,000,000 $1,000,000,000,000
More informationBlueprint Integrated Pilot Programs
Blueprint Integrated Pilot Programs Improving Access Improving Quality Improving Efficiency National Conference of State Legislatures December 10, 2008 Craig Jones MD Craig.jones@state.vt.us Health Care
More informationNGA and Center for Health Care Strategies Summit: High Utilizers
Medicaid Chronic Care Initiative: Strategies for High Utilizers NGA and Center for Health Care Strategies Summit: High Utilizers February 12, 2013 Eileen Girling, MPH, RN, CAMS Director, VCCI Department
More informationBuilding the Oncology Medical Home John D. Sprandio, M.D., FACP Consultants in Medical Oncology & Hematology, P.C. Oncology Management Services, LLC
Building the Oncology Medical Home John D. Sprandio, M.D., FACP Consultants in Medical Oncology & Hematology, P.C. Oncology Management Services, LLC Oncology Patient-Centered Medical Home Update Background
More informationRoadmap to accountable care: The chicken or the egg technology investment or clinical process improvement?
Roadmap to accountable care: The chicken or the egg technology investment or clinical process improvement? August 29, 2012 Meet the Presenters Michael Griffis CIO Innovative Practices Tucson, AZ Beth Hartquist,
More informationReducing Hospital Admissions Through the Use of IT. Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods
Reducing Hospital Admissions Through the Use of IT Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods Conflict of Interest Steven Milligan, MD Has no real or apparent conflicts
More informationExpansion of Pharmacy Services within Patient Centered Medical Homes. Jeremy Thomas, PharmD Associate Professor Department Pharmacy Practice
Expansion of Pharmacy Services within Patient Centered Medical Homes Jeremy Thomas, PharmD Associate Professor Department Pharmacy Practice What is a Patient Centered Medical Home (PCMH)? "an approach
More informationMedical Home Summit September 20, 2011
Medical Home Summit September 20, 2011 1 Three Dimensions of Value by Institute of Healthcare Improvement Population Health Experience of Care Per Capita Cost Care Management : The unintended consequences
More informationThe Pennsylvania Chronic Care Initiative
The Pennsylvania Chronic Care Initiative Richard L. Snyder, M.D. Senior Vice President Chief Medical Officer Independence Blue Cross William J. Warning II, M.D. Program Director Crozer-Keystone Family
More informationShared Decision Making & Patients with Multiple Chronic Conditions
Shared Decision Making & Patients with Multiple Chronic Conditions Sheri Ver Steeg, RN, MSN-HCSM Monica Vail, RN 2012 Mercy Medical Center, Mercy Clinics, Inc. All rights reserved Disclosures Our Shared
More informationPRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management
PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication
More informationThe Playbook: Better Care for People with Complex Needs
The Playbook: Better Care for People with Complex Needs Catherine Arnold Mather, MA Director Institute for Healthcare Improvement October 26, 2017 The Better Care Playbook is supported by a funders collaborative
More informationHypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc.
Hypertension Best Practices Symposium Sponsored by AMGA and Daiichi Sankyo, Inc. October 13-15, 15, 2010 Scottsdale, AZ Kaiser Permanente of the Mid-Atlantic States (KPMAS) 1 KPMAS Medical Group Profile
More informationCatholic Medical Partners
Improving Health Outcomes Patricia Podkulski, MS,RN October 13, 2011 Catholic Medical Partners 2 Independent Practice Association WNY: Erie/Niagara counties 900 physicians Four (4) Acute Care Hospitals
More informationRed Carpet Care: Intensive Case Management Program for Super-Utilizers
Red Carpet Care: Intensive Case Management Program for Super-Utilizers Alice Stollenwerk Petrulis, MD Linda C. Stokes, PhD The MetroHealth System Picture of MH MetroHealth 750 bed facility includes Rehab,
More informationCathy Schoen. The Commonwealth Fund Grantmakers In Health Webinar October 3, 2012
Innovating Care for Chronically Ill Patients Cathy Schoen Senior Vice President The Commonwealth Fund www.commonwealthfund.org cs@cmwf.org Grantmakers In Health Webinar October 3, 2012 Chronically Ill:
More informationHSCRC Update on Maryland's Health Care Transformation. March 2017
HSCRC Update on Maryland's Health Care Transformation March 2017 Background: Maryland s All-Payer Model Since 1977, Maryland has had an all-payer hospital ratesetting system In 2014, Maryland updated its
More informationBlue Cross & Blue Shield of Rhode Island (BCBSRI) Advanced Primary Care Program Policies
Blue Cross & Blue Shield of Rhode Island (BCBSRI) Advanced Primary Care Program Policies Effective 1/1/2016 The following program policies are applicable to all contracted providers and practices participating
More informationNew Models of Health Care: The Patient Centered Medical Home. Mark Gwynne, DO UNC- Chapel Hill Department of Family Medicine August 17, 2013
New Models of Health Care: The Patient Centered Medical Home Mark Gwynne, DO UNC- Chapel Hill Department of Family Medicine August 17, 2013 Objectives of this session: What s the burning platform for change?
More informationJourney in managing practice variation in Diabetes and Hypertension (Part 2/2)
Journey in managing practice variation in Diabetes and Hypertension (Part 2/2) For Part 1 of this presentation, go to http://rightcare.berkeley.edu/sacramento-university-of-best-practices Parag Agnihotri,
More informationNicole Harmon, MBA, PCMH CCE Senior Director, PCMH Advisory Services HANYS Solutions Patient-Centered Medical
Nicole Harmon, MBA, PCMH CCE Senior Director, PCMH Advisory Services 2017 HANYS Solutions Patient-Centered Medical Home Advisory Services Overview Current landscape Medical neighborhood Patient-Centered
More informationInnovative Reimbursement Models Value-Based Insurance Design and the Medical Home En Route to an ACO Model
Innovative Reimbursement Models Value-Based Insurance Design and the Medical Home En Route to an ACO Model Mary Ellen Benzik,MD PCPCC Conference March 14, 2011 Community Collaboration to Transform Health
More informationPhysician Compensation for Quality Within Groups: Complying with Stark and State of The Art. Traditional Physician Compensation Models
Physician Compensation for Quality Within Groups: Complying with Stark and State of The Art Alice G. Gosfield, Esq. Medicare and Medicaid Institute American Health Lawyers Association March 29, 2012 c.2012,
More informationFrom Bundles to Global Capitation: Aligning Care Models to Payment Models. The 16 th Annual Population Health Colloquium Philadelphia, PA
From Bundles to Global Capitation: Aligning Care Models to Payment Models The 16 th Annual Population Health Colloquium Philadelphia, PA March 8, 2016 The U.S. Payer Market is Committed to Dramatically
More informationAttaining the True Patient-Center in the PCMH Through Health Coaching and Office-Based Care Coordination
Attaining the True Patient-Center in the PCMH Through Health Coaching and Office-Based Care Coordination Heartland Rural Physician Alliance Annual Conference IV May 8, 2015 William Appelgate, PhD, CPC
More informationGeisinger s Use of Technology in Case Management and the Medical Home: A Heart Failure Study
Geisinger s Use of Technology in Case Management and the Medical Home: A Heart Failure Study JOANN SCIANDRA, RN, BSN, CCM DOREEN SALEK, BS, RN, CCS/CPC DANIEL MAENG, PHD February 18, 2015 Geisinger at
More informationMeet the Campaign Team
Today s Agenda 1. Understand goals of the Measure Up/Pressure Down national campaign 2. Learn key care processes for improving blood pressure control 3. Identify Measure Up/Pressure Down resources that
More informationPBGH Response to CMMI Request for Information on Advanced Primary Care Model Concepts
PBGH Response to CMMI Request for Information on Advanced Primary Care Model Concepts 575 Market St. Ste. 600 SAN FRANCISCO, CA 94105 PBGH.ORG OFFICE 415.281.8660 FACSIMILE 415.520.0927 1. Please comment
More informationMEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE
MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE Presented by: Linda Efferen, MD, MBA Medical Director Suffolk Care Collaborative 19 THE MAX SERIES SUPPORTS AN INTERDISCIPLINARY
More informationHealth Information Technology
ACO Congress Oct 25, 2010 Los Angeles, CA Patient Centered Medical Home and Accountable Care Organizations Health Information Technology David K. Nace MD, Medical Director, McKesson Corporation Co-Chair,
More informationNYSPFP- Readmission Collaborative Domain II - Kick-off Webinar Improving Care Transitions Between Hospitals and SNFs
NYSPFP- Readmission Collaborative Domain II - Kick-off Webinar Improving Care Transitions Between Hospitals and SNFs February 28, 2017 A partnership of the Healthcare Association of New York State and
More informationMedicare Advantage in Practice: Enhanced Care Models for High Need Patients
Medicare Advantage in Practice: Enhanced Care Models for High Need Patients Rebekah Dube, Pharm.D. VP, Health Plan Clinical Programs & Interim VP, Health Plan Products Who is Martin s Point Health Care?
More informationJumpstarting population health management
Jumpstarting population health management Issue Brief April 2016 kpmg.com Table of contents Taking small, tangible steps towards PHM for scalable achievements 2 The power of PHM: Five steps 3 Case study
More informationMeasuring High Performers and Assessing Readiness to Change Looking Beyond the Lamppost
Measuring High Performers and Assessing Readiness to Change Looking Beyond the Lamppost Mathematica Policy Research Washington, DC November 19, 2014 Moderator Timothy Lake Director of Health Research,
More informationObjectives. Physician Leadership Engagement to Produce System Change
Physician Leadership Engagement to Produce System Change David Swieskowski, MD, MBA Senior VP & Chief Accountable Care Officer Mercy Medical Center Des Moines, Iowa Objectives Discuss adoption of change
More informationPersonalized Primary Care Annual Meeting. Care Management Catherine Hamilton, BSN, MS, MBA
Personalized Primary Care Annual Meeting Care Management Catherine Hamilton, BSN, MS, MBA Care Manager Assessments 75% of care managers assessed Observed processes Evaluated against NCQA 2014 Medical Home
More informationKatherine Schneider, MD, MPhil Senior Vice President, Health Engagement July 29, 2011
Accountable Care: Health System View CHC Best Practices Forum Katherine Schneider, MD, MPhil Senior Vice President, Health Engagement July 29, 2011 Who we are Southeastern New Jersey s largest health system
More informationMichigan Primary Care Transformation (MiPCT) Project Frequently Asked Questions
Michigan Primary Care Transformation (MiPCT) Project Frequently Asked Questions Demonstration Design 1. What is the Michigan Primary Care Transformation (MiPCT) Project? The Centers for Medicare and Medicaid
More informationED PAUSE. Meadowview Regional Medical Center Missy Hershey, MSN, RN, CCM
ED PAUSE Meadowview Regional Medical Center Missy Hershey, MSN, RN, CCM BASELINE DATA April 2017 Completed a Deep-Dive last 2 Quarters of patients who were readmitted. Areas of Opportunity Identified:
More informationMinnesota Department of Health (MDH) Health Care Homes (HCH) Initial Certification. Reviewed: 03/15/18
Minnesota Department of Health (MDH) Health Care Homes (HCH) Initial Certification Reviewed: 03/15/18 1 Learning Objectives 1. Describe the HCH legislative rule subpart criteria required for initial certification.
More informationHealthcare Financial Management Association October 13 th, 2016 Introduction to Accountable Care Organizations and Clinically Integrated Networks
Healthcare Financial Management Association October 13 th, 2016 Introduction to Accountable Care Organizations and Clinically Integrated Networks Agenda Define ACO, CIN, and Coordinated Care Review ACO/CIN
More informationMonarch HealthCare, a Medical Group, Inc.
Monarch HealthCare, a Medical Group, Inc. Accountable Care in the Independent Practice Model June 7, 2010 Jay J. Cohen, MD, MBA President/Chairman Monarch HealthCare Monarch HealthCare, a Medical Group,
More informationRisk Stratification for Population Health Management
STEPS FOR SUCCESS IN Risk Stratification for Population Health Management EVERY DOCTOR HAS EXPERIENCED THE 80/20 RULE WHEN IT COMES TO TREATING THEIR SICKEST PATIENTS, says Leonard Fromer, MD, FAAFP, Executive
More informationKeeping Your Diabetes Education Program Stable In the Era Of Health Care Reform and Accountable Care Organizations
Keeping Your Diabetes Education Program Stable In the Era Of Health Care Reform and Accountable Care Organizations Nicole Downey, MBA, RD, CDE Program Director Diabetes Services The Polyclinic Seattle,
More informationUsing Data for Proactive Patient Population Management
Using Data for Proactive Patient Population Management Kate Lichtenberg, DO, MPH, FAAFP October 16, 2013 Topics Review population based care Understand the use of registries Harnessing the power of EHRs
More informationThe New York State Value-Based Payment (VBP) Roadmap. Primary Care Providers March 27, 2018
The New York State Value-Based Payment (VBP) Roadmap Primary Care Providers March 27, 2018 1 Housekeeping All lines have been muted To ask a question at any time, use the Chat feature in WebEx We will
More informationTransitions of Care: From Hospital to Home
Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss
More informationEmbedded Case Manager
Embedded Case Manager Joann Sciandra, RN, BSN, CCM Medical Home Summit ProvenHealth Navigator Geisinger Health System An Integrated Health Service Organization Provider Facilities Managed Care Companies
More informationThe Minnesota Accountable Health Model
The Minnesota Accountable Health Model L E A R N I N G S F R O M S I M : I N T E G R AT I O N O F P R I M A R Y A N D B E H AV I O R A L H E A LT H R U R A L H E A LT H C O N F E R E N C E J U N E 2 0,
More informationAdopting a Care Coordination Strategy
Adopting a Care Coordination Strategy Authors: Henna Zaidi, Manager, and Catherine Castillo, Senior Consultant Current state of health care The traditional approach to health care delivery is quickly becoming
More informationManaging Patients with Multiple Chronic Conditions
Best Practices Managing Patients with Multiple Chronic Conditions Arch Health Partners Case Study Organization Profile Palomar Pomerado Health, a public hospital system that includes 2 hospital campuses
More informationSustaining a Patient Centered Medical Home Program
Sustaining a Patient Centered Medical Home Program Partners Healthcare, Center for Population Health Colleen Blanchette Keri Sperry Terry Wilson-Malam Learning Objectives After this presentation, you will
More informationValue-Based Models: Two Successful Payer-Provider Approaches March 1, 2016
Value-Based Models: Two Successful Payer-Provider Approaches March 1, 2016 Clifford T. Fullerton, MD, MSc President, Baylor Scott & White Quality Alliance Chief Population Health Officer, Baylor Scott
More informationPatient-Centered Medical Home Best Practices: Case Study Examples
Patient-Centered Medical Home Best Practices: Case Study Examples Mona Chitre, PharmD, CGP Director of Clinical Services, Strategy, and Policy FLRx Pharmacy Management Excellus Health Plans Disclosures
More informationN.E.W.T. Level Measurement:
N.E.W.T. Level Measurement: Voldemort or Dumbledore? Nathan Spell, MD, FACP Chief Quality Officer, Emory University Hospital Georgia Chapter Scientific Meeting American College of Physicians Savannah,
More informationDesigning Reliable Value-based Systems of Care for Chronic Disease and Prevention
Designing Reliable Value-based Systems of Care for Chronic Disease and Prevention Frederick J. Bloom, Jr. MD MMM President, Guthrie Medical Group 1/23/15 Where We Want to Be 1. Affordable coverage for
More informationIMPROVING TRANSITIONS OF CARE IN POPULATION HEALTH
IMPROVING TRANSITIONS OF CARE IN POPULATION HEALTH TABLE OF CONTENTS 1. The Transitions Challenge 2. Impact of Care Transitions 3. Patient Insights from Project Boost 4. Identifying Patients 5. Improving
More informationAligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care
Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care Peggi M. Czinger MPH Director, Network Care Management COE The Care Management Company of Montefiore The Bronx:
More informationPotential for an additional 5% PDCM-PCP BCBSM Value Based Reimbursement (VBR) onto your Patient Centered Medical Home designation VBR (estimated
Revised 1/25/2018 1 Potential for an additional 5% PDCM-PCP BCBSM Value Based Reimbursement (VBR) onto your Patient Centered Medical Home designation VBR (estimated average of $4,000 per physician, varies
More informationThe BOOST California Collaborative
The BOOST California Collaborative California HealthCare Foundation Hospital Association of Southern California LA Care Health Plan The John A. Hartford Foundation Objectives for the Day Review the rationale
More informationPhysician Engagement
Pathways for Successful Accountable Care Organizations: Physician Engagement Thomas Kloos, MD Jim Barr, MD Atlantic ACO & Optimus Healthcare Partners ACO Helping providers Care Better for their patients.
More informationMonthly Campaign Webinar. March 16, 2017
Monthly Campaign Webinar March 16, 2017 TODAY S WEBINAR Together 2 Goal Updates Webinar Reminders Goal Post March Newsletter Highlights Minimally Disruptive Medicine & Diabetes Q&A Dr. Victor Montori of
More informationBridging the Gap: Discharge Clinics Providing Safe Transitions for High Risk Patients
Bridging the Gap: Discharge Clinics Providing Safe Transitions for High Risk Patients Northwest Patient Safety Conference May 15, 2012 Dr. Shay Martinez Medical Director, Aftercare Clinic Harborview Medical
More informationA Journey PCMH & Practice Transformation PCMH 101. Kentucky Primary Care Association Lexington Kentucky June 11, 2014
A Journey PCMH & Practice Transformation PCMH 101 Kentucky Primary Care Association Lexington Kentucky June 11, 2014 Overview of Journey Today What an overview of PCMH Why PCMH & practice transformation
More informationBCBSM Physician Group Incentive Program. Patient-Centered Medical Home Domains of Function. Interpretive Guidelines
BCBSM Physician Group Incentive Program Patient-Centered Medical Home Domains of Function Interpretive Guidelines October 2009 Table of Contents Page 1.0 PATIENT-PROVIDER PARTNERSHIP 1 2.0 PATIENT REGISTRY
More informationEmblemHealth Advocate for Quality
EmblemHealth Advocate for Quality 2013 Average Health Care Spending per Capita, 1980 2009 Adjusted for differences in cost of living 1 Dollars Source: OECD Health Data 2011 (June 2011). THE COMMONWEALTH
More informationProduct and Network Innovation: Strategies to Achieve Triple Aim Success. Patrick Courneya, MD Medical Director, HealthPartners October 31, 2013
Product and Network Innovation: Strategies to Achieve Triple Aim Success Patrick Courneya, MD Medical Director, HealthPartners October 31, 2013 Agenda About Minnesota s Market Measurement building blocks
More informationManaging Patients with Multiple Chronic Conditions
Managing Patients with Multiple Chronic Conditions Sponsored by AMGA and Merck & Co., Inc. 1 Group Pre-work Affinity Medical Group Heart, Lung & Vascular Center COURAGE Clinic 2 Medical Group Profile Affinity
More informationA Clinically Integrated Network Approach
Duke Medicine ACO Preparedness A Clinically Integrated Network Approach Bill Schiff, MHA Duke Medicine Private Diagnostic Clinic, PLLC. (PDC) Duke Faculty Practice 1 A. Duke Medicine Organizing for HealthCare
More informationMedicare Shared Savings ACOs: One Organization s Lessons Learned. Gregory A. Spencer MD FACP Chief Medical Officer Crystal Run Healthcare LLP
Medicare Shared Savings ACOs: One Organization s Lessons Learned Gregory A. Spencer MD FACP Chief Medical Officer Crystal Run Healthcare LLP Learning Objectives Identify organizational strengths and weaknesses
More informationVisit to download this and other modules and to access dozens of helpful tools and resources.
This is the third module of Coach Medical Home a six-module curriculum designed for practice facilitators who are coaching primary care practices around patient-centered medical home (PCMH) transformation.
More informationCoastal Medical, Inc.
A Culture of Collaboration The Organization Physician-owned group Currently 19 offices across the state of Rhode Island and growing 85 physicians, 101 care providers The Challenge Implement a single, unified
More informationA Practical Approach Toward Accountable Care and Risk-Based Contracting: Design to Implementation
A Practical Approach Toward Accountable Care and Risk-Based Contracting: Design to Implementation Daniel J. Marino, President/CEO, Health Directions Asad Zaman, MD June 19, 2013 Session Objectives Establish
More informationExpanding Your Pharmacist Team
CALIFORNIA QUALITY COLLABORATIVE CHANGE PACKAGE Expanding Your Pharmacist Team Improving Medication Adherence and Beyond August 2017 TABLE OF CONTENTS Introduction and Purpose 1 The CQC Approach to Addressing
More informationStrengthening Primary Care for Patients:
Strengthening Primary Care for Patients: Geisinger Health Plan Danville, Pa. Background Geisinger Health Plan (GHP) is a nonprofit health maintenance organization serving the health care needs of more
More informationImproving Quality Outcomes in a Risk-Based World: A Davies Story Session #100, March 7, 2018
Improving Quality Outcomes in a Risk-Based World: A Davies Story Session #100, March 7, 2018 David Cloyed, MS, RN-BC, Applications Manager, Nebraska Medicine Tammy Winterboer, PharmD, BCPS, Director, Clinical
More informationIntegrated Health Networks and Healthcare Reform in the U.S. Howard P. Kern, President Sentara Healthcare Norfolk, Virginia USA
Integrated Health Networks and Healthcare Reform in the U.S. Howard P. Kern, President Sentara Healthcare Norfolk, Virginia USA Agenda Current Structure of Healthcare Delivery in the U.S. Sentara Healthcare
More informationPopulation Health for Rural Hospitals: 3. Patient Care Coordination and the Intensive Medical Home
Population Health for Rural Hospitals: 3. Patient Care Coordination and the Intensive Medical Home National Rural Health Resource Center Webinar Series: Population Health for Rural Hospitals For February
More informationAn Emerging Rural ACO: Chautauqua Region s Transitioning Medical Neighborhood/ Accountable Care Community. Stewards of Change June 11, 2013
An Emerging Rural ACO: Chautauqua Region s Transitioning Medical Neighborhood/ Accountable Care Community Stewards of Change June 11, 2013 Chautauqua County, New York Population: 130,000+ Northern tip
More information