Improving Diabetes Care in 75 Minutes. Moderator: Jerry Penso, M.D., M.B.A., President & CEO, AMGA

Size: px
Start display at page:

Download "Improving Diabetes Care in 75 Minutes. Moderator: Jerry Penso, M.D., M.B.A., President & CEO, AMGA"

Transcription

1 Improving Diabetes Care in 75 Minutes Moderator: Jerry Penso, M.D., M.B.A., President & CEO, AMGA

2 SESSION OBJECTIVES 1. Identify specific tactics that health care delivery systems can implement to improve a bundle of outcome measures in diabetes 2. Learn novel ways to engage the entire care team and patients in improving health 3. Discover the advantages of joining a national peer-led campaign to improve diabetes care 2016 AMGF

3 DISCLOSURE Presenters and moderator have no relevant financial or nonfinancial relationships to disclose

4 AGENDA TEAM TECH TRANSPARENCY Robert Zimmerman, M.D. Assistant Medical Director C. Todd Staub, M.D. SVP Physician Relations, OptumCare Lori Arnoldussen, RN Clinical Quality Coordinator

5 IMPROVE DIABETES CARE IN 75 MINUTES: ABOUT TOGETHER 2 GOAL Jerry Penso, M.D., M.B.A. President and CEO, AMGA; President, AMGA Foundation

6 ABOUT AMGA

7 ABOUT TOGETHER 2 GOAL

8 THE REACH OF TOGETHER 2 GOAL CAMPAIGN PARTICIPANTS 150 groups in 35 states 61,000 FTE physicians 2.0 million patients with Type 2 diabetes

9

10 CAMPAIGN GOAL Improve care for 1 million people with Type 2 diabetes

11 IMPROVEMENT THROUGH 2017 Q1 Patients with Improved Care Age ,000 Age ,000

12 IMPROVE DIABETES CARE IN 75 MINUTES: TEAM Robert P. Zimmerman, M.D. Assistant Medical Director, Excela Health Medical Group

13 OBJECTIVES Discuss Care Teams Make up Function Must haves Required support Excela Health Medical Group & Team Based Care/ Together 2 Goal Team Based Care Model Form extended teams Engage teams Optimize processes

14 PROVIDING QUALITY CARE IS A TEAM SPORT

15 HEALTH CARE TEAMS Core Team v. Extended Team Core Team Patient Centered PCP Care team Members Daily Interaction Extended Team Members Additional team members to augment Core PCP Care Team Brings limited resources to the table Intermittent interaction

16 HEALTH CARE TEAMS Function to Improve Standard Work to Decrease Variability Support for Quality Improvement Access Education Care Coordination and Delivery Patient Engagement and Self Management Patient and Care Team Satisfaction Patient Safety

17 HEALTH CARE TEAMS Must have PATIENT AT THE CENTER! Common goals (define and track) Members with well-defined roles and responsibilities and awareness / understanding of those roles Authority Responsibility Accountability Open Lines of Communication

18 HEALTH CARE TEAMS Must be given System buy-in Education Resources Time to meet and build relationships, tools, data Structure Process

19 EXCELA HEALTH MEDICAL GROUP: TEAMS & T2G Excela Health Medical Group: Teams & T2G

20 ABOUT EXCELA HEALTH MEDICAL GROUP ABOUT EXCELA HEALTH MEDICAL GROUP The Excela Health Medical Group is a network of integrated, multi-specialty practices and physicians located in Southwestern Pennsylvania. EHMG is part of Excela Health, a non-profit health system formed in locations -120,000 covered lives - Implementing PCMH model with five recognized Level 3 by NCQA Across 14 specialties

21 ABOUT EXCELA HEALTH MEDICAL GROUP Information Technology Outpatient EHR - Allscripts Touchworks Patient Portal Follow My Health IBM Watson Health solutions IBM Phytel Remind / Outreach 2015 IBM Phytel Insight / Coordinate 2016

22 STRUCTURE OF EHMG QUALITY PROGRAM Physician Quality Committee Set strategy Manage clinical quality and satisfaction goals Call out/ set goals for Corporate Quality Measures Teams to support/operationalize strategy Quality Team Quality Coordinators PCP Care Teams Primary Care Quality Work Group Together 2 Goal Team

23 STEPS 1. Implemented Team Based Care Model STEPS 2. Established Extended Teams 3. Engaged Teams 4. Optimized Processes Through Open Communication

24 1 Implemented Team Based Care Model Implementation of Team Based Care Develop Core Teams Roles and responsibilities Develop standard work/ processes Population-based care Panel Ownership

25 2 Established Extended Teams Established Primary Care Quality Workgroup to augment Primary Care Teams Identified MAs, Patient Information Coordinators, other quality champions across 30 practices Connected the dots among frontline patient care, payer quality programs, and financial impact of programs Empowered to problem solve Established Together 2 Goal Diabetes Team

26 3 Engaged Teams Staff engagement by aligning incentives What s the goal? Improve diabetic care to our patients Provider and staff incentives or skin in the game Staff individual merit increases tied to quality measure performance Tied T2G performance to provider compensation Supports culture of team-based care T2G Planks

27 4 Optimized Processes Through Open Communication Created a culture of open communication Provider group leading change Workgroup + T2G teams actively engaged with Core PCP Teams Staff empowered to share what they needed to be successful Staff feel they are making valued contributions Address I can t do this because Staff wanted to be their best and were able to articulate needs Began asking and addressing What is our data? Why is it our data? What can we do about our data?

28 STEPS 1. Implemented Team Based Care Model 2. Established Extended Teams 3. Engaged Teams 4. Optimized Processes Through Open Communication STEPS Next: Technology Transparency

29 IMPROVE DIABETES CARE IN 75 MINUTES: TECH C. Todd Staub, M.D., FACP SVP Physician Relations, OptumCare

30 Founded primary care practices Two decades of growth and evolution Creating a new culture of team empowerment for primary care Moving to value and pop health Joined OptumCare December physicians 125 APRNs and PAs 400,000 patients statewide Two global cap MA contracts January 2018

31 OPTUMCARE: BUILDING A NATIONAL AMBULATORY DELIVERY SYSTEM

32 Top performer AMGA Measure Up/Pressure Down groups over 150 Top ten percent in Together 2 Goal Top ten percent in MSSP quality ranking 4 ½ stars MA plan Achieved savings in MSSP and commercial ACO

33 FIRST GENERATION TOOLS

34 CREATING BETTER TOOLS TO FIT THE JOB

35 2 ND AND 3 RD GENERATION TOOLS

36 2 ND AND 3 RD GENERATION TOOLS QIS/ProCore fed from data warehouse Daily refresh of data Combine processes: HCC and care gaps Workflow: assign to right team members Outreach: delegated team process Ongoing monitoring of performance Adding in claims data

37 CUSTOM FEEDS TO EVERY APP: A LOT OF PLUMBING MAINTENANCE!

38 DATA LAKE: UNIFIED FEED WITH MULTIPLE APPS

39 TECHNOLOGY & WORKFLOW TO SUPPORT QUALITY METRICS Technology with human centered design Workflow lean and design thinking Within EHR environment user facing Just in time where the clicks need to occur Action steps right next to gaps Daily refresh eliminate rework C. Todd Staub MD FACP

40 IMPROVE DIABETES CARE IN 75 MINUTES: TRANSPARENCY Lori Arnoldussen, R.N. Clinical Quality Coordinator, ThedaCare Physicians

41 THEDACARE Integrated health system in Northeast WI 7 hospitals and 36 primary care clinics throughout 9 counties, with both rural and urban sites

42 LAND OF THE FRIDAY FISH FRY!

43 LAND OF THE FRIDAY FISH FRY!

44 GUIDING PRINCIPLE Quality and safety for our patients is our #1 priority Goal is achieve ZERO defects May mean something different inpatient vs ambulatory Missed A1c, for example, is a defect in ambulatory world Must measure to improve (can t show improvement on what you are not measuring)

45 TRANSPARENCY JOURNEY Former CEO Dr. John Toussaint was passionate about transparency before it was cool Touchpoint Health Plan shared provider level data Early adopter of Epic in 1999

46 WCHQ Founding member WCHQ: Wisconsin Collaborative for Healthcare Quality Publish on website members rates for various measures Our goal is to be in the 90th percentile for each measure (= #1 or #2 in state) Transparent state data has driven up the quality of all the organizations in our state

47 abouthealth Newer generation of sharing data and tactics to improve health of our communities, by delivering a consistent and reliable high quality healthcare, at a lower and more affordable cost 6 major healthcare systems in WI working together (collabetition)

48 abouthealth

49 INTERNAL TRANSPARENCY Quality Plan 10 metrics Compensation for meeting tiered rates, based at group level Data shared on intranet, at provider meetings, staff meetings, Quality team meetings Open to view to whole system Drives health competition

50 MONTHLY QUALITY PLAN

51 MONTHLY QUALITY PLAN

52 MONTHLY QUALITY PLAN

53 INTERNAL TRANSPARENCY

54 INTERNAL TRANSPARENCY

55 INTERNAL TRANSPARENCY

56 INTERNAL TRANSPARENCY

57 INTERNAL TRANSPARENCY

58 INTERNAL TRANSPARENCY

59 INTERNAL TRANSPARENCY

60 LEARNINGS Initially: I always check an A1c twice a year Then: mistrust of data YOUR data is wrong Acceptance: ok, well what do I need to do? Not easy/intuitive on how to manage a population

61 PROCESS Ensure data validity Plan-Do-Study-Act Share data (assume you are at believing it at this point) Clarification of roles (Med Assistant, RN, MD) We have done this without ambulatory care managers

62 PROCESS Prioritize measures Low hanging fruit to start with Builds confidence and experience with the processes of reading reports and acting upon them Advance to more complicated measures Visual management of progress and success

63 KEYS TO SUCCESS Quality is on every agenda Multiple methods of seeing the same data and communication of that data Data is not mine, it s ours

64 IMPROVE DIABETES CARE IN 75 MINUTES: Q&A Moderator: Jerry Penso, M.D., M.B.A. President and CEO, AMGA; President, AMGA Foundation

65 QUESTIONS

Examining the Differences Between Commercial and Medicare ACO Models

Examining the Differences Between Commercial and Medicare ACO Models Examining the Differences Between Commercial and Medicare ACO Models Michelle Copenhaver December 10, 2015 Agenda 1 Understanding Accountable Care Organizations 2 Moving to Accountable Care: Enhancing

More information

CREATING A NATIONAL CAMPAIGN TO IMPROVE HYPERTENSION CONTROL. Improving chronic care: It takes a team

CREATING 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 information

Complex Patient Care Redesign: ThedaCare Innovation. Gregory Long, MD Chief Medical Officer

Complex Patient Care Redesign: ThedaCare Innovation. Gregory Long, MD Chief Medical Officer Complex Patient Care Redesign: ThedaCare Innovation Gregory Long, MD Chief Medical Officer ThedaCare Northeastern Wisconsin An Integrated Community Health System; >7000 employees Primary service area of

More information

System Options to Achieve the Triple Aim

System Options to Achieve the Triple Aim D30/E30 This presenter has nothing to disclose System Options to Achieve the Triple Aim David M. Williams, MD, CPE Medical Director UnityPoint Health Partners December 10, 2014 Objectives Evaluate their

More information

7/7/17. Value and Quality in Health Care. Kevin Shah, MD MBA. Overview of Quality. Define. Measure. Improve

7/7/17. 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 information

Prevea Health Automates Population Health Management and Improves Health Outcomes

Prevea Health Automates Population Health Management and Improves Health Outcomes CASE STUDY Prevea Health Prevea Health Automates Population Health Management and Improves Health Outcomes After adopting the patient-centered medical home care delivery model to improve the health and

More information

A strategy for building a value-based care program

A strategy for building a value-based care program 3M Health Information Systems A strategy for building a value-based care program How data can help you shift to value from fee-for-service payment What is value-based care? Value-based care is any structure

More information

Sharp HealthCare ACO. Presented by: Donald C. Balfour, M.D. President and Medical Director Sharp Rees-Stealy Medical Group

Sharp HealthCare ACO. Presented by: Donald C. Balfour, M.D. President and Medical Director Sharp Rees-Stealy Medical Group Sharp HealthCare ACO Presented by: Donald C. Balfour, M.D. President and Medical Director Sharp Rees-Stealy Medical Group Institute for Quality Leadership Annual Conference October 4, 2012 Sharp ACO Collaborations

More information

ACOs: Transforming Systems with New Payment Models & Community Integration

ACOs: 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 information

Using Data for Proactive Patient Population Management

Using 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 information

Connected Care Partners

Connected Care Partners Connected Care Partners Our Discussion Today Introducing the Connected Care Partners CIN What is a Clinically Integrated Network (CIN) and why is the time right to join the Connected Care Partners CIN?

More information

Thought Leadership Series White Paper The Journey to Population Health and Risk

Thought Leadership Series White Paper The Journey to Population Health and Risk AMGA Consulting Thought Leadership Series White Paper The Journey to Population Health and Risk The Journey to Population Health and Risk Howard B. Graman, M.D., FACP White Paper, January 2016 While the

More information

Describe the process for implementing an OP CDI program

Describe the process for implementing an OP CDI program 1 Outpatient CDI: The Marriage of MACRA and HCCs Marion Kruse, RN, MBA Founding Partner LYM Consulting Columbus, OH Learning Objectives At the completion of this educational activity, the learner will

More information

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred 1

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred   1 POPULATION HEALTH PLAYBOOK Mark Wendling, MD Executive Director LVPHO/Valley Preferred www.populytics.com 1 Today s Agenda Outline LVHN, LVPHO and Populytics Overview Population Health Approach Population

More information

The Accountable Care Organization Specific Objectives

The Accountable Care Organization Specific Objectives Accountable Care Organizations and You E. Christopher h Ellison, MD, F.A.C.S Senior Associate Vice President for Health Sciences CEO, OSU Faculty Group Practice Chair, Department of Surgery Ohio State

More information

Building the Universal Roadmap to Population Health Management

Building the Universal Roadmap to Population Health Management Building the Universal Roadmap to Population Health Management Executive Webinar January 21, 2016 Karen Handmaker, MPP, PCMH CCE IBM Watson Health House Keeping 1. Using the control panel Use the control

More information

Using EHRs and Case Management to Improve Patient Care and Population Health

Using EHRs and Case Management to Improve Patient Care and Population Health Using EHRs and Case Management to Improve Patient Care and Population Health Session #211, February 22, 2017 Thomas Schiller, MD and Jennifer Kuroda, SwedishAmerican Health System A Division of UW 1 Speaker

More information

AmeriHealth Michigan Provider Overview. April, 2014

AmeriHealth Michigan Provider Overview. April, 2014 AmeriHealth Michigan Provider Overview April, 2014 Who We Are Our Mission Dual Demonstration of Michigan AmeriHealth VIP Care Plus Agenda Our Record of Success Integrated Care Management Provider Partnerships

More information

From Reactive to Proactive: Creating a Population Management Platform

From 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 information

Population 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 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 information

Payment Reform Strategies. Ann Thomas Burnett BlueCross BlueShield of South Carolina

Payment Reform Strategies. Ann Thomas Burnett BlueCross BlueShield of South Carolina Payment Reform Strategies Ann Thomas Burnett BlueCross BlueShield of South Carolina Disclosure I have no relevant financial relationships with commercial interests to disclose. The Current Market Landscape

More information

Introducing AmeriHealth Caritas Iowa

Introducing AmeriHealth Caritas Iowa Introducing AmeriHealth Caritas Iowa A presentation for Iowa providers. CPC; Q215 Iowa V1 Who We Are Who We Serve Agenda Our Mission AmeriHealth Caritas Iowa Why Partner With Us? Questions 2 2 Who We Are

More information

Population 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 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 information

INTEGRATED DATA ANALYTICS AND CARE WORKFLOW OPTIMIZATION

INTEGRATED DATA ANALYTICS AND CARE WORKFLOW OPTIMIZATION INTEGRATED DATA ANALYTICS AND CARE WORKFLOW OPTIMIZATION CASE STUDY October 2016 1 AGENDA 1 2 3 INTRODUCTIONS Speaker and System 4 Q+A VALUE OF INTEGRATED DATA Why effective ACOs require EHR, Claims, and

More information

ACHIEVING POPULATION HEALTH: THE POWER OF TEAM BASED CARE

ACHIEVING POPULATION HEALTH: THE POWER OF TEAM BASED CARE ACHIEVING POPULATION HEALTH: THE POWER OF TEAM BASED CARE JAMES JERZAK M.D. KATHY KERSCHER, MBA BELLIN HEALTH GREEN BAY WI IHI NATIONAL FORUM 12 13 2017 2 GREEN BAY, WISCONSIN Agenda Why Team-Based Care

More information

Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director

Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director AMGA Pre-conference Workshop 1 April 14, 2011 Washington, D.C. Disclosure Nothing in Today

More information

Disclaimer This webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws.

Disclaimer This webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws. Disclaimer This webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws. This should not be used as legal advice. Itentive recognizes that

More information

IBM Watson Health Utica Park Clinic The need The solution The benefit

IBM Watson Health Utica Park Clinic The need The solution The benefit Utica Park Clinic Population health management helps Utica Park Clinic ease the transition to value-based care Overview The need Utica Park Clinic needed to balance the challenging financial implications

More information

Product 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 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 information

Goals & Challenges for Outpatient Quality Directors. Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE

Goals & Challenges for Outpatient Quality Directors. Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE Goals & Challenges for Outpatient Quality Directors Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE Objectives Learn a practical way for Quality Directors to align Quality Measures

More information

HealthPartners and the Triple Aim. IHI Open School August 23, 2012 Beth Waterman, RN MBA Chief Improvement Officer HealthPartners

HealthPartners and the Triple Aim. IHI Open School August 23, 2012 Beth Waterman, RN MBA Chief Improvement Officer HealthPartners HealthPartners and the Triple Aim IHI Open School August 23, 2012 Beth Waterman, RN MBA Chief Improvement Officer HealthPartners HealthPartners Not for profit, consumer governed Integrated care and financing

More information

Appleton, WI Lori Arnoldussen Kim Wildes

Appleton, WI Lori Arnoldussen Kim Wildes Appleton, WI Lori Arnoldussen Kim Wildes The speaker has no actual or potential conflict of interest in relation to this presentation. ThedaCare Physicians 200 Providers 27 Clinic locations 480, 260 office

More information

Building & Strengthening Patient Centered Medical Homes in the Safety Net

Building & Strengthening Patient Centered Medical Homes in the Safety Net Blue Shield of California Foundation County Coverage Expansion Planning Workshop #2 Building & Strengthening Patient Centered Medical Homes in the Safety Net July 8, 2011 Presented by: Kathryn Phillips,

More information

New Strategies in Value Based Care

New Strategies in Value Based Care New Strategies in Value Based Care D. Keith Fernandez, M.D. Chief Clinical Officer, Privia Health CEO, Privia Medical Group Gulf Coast 713-545-1366 kfernandez@priviahealth.com none Disclosures Learning

More information

Rural and Independent Primary Care.

Rural and Independent Primary Care. Rural and Independent Primary Care www.caravanhealth.com Agenda 2015 Results from Rural ACO Participants Fundamental population health programs. Overview of additional rural value-based payments Opportunities

More information

Sustaining a Patient Centered Medical Home Program

Sustaining 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 information

Population 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 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 information

Strategy Guide Specialty Care Practice Assessment

Strategy 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 information

Understanding the Initiative Landscape in Medi-Cal. IHA Stakeholder Meeting September 23, 2016 Sarah Lally, Project Manager

Understanding the Initiative Landscape in Medi-Cal. IHA Stakeholder Meeting September 23, 2016 Sarah Lally, Project Manager Understanding the Initiative Landscape in Medi-Cal IHA Stakeholder Meeting September 23, 2016 Sarah Lally, Project Manager Agenda Welcome / Introduction Sarah Lally, Project Manager Inland Empire Health

More information

Physician Engagement

Physician 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 information

Population Health Management Tools to Improve Care for Individuals and Populations of Patients

Population Health Management Tools to Improve Care for Individuals and Populations of Patients June 1, 2015 Population Health Management Tools to Improve Care for Individuals and Populations of Patients Joel Diamond, MD, FAAP Building Population Health Information-powered clinical decision-making

More information

How Data-Driven Safety Culture Changes Can Lower HAC Rates

How Data-Driven Safety Culture Changes Can Lower HAC Rates How Data-Driven Safety Culture Changes Can Lower HAC Rates Session #226, February 23, 2017 Holly O Brien & Abby Dexter Children s Hospital of Wisconsin 1 Speaker Introduction Holly O Brien, MSN RN Safety

More information

40,000 Covered Lives: Improving Performance on ACO MSSP Metrics

40,000 Covered Lives: Improving Performance on ACO MSSP Metrics Success Story 40,000 Covered Lives: Improving Performance on ACO MSSP Metrics EXECUTIVE SUMMARY The United States healthcare system is the most expensive in the world, but data consistently shows the U.S.

More information

Improving Clinical Flow ECHO Collaborative Change Package

Improving Clinical Flow ECHO Collaborative Change Package Primary Drivers (driver diagram) Change Concepts Change Ideas Examples, Tips, and Resources Engaged Leadership Develop culture for transformation Use walk-arounds and attendance at team meetings to talk

More information

One Medicine: Incorporating Population Health Principles and Best Practices into Clinical Workflow

One Medicine: Incorporating Population Health Principles and Best Practices into Clinical Workflow One Medicine: Incorporating Population Health Principles and Best Practices into Clinical Workflow March 5, 2018 Jayne Bassler President, Population Health Services Organization Senior Vice President,

More information

Transitions of Care: Primary Care Perspective. Patrick Noonan, DO

Transitions of Care: Primary Care Perspective. Patrick Noonan, DO Transitions of Care: Primary Care Perspective Patrick Noonan, DO Disclosures None Bio Outpatient primary care internist at New Pueblo Medicine Completed residency at the University of Iowa Graduated from

More information

Managing Population Health in Northeast Georgia: One Medical Group's Experience

Managing Population Health in Northeast Georgia: One Medical Group's Experience September 21, 2013 Managing Population Health in Northeast Georgia: One Medical Group's Experience By Mark Hagland Northeast Georgia Physicians Group (NGPG), based in Gainesville, Georgia, a suburb of

More information

Primary Care Transformation in the Era of Value

Primary Care Transformation in the Era of Value Primary Care Transformation in the Era of Value CMS Innovation Center & Primary Care Bruce Finke, MD Janel Jin, MSPH Gabrielle Schechter, MPH Center for Medicare & Medicaid Innovation Centers for Medicare

More information

Improving Care and Lowering Costs: The Use of Clinical Data by Medicaid Managed Care Organizations. April 26, 2018

Improving Care and Lowering Costs: The Use of Clinical Data by Medicaid Managed Care Organizations. April 26, 2018 Improving Care and Lowering Costs: The Use of Clinical Data by Medicaid Managed Care Organizations April 26, 2018 Agenda Welcome and Overview of Interview Results Claudia Ellison, Director of Programs,

More information

HIT Innovations to Build an Empowering and Learning Culture March 2, 2016

HIT Innovations to Build an Empowering and Learning Culture March 2, 2016 HIT Innovations to Build an Empowering and Learning Culture March 2, 2016 Jignesh Sheth, MD, Senior Vice President for Clinical Operations Courtney Dempsey, Clinical Innovation Specialist Conflict of Interest

More information

The Four Pillars of Ambulatory Care Management - Transforming the Ambulatory Operational Framework

The Four Pillars of Ambulatory Care Management - Transforming the Ambulatory Operational Framework The Four Pillars of Ambulatory Care Management - Transforming the Ambulatory Operational Framework Institution: The Emory Clinic, Inc. Author/Co-author(s): Donald I. Brunn, Chief Operating Officer, The

More information

CAHPS Focus on Improvement The Changing Landscape of Health Care. Ann H. Corba Patient Experience Advisor Press Ganey Associates

CAHPS Focus on Improvement The Changing Landscape of Health Care. Ann H. Corba Patient Experience Advisor Press Ganey Associates CAHPS Focus on Improvement The Changing Landscape of Health Care Ann H. Corba Patient Experience Advisor Press Ganey Associates How we will spend our time together Current CAHPS Surveys New CAHPS Surveys

More information

UNITED STATES HEALTH CARE REFORM: EARLY LESSONS FROM ACCOUNTABLE CARE ORGANIZATIONS

UNITED 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 information

Presbyterian Healthcare Services Care Management

Presbyterian Healthcare Services Care Management Presbyterian Healthcare Services Care Management Kathy M. Garcia RN, BSN Director of Nursing, Primary Care Service Line November 2012 Future Healthcare Challenges Increasing number of patients Decreasing

More information

Practice Transformation Networks

Practice Transformation Networks Practice Transformation Networks The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U. S. Department of Health & Human Services, Centers for Medicare and Medicaid

More information

Lahey Health and Cleveland Clinic: Building a Primary Care Strategy out of a Surgical Legacy

Lahey Health and Cleveland Clinic: Building a Primary Care Strategy out of a Surgical Legacy Lahey Health and Cleveland Clinic: Building a Primary Care Strategy out of a Surgical Legacy AMGA 2015 March 26, 2015 Kimberly Smith, Managing Partner, Eastern Region and Vice Chair, Witt/Kieffer David

More information

Patient-Centered Medical Home 101: General Overview

Patient-Centered Medical Home 101: General Overview Patient-Centered Medical Home 101: General Overview Publicly Available Slide Deck Last Updated: January 2015 Suggested Citation: PCPCC Map Tools. (2015). Patient-Centered Medical Home 101: General Overview.

More information

Specialty practices and primary care practices join forces in providing patient centered medical care

Specialty practices and primary care practices join forces in providing patient centered medical care Welcome, Neighbor! Specialty practices and primary care practices join forces in providing patient centered medical care We often hear our patients express their frustration as they navigate among their

More information

Alternative Payment Models for Behavioral Health Kim Cox VP, Provider Network

Alternative Payment Models for Behavioral Health Kim Cox VP, Provider Network Alternative Payment Models for Behavioral Health Kim Cox VP, Provider Network Kim Cox Vice President, Provider Network, Optum Kim Cox is Vice President of Provider Network. She joined Optum in February

More information

Jumpstarting population health management

Jumpstarting 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 information

Midmark White Paper The Connected Point of Care Ecosystem: A Solid Foundation for Value-Based Care

Midmark White Paper The Connected Point of Care Ecosystem: A Solid Foundation for Value-Based Care Midmark White Paper The Connected Point of Care Ecosystem: A Solid Foundation for Value-Based Care Introduction This white paper examines how new technologies are creating a fully connected point of care

More information

Skating to Where the Puck is Going: Living, Thriving and Growing in the World of Value-Based Care

Skating to Where the Puck is Going: Living, Thriving and Growing in the World of Value-Based Care Skating to Where the Puck is Going: Living, Thriving and Growing in the World of Value-Based Care Craig E. Samitt, MD, MBA AMGA Institute for Quality Leadership November 13, 2014 Introduction to Dean

More information

From 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 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 information

Payer Perspectives On Value-based Contracting

Payer Perspectives On Value-based Contracting Payer Perspectives On Value-based Contracting Miles Snowden, MD, MPH, CEBS Chief Medical Officer 1 A simple goal Making the health system work better for everyone 2 Optum serves 60,000,000+ individuals

More information

Best Practices Contracting for Health IT Supporting Pay-for-Performance (P4P) Early Findings

Best Practices Contracting for Health IT Supporting Pay-for-Performance (P4P) Early Findings Best Practices Contracting for Health IT Supporting Pay-for-Performance (P4P) Early Findings Researchers: Martin, Thomas R. PhD, Assistant Professor St. Joseph s University Department of Health Services;

More information

Practical Population Health

Practical Population Health Practical Population Health Key Steps to Identify, Stratify, and Manage Patients HFMA Managed Care Meeting January 29, 2015 Objectives Discuss the key capabilities for an effective care model for population

More information

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013 5D QAPI from an Operational Approach Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Objectives Review the post-acute care data agenda. Explain QAPI principles Describe leadership

More information

Reducing 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 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 information

Bright Spots in primary care

Bright Spots in primary care Bright Spots in primary care A High- Performing Teaching Practice: Site Visit to Oregon Health & Science University s (OHSU) Family Medicine Clinic at Gabriel Park General information Tom Bodenheimer MD

More information

Advancing Primary Care Delivery

Advancing Primary Care Delivery Advancing Primary Care Delivery Tenth National Pay for Performance Summit March 3, 2015 Simeon Schwartz, MD CEO, WESTMED Medical Group, P.C. WESTMED Medical Group Established 1996 by 16 physicians 300

More information

Population Health: Tamara Cull, MSW, LCSW, ACM National Director, Care Management, Value Based Programs and Operations November, 2014

Population Health: Tamara Cull, MSW, LCSW, ACM National Director, Care Management, Value Based Programs and Operations November, 2014 In the Hospital and Health System ACO Tamara Cull, MSW, LCSW, ACM National Director, Care Management, Value Based Programs and Operations November, 2014 What We ll Be Discussing Who is CHI What are we

More information

Making Differences Matter Redesign Ambulatory Medication Reconciliation

Making Differences Matter Redesign Ambulatory Medication Reconciliation Making Differences Matter Redesign Ambulatory Medication Reconciliation AMGA Annual Meeting April 5 2014 Presenters Thomas N. Atkins, MD MMM,FAAFP, FACPE, CPE Steven A. Mitnick MD MBA Katherine T. Manuel,

More information

Decreasing Medical. Costs. Are your members listening to you? PRESENTED BY: September 22, 2016

Decreasing Medical. Costs. Are your members listening to you? PRESENTED BY: September 22, 2016 Decreasing Medical Costs Are your members listening to you? PRESENTED BY: Aaron Crowell, Executive Vice President, MTM, Inc. Gary Jacobs, Executive Vice President, CareCentrix Dan Masciopinto, SVP of Product,

More information

Patient Engagement in the Population Health Management Era

Patient Engagement in the Population Health Management Era Patient Engagement in the Population Health Management Era Creagh Milford, DO, MPH President, Population Health Services A Catholic healthcare ministry serving Ohio and Kentucky Agenda Agenda I. Overview

More information

Shared Governance and Analytics Framework Improves Quality

Shared Governance and Analytics Framework Improves Quality Shared Governance and Analytics Framework Improves Quality Session 154, March 7, 2018 Kate Mundell, MBA, PMP MultiCare Connected Care Amber Theel, BSN, MBA, CPHQ, CPHRM MultiCare Health System 1 Conflict

More information

Delivering Great Care with High Reliability

Delivering Great Care with High Reliability FE4 These presenters have nothing to disclose Delivering Great Care with High Reliability The Orlando Health Journey December 5, 2016 Joelle Baehrend, MA Director, Institute of Healthcare Improvement 1

More information

Essentia Health. A View on Information Technology. ND HIMS Conference April 12, Tim Sayler, COO Essentia Health - West

Essentia Health. A View on Information Technology. ND HIMS Conference April 12, Tim Sayler, COO Essentia Health - West Essentia Health A View on Information Technology ND HIMS Conference April 12, 2017 Tim Sayler, COO Essentia Health - West Me Discussing Information Technology Who is Essentia Overview Why: Information

More information

Managing Patients with Multiple Chronic Conditions

Managing 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 information

Value Proposition: Tiered Network Plan Design for Navigator by Tufts Health Plan

Value Proposition: Tiered Network Plan Design for Navigator by Tufts Health Plan Value Proposition: Tiered Network Plan Design for Navigator by Tufts Health Plan John D. Freedman, MD, MBA National Health Policy Forum July 28, 2005 Outline Objectives Understand market dynamics and rationale

More information

ACHIEVING THE TRIPLE AIM THROUGH LARGE SCALE IMPROVEMENT EFFORTS JASON FOLTZ, D.O. TEACHERS OF QUALITY ACADEMY QI SYMPOSIUM MARCH 2, 2016

ACHIEVING THE TRIPLE AIM THROUGH LARGE SCALE IMPROVEMENT EFFORTS JASON FOLTZ, D.O. TEACHERS OF QUALITY ACADEMY QI SYMPOSIUM MARCH 2, 2016 ACHIEVING THE TRIPLE AIM THROUGH LARGE SCALE IMPROVEMENT EFFORTS JASON FOLTZ, D.O. TEACHERS OF QUALITY ACADEMY QI SYMPOSIUM MARCH 2, 2016 OVERVIEW: WHAT, WHO, HOW? What: How do you move a large multi-specialty

More information

update An Inside Look Into the EHR Intersections of the Updated Patient-Centered Medical Home (PCMH) Care Model May 12, 2016

update An Inside Look Into the EHR Intersections of the Updated Patient-Centered Medical Home (PCMH) Care Model May 12, 2016 update An Inside Look Into the EHR Intersections of the Updated Patient-Centered Medical Home (PCMH) Care Model May 12, 2016 Agenda PCMH: 360 o PCMH to date o Evidence based results o Updated Standards:

More information

Data The New Healthcare Currency

Data The New Healthcare Currency Data The New Healthcare Currency Safety Net Analytics Program Los Angeles, CA February 16, 2017 Scott Barlow CEO 2 Revere Health Founded in 1969, with over 170 physicians. High growth rate. Multi-specialty,

More information

Patient Centered Medical Home: Transforming Primary Care in Massachusetts

Patient 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 information

Intelligent Healthcare. Intelligent Solutions for Achieving Clinical Integration & Accountable Care. Case Study: Advocate Physician Partners

Intelligent Healthcare. Intelligent Solutions for Achieving Clinical Integration & Accountable Care. Case Study: Advocate Physician Partners Solutions for Achieving Clinical Integration & Accountable Care Case Study: Advocate Physician Partners Provide physicians with the right information, and they will make the right decisions. Paul Katz,

More information

EHR Enablement for Data Capture

EHR Enablement for Data Capture EHR Enablement for Data Capture Baylor Scott & White (15 min) Bonnie Hodges, RN University of Chicago Medicine(15 min) Susan M. Sullivan, RHIA, CPHQ Kaiser Permanente (15 min) Molly P. Clopp, RN Tammy

More information

Clinical 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 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 information

CPC+ CHANGE PACKAGE January 2017

CPC+ CHANGE PACKAGE January 2017 CPC+ CHANGE PACKAGE January 2017 Table of Contents CPC+ DRIVER DIAGRAM... 3 CPC+ CHANGE PACKAGE... 4 DRIVER 1: Five Comprehensive Primary Care Functions... 4 FUNCTION 1: Access and Continuity... 4 FUNCTION

More information

The influx of newly insured Californians through

The influx of newly insured Californians through January 2016 Managing Cost of Care: Lessons from Successful Organizations Issue Brief The influx of newly insured Californians through the public exchange and Medicaid expansion has renewed efforts by

More information

The Cleveland Clinic s Journey from Volume to Value in the Era of Healthcare Reform

The Cleveland Clinic s Journey from Volume to Value in the Era of Healthcare Reform The Cleveland Clinic s Journey from Volume to Value in the Era of Healthcare Reform David L. Longworth, M.D. Chair, Medicine Institute Associate Chief of Staff, Clinical Integration Development Cleveland

More information

From Implementation to Optimization: Moving Beyond Operations

From Implementation to Optimization: Moving Beyond Operations From Implementation to Optimization: Moving Beyond Operations Session 260, March 8, 2018 Scott Aikey, Sr. Director, Core Clinical Applications Children s Hospital of Philadelphia 1 Conflict of Interest

More information

Medicare 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 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 information

Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual

Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual 2016 This document is a guide to the 2016 Arkansas Blue Cross and Blue Shield Patient-Centered Medical Home program (Arkansas

More information

The Connected Point of Care Ecosystem: A Solid Foundation for Value-Based Care

The Connected Point of Care Ecosystem: A Solid Foundation for Value-Based Care Includes Suggestions for Leveraging Improved BP Measurements to Achieve Quality Metrics Midmark White Paper The Connected Point of Care Ecosystem: A Solid Foundation for Value-Based Care Introduction This

More information

Value-Based Care Contracting and Legal Issues

Value-Based Care Contracting and Legal Issues Session 4b Value-Based Care Contracting and Legal Issues Presented by: Janet Walker Farrer General Counsel and Insurance Legal Department Chair Ascension Health Leah Stewart Associate Vice President for

More information

Blue 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 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 information

Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation. April 4, :45 5:00 pm

Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation. April 4, :45 5:00 pm Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation April 4, 2014 3:45 5:00 pm 1 Introduction Kevin McCune, MD Chief Medical Officer Advocate Medical Group Peg Stone Vice

More information

THE BEST OF TIMES: PHARMACY IN AN ERA OF

THE BEST OF TIMES: PHARMACY IN AN ERA OF OBJECTIVES THE BEST OF TIMES: PHARMACY IN AN ERA OF ACCOUNTABLE CARE Toni Fera, BS, PharmD October 17, 2014 1. Describe the role of pharmacists in accountable care organizations (ACO). 2. List four key

More information

Delivering Great Care with High Reliability The Orlando Health Journey

Delivering Great Care with High Reliability The Orlando Health Journey FE5 These presenters have nothing to disclose Delivering Great Care with High Reliability The Orlando Health Journey December 11, 2017 Frank Federico, RPh Vice President Patricia McGaffigan, RN, MS, CPPS

More information

group practice journal

group practice journal group practice journal PUBLICATION OF THE AMERICAN MEDICAL G R O U P A S S O C I A T I O N The Sharp Experience: A Journey to Healthcare Excellence 2009 Acclaim Award Honoree Sharp Rees-Stealy Medical

More information

Transforming Delivery Systems for Population Health

Transforming Delivery Systems for Population Health Transforming Delivery Systems for Population Health George Isham, M.D., M.S. Senior Advisor, HealthPartners Senior Fellow, HealthPartners Institute for Education and Research October 9, 2015 Presenter

More information