Comprehensive Primary Care: Our Success Story
|
|
- Martina Allen
- 5 years ago
- Views:
Transcription
1 Comprehensive Primary Care: Our Success Story March 2, 2016 Tamra Lavengood, RN, BSN, MSN CPC Coordinator and Clinical Performance Coordinator Centura Health Physician Group, Centura Health Will McConnell, PhD, MBA, MS VP Operations and Outreach Strategy Mercy Regional Medical Center, Centura Health
2 Introductions Tamra Lavengood, RN, BSN, MSN, CPNP, CCNS Clinical Performance Coordinator for Centura Health Physician Group in Colorado Coordinator for the Comprehensive Primary Care Initiative for Mercy Family Medicine in Durango, Colorado Will McConnell, PhD, MBA, MS VP Operations and Outreach Strategy for Mercy Regional Medical Center in Durango, ColoradoWill McConnell, PhD, MBA, MS VP Operations and Outreach Strategy Mercy Regional Medical Center
3 Conflict of Interest Tamra Lavengood, RN, BSN, MSN Will McConnell, PhD, MBA, MS Have no real or apparent conflicts of interest to report
4 Learning Objectives Objectives: Identify four qualitative and four quantitative elements used to determine an individual's health risk Construct an adaptation of a paper or electronic risk stratification tool using the Mercy Adult Risk Stratification Tool (MARST) Adapt a methodology for emergency department (ED) and hospital follow up Influence electronic health record (EHR) vendors to adapt a risk stratification methodology that assesses the whole person Influence the current healthcare environment to prepare for population health management
5 Agenda The Beginnings What is the CPC Initiative? Why did Mercy Family Medicine choose to participate? Barriers Our Comprehensive Primary Care Initiative Story Task Force 9 milestones, key elements Empanelment Risk stratification Mercy Adult Risk Stratification Tool (MARST) development Care Management vs. Care Coordination ED and hospital follow-up Outcomes and lessons learned
6 Benefits Realized for the Value of Health IT STEPSTM VALUE CATEGORIES Treatment/Clinical: Care Management for high-risk patients identified by risk stratification looking at the whole person; ED and hospital follow-up care management; and care management to include behavioral health integration Savings: Realized by decreased Per Member Per Month (PMPM) expenses for Medicare population due to decreased ED utilization, hospital admissions for any cause and hospital admissions for Ambulatory Care Sensitive Conditions (ACSC)
7 What is the Comprehensive Primary Care Initiative? Four-year multi-payer initiative designed to strengthen primary care Population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five Comprehensive primary care functions. Risk stratified care management Access and continuity Planned care for chronic conditions and preventive care Patient and caregiver engagement Coordination of care across the medical neighborhood
8 What is the Comprehensive Primary Care Initiative? Demographics 474 practice sites 2,200 practitioners 2.7 million active patients 38 public and private payers 335,000 Medicare beneficiaries Purpose Improved care Better health for populations Lower costs Inform future Medicare and Medicaid policy
9 What is the Comprehensive Primary Care Initiative? Payment Model Participating primary care practices receive two forms of financial support on behalf of their fee-for-service (FFS) Medicare beneficiaries: A monthly non-visit based care management fee The opportunity to share in any net savings to the Medicare program
10 Why did Mercy Family Medicine Choose to Participate? Value-based purchasing was getting a lot of attention We needed to identify viable payment models and prepare for the future Cost neutral solution Alignment with PCMH status Great group of clinicians and staff Huge potential within CPC Timing was right
11 Barriers to get the Comprehensive Primary Care Initiative started One more thing to do Do we have the bandwidth? Moving into uncertain territory with CPC A lot of additional reporting and process work would be needed No real quantifiable risk stratification tools in the beginning Practice was recently acquired
12 Comprehensive Primary Care Initiative: Our Story Center for Medicare and Medicaid had a great idea! Privileged to be a part of initiative Started with a Task Force
13 Comprehensive Primary Care: 9 Milestones 1. Budget 2. Care management for high-risk patients 3. Access and continuity 4. Patient experience 5. Quality improvement 6. Care coordination across the medical neighborhood 7. Shared decision making 8. Participation in learning collaboratives 9. Health Information Technology
14 Comprehensive Primary Care Initiative: Our Story CMS selected key elements that aligned with Patient Centered Medical Home elements Milestone 2: Empanelment; Risk Stratification; Care Management; Behavioral Health Integration
15 Comprehensive Primary Care Initiative: Our Story Empanelment End of 2012 = 79% End of 2015 = 99.9% Four Cut Method (1) Care Teams (1) Panel Size: How Many Patients Can One doctor Have?, Mark Murray, MD,MPA, Mike Davies, MD, Barbara Boushon, RN,Fam Pract Manag Apr; 14(4):44-51
16 Comprehensive Primary Care Initiative: Our Story Risk Stratification All 500 clinics asked to develop their own risk stratification methodology Mercy Family Medicine reviewed tools from: California Quality Collaborative AAFP Risk Stratification Tool Telluride Medical Center in Colorado (another CPC practice)
17 Risk Stratification in CPC Practices Comprehensive Primary Care practices risk stratify their patients by: Clinical intuition: 71% Practice developed clinical algorithm: 61% Published clinical algorithm: 40% Claims: 24% EHR methodology: 19% Practices were able to select more than one method
18 Comprehensive Primary Care Initiative Our Story Developed our own Mercy Adult Risk Stratification Tool (MARST) and the Mercy Pediatric Risk Stratification Tool (MPRST) Critical to have not only Objective elements but Subjective elements as well
19
20
21 HIT Needed for Risk Stratification Using the system we had Our risk stratification elements flow exactly like our EHR
22 Mercy Adult Risk Stratification Tool Have risk stratified over 14,300 patients 1.1% Highest risk Level % High risk Level 5 (6.5%) and Level 4 (13.9%) 25.3% Medium risk Level % Low risk Level % Low risk Level 1
23 Risk Stratification and Care Management
24 Risk Stratification Care Management
25 Behavioral Health Integration Behavioral Health care is needed for the majority of level 6 patients In house Licensed Clinical Social Worker Warm handoffs Scheduled patients Evaluation tools: PHQ9 Tracking depression screening
26 Care Coordination Care coordination across the Medical Neighborhood Emergency Department discharges Hospital discharges
27
28 Medicare Expenses Per Patient Per Month, All Attributed Patients
29 Medicare Expenses Per Patient Per Month, for Patients in the Highest Risk Quartile
30 Hospital admissions, ED Visits, 30 day Re-Admissions for all attributed Medicare Patients
31 Hospital admissions, ED Visits, 30 day Re-Admissions for all Medicare patients in the highest risk quartile
32 A Summary of How Benefits Were Realized for the Value of Health IT STEPSTM VALUE CATEGORIES Treatment/Clinical: Care Management for high-risk patients via shared care plans, and improved communication with providers both inpatient and outpatient; Care Management, including behavioral health integration for high-risk patients and for chronic disease management led to reduced ED visits and hospitalizations for any cause and for Ambulatory Care Sensitive Conditions (ACSC); Care Management communication between the inpatient and outpatient settings for ED and hospital discharges enabling follow up at 97.5% within 1.8 day for ED visits and 96.7% within 8hrs for hospital discharges
33 A Summary of How Benefits Were Realized for the Value of Health IT STEPSTM VALUE CATEGORIES Savings: Decreased Per Member Per Month (PMPM) expenses for Medicare population of $608, 10 th lowest in Colorado region of 75 practices of which $677 is the median and high $1,168; decreased for Highest-Risk Quartile PMPM expense of $989, 10 th lowest and median of $1,191 and high $2,247 for Colorado region Decreased ED utilization by 5% from 611 to 580 (not risk adjusted) per 1000 Medicare patients per year from last quarter equaling cost savings of $52K ($650/visit) Decreased hospital admissions for any cause of 1.1% per 1000 Medicare patients per year from last quarter cost savings of $135,200 ($26,000/stay) Decreased hospital admissions for Ambulatory Care Sensitive Conditions (ACSC) by 8% per 1000 Medicare patients per year from last quarter cost savings of $135,200. Total cost savings annually $1,289,600
34 Questions Please reach out to us: Tamra Lavengood RN, BSN, MSN Will McConnell PhD, MBA, MS Clinical Performance Coordinator VP Operations and Strategic Outreach CPCI Coordinator Mercy Family Medicine Mercy Regional Medical Center Centura Health Physician Group Centura Health (direct) (direct) (cell) 1 Mercado Street Suite295 Durango CO 81301
Leveraging Health IT to Risk Adjust Patients Session ID: QU2; February 19 th, 2017
Leveraging Health IT to Risk Adjust Patients Session ID: QU2; February 19 th, 2017 Tamra Lavengood, RN, BSN, MSN CPC Coordinator and Clinical Performance Coordinator Centura Health Physician Group, Centura
More informationNicholas E. Davies Enterprise Award of Excellence Population Management Case Study
Applicant Organization: Centura Health Organization s Address: 188 Inverness Dr. W #500, Englewood, CO 80112 Submitter: Amy Feaster, Vice President of Information Technology Email: amyfeaster@centura.org
More informationCPC+ Oregon Practice Application Webinar. David Dorr, MD, MS Ron Stock, MD, MA
CPC+ Oregon Practice Application Webinar David Dorr, MD, MS Ron Stock, MD, MA We Want To Hear From You! Type questions into the Questions Pane at any time during this presentation Presenters David A. Dorr,
More informationMEDICAL HOMES Arkansas Hospital Association
MEDICAL HOMES Arkansas Hospital Association Framing our discussion Environmental snapshot of health care Hospitals and the PCMH Arkansas Medical Homes Patients/Consumers 2 1 Health Policy is changing Budget
More informationPrimary 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 informationTwo-Year Effects of the Comprehensive Primary Care Initiative on Practice Transformation and Medicare Fee-for-Service Beneficiaries Outcomes
Two-Year Effects of the Comprehensive Primary Care Initiative on Practice Transformation and Medicare Fee-for-Service Beneficiaries Outcomes Deborah Peikes, Stacy Dale, Erin Taylor, Arkadipta Ghosh, Ann
More informationof Program Success and
PCMH Evaluations: Key Drivers of Program Success and Measurement Development Robert Phillips, MD, MSPH, American Board of Family Medicine Deborah Peikes, PhD, MPA, Mathematica Michael Bailit, MBA, Bailit
More informationBuilding & 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 informationThe Patient-Centered Medical Home Model of Care
The Patient-Centered Medical Home Model of Care May 11, 2017 Louise Bryde Principal Presentation Outline Imperatives for Change Overview: What Is a Patient-Centered Medical Home? The Medical Neighborhood
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 informationPatient-centered medical homes (PCMH): Eligible providers.
ACTION: Final DATE: 09/20/2016 8:11 AM 5160-1-71 Patient-centered medical homes (PCMH): Eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
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 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 informationChapter VII. Health Data Warehouse
Broward County Health Plan Chapter VII Health Data Warehouse CHAPTER VII: THE HEALTH DATA WAREHOUSE Table of Contents INTRODUCTION... 3 ICD-9-CM to ICD-10-CM TRANSITION... 3 PREVENTION QUALITY INDICATORS...
More informationGetting Ready for the Maryland Primary Care Program
Getting Ready for the Maryland Primary Care Program Presentation to Maryland Academy of Nutrition and Dietetics March 19, 2018 Maryland Department of Health All-Payer Model: Performance to Date Performance
More informationElizabeth Mitchell December 1, Transforming Healthcare in an Uncertain Environment
Transforming Healthcare in an Uncertain Environment Elizabeth Mitchell, President & CEO Network for Regional Healthcare Improvement 2017 We have a problem Health Spending as a Share of GDP United States,
More informationPatient-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 informationLessons from the States: Oregon s APM Model
Lessons from the States: Oregon s APM Model F R I D AY, N O V E M B E R 6, 2 0 1 5 2 : 0 0 P M E T C R A I G H O S T E T L E R, E X E C U T I V E D I R E C T O R, O P C A K E R S T E N B U R N S L A U
More informationPractice Transformation Alignment: NYS PCMH Marcus Friedrich, MD, MBA, FACP Chief Medical Officer Office of Quality and Patient Safety NY State
Practice Transformation Alignment: NYS PCMH Marcus Friedrich, MD, MBA, FACP Chief Medical Officer Office of Quality and Patient Safety NY State Department of Health Marcus.Friedrich@health.ny.gov 2 Primary
More informationTO BE RESCINDED Patient-centered medical homes (PCMH): eligible providers.
ACTION: Final DATE: 09/21/2018 3:40 PM TO BE RESCINDED 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model
More informationNY State initiatives for Primary Care Practices: CPC plus - Webinar
NY State initiatives for Primary Care Practices: CPC plus - Webinar Marcus Friedrich, MD, MBA, FACP Medical Director NYSDOH - Office of Quality and Patient Safety August 30, 2016 August 30, 2016 2 Primary
More informationArkansas 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 informationThe Patient Protection and Affordable Care Act Summary of Key Health Information Technology Provisions June 1, 2010
The Patient Protection and Affordable Care Act Summary of Key Health Information Technology Provisions June 1, 2010 This document is a summary of the key health information technology (IT) related provisions
More informationOverview. Patient Centered Medical Home. Demonstrations and Pilots: Judith Steinberg, MD, MPH March 6, 2009
Patient Centered Medical Home Judith Steinberg, MD, MPH March 6, 2009 Patient Centered Medical Home Payment Reform & Incentive Alignment Transparency and Measurement Quality Improvement Practice Transformation
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 informationEvolving Roles of Pharmacists: Integrating Medication Management Services
Evolving Roles of Pharmacists: Integrating Management Services Marie Smith, PharmD, FNAP Palmer Professor and Assistant Dean, Practice and Policy Partnerships UCONN School of Pharmacy (marie.smith@uconn.edu)
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 informationMedicaid Accountable Care Collaborative (ACC) Durango Community Forum, August 27, 2013
Medicaid Accountable Care Collaborative (ACC) Durango Community Forum, August 27, 2013 ACCOUNTABLE CARE COLLABORATIVE (ACC) BACKGROUND 2 New Medicaid Delivery System Developed in response to: Failed attempts
More informationThe Comprehensive Primary Care Initiative: New Payment Models Will Rely on Use of Health IT
The Comprehensive Primary Care Initiative: New Payment Models Will Rely on Use of Health IT Richard J. Baron, MD, MACP Group Director, Seamless Care Models Innovation Center, CMS Advancing Primary Care
More informationWhy Are We Doing This?
ALIGNING PAYMENT WITH PATIENT-CENTERED CARE AND VALUE-BASED PAY Craig Hostetler MPCA Annual Conference August 5 th, 2013 Why Are We Doing This? Why Take the Risk? Our stakeholders wanted something better
More informationThe Future of Physician Reimbursement
The Future of Physician Reimbursement EBG (PQRS-Quality Measures) yield Outcome Report Yield Increased Quality Yield Decreased Cost yield Increased Patient Satisfaction - CAHPS Consumer Assessment of Healthcare
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 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 informationRisk Adjusted Diagnosis Coding:
Risk Adjusted Diagnosis Coding: Reporting ChronicDisease for Population Health Management Jeri Leong, R.N., CPC, CPC-H, CPMA, CPC-I Executive Director 1 Learning Objectives Explain the concept Medicare
More informationColorado State Innovation Model (SIM) Cohort 3 Request for Application (RFA) Packet
Colorado State Innovation Model (SIM) Cohort 3 Request for Application (RFA) Packet 1 P age REQUEST FOR APPLICATION (RFA) TIMELINE OVERVIEW For questions related to the Cohort 3 SIM Practice Request for
More informationPatient-centered medical homes (PCMH): eligible providers.
ACTION: Final DATE: 09/21/2018 3:40 PM 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
More informationA Care Coordination Model for Value-Based Performance Programs
A Care Coordination Model for Value-Based Performance Programs Richard S. Chung, MD Chief Clinical Officer APS Healthcare 8th National Pay for Performance (P4P) Summit February 20, 2013 Hyatt Regency Hotel,
More informationDual-eligible SNPs should complete and submit Attachment A and, if serving beneficiaries with end-stage renal disease (ESRD), Attachment D.
Attachment A: Model of Care for Dual-eligible SNPs MA Contract Name: Geisinger Health Plan MA Contract Number: H3954-097 Type of Dual-eligible SNP: Full The model of care describes the MAO's approach to
More informationComprehensive Primary Care Plus (CPC+): What You Need to Know Before Applying
Medical Group Strategy Council Physician Practice Roundtable Comprehensive Primary Care Plus (CPC+): What You Need to Know Before Applying August 8, 2016 2 Today s Presenters Ingrid Lund, PhD Practice
More informationTotal Cost of Care in Action
Total Cost of Care in Action Meredith Roberts Tomasi, Sr. Program Director, Q Corp Doug Rupp, Sr. Health Analyst, Q Corp The information in this presentation may be subject to copyright and may not be
More informationWestern Slope SIM/TCPi Spring Collaborative Learning Session
Western Slope SIM/TCPi Spring Collaborative Learning Session 5.75 AMA PRA Category 1 Credit(s) July 13, 2018 DoubleTree by Hilton 7:30-8:00am 8:00-8:30am Welcome: Registration and Continental Breakfast
More informationHardwiring Technology into Care Delivery to Increase HCAHPS
Hardwiring Technology into Care Delivery to Increase HCAHPS March 1, 2016 Peggy Grant, Ph.D. Director of Innovation and Performance Improvement Community Regional Medical Center Conflict of Interest Peggy
More informationState Policy Report #47. October Health Center Payment Reform: State Initiatives to Meet the Triple Aim. Introduction
Health Center Payment Reform: State Initiatives to Meet the Triple Aim State Policy Report #47 October 2013 Introduction Policymakers at both the federal and state levels are focusing on how best to structure
More informationCPC+ 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 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 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 informationQuality Measures and Federal Policy: Increasingly Important and A Work in Progress. American Health Quality Association Policy Forum Washington, D.C.
Quality Measures and Federal Policy: Increasingly Important and A Work in Progress American Health Quality Association Policy Forum Washington, D.C. February 9, 2016 Quality Journey NCQA Develops Health
More informationNew York State Department of Health Innovation Initiatives
New York State Department of Health Innovation Initiatives HCA Quality & Technology Symposium November 16 th, 2017 Marcus Friedrich, MD, MBA, FACP Chief Medical Officer Office of Quality and Patient Safety
More informationMACRA, MIPS, and APMs What to Expect from all these Acronyms?!
MACRA, MIPS, and APMs What to Expect from all these Acronyms?! ACP Pennsylvania Council Meeting Saturday, December 5, 2015 Shari M. Erickson, MPH Vice President, Governmental Affairs & Medical Practice
More informationJoseph W. Thompson, MD, MPH Arkansas Surgeon General Director, Arkansas Center for Health Improvement
Joseph W. Thompson, MD, MPH Arkansas Surgeon General Director, Arkansas Center for Health Improvement Arkansas Health System Improvement Workforce Payment System Health Information Technology Insurance
More informationLow-Income Health Program (LIHP) Evaluation Proposal
Low-Income Health Program (LIHP) Evaluation Proposal UCLA Center for Health Policy Research & The California Medicaid Research Institute Background In November of 2010, California s Bridge to Reform 1115
More informationReconciling Abstracted to Electronic Quality Measures
Reconciling Abstracted to Electronic Quality Measures Tuesday, March 1, 2016 Keith F. Woeltje, PhD, MD, VP and Chief Medical Information Officer BJC HealthCare Center for Clinical Excellence Liz Richard,
More informationQuality Measurement and Reporting Kickoff
Quality Measurement and Reporting Kickoff All Shared Savings Program ACOs April 11, 2017 Sandra Adams, RN; Rabia Khan, MPH Division of Shared Savings Program Medicare Shared Savings Program DISCLAIMER
More informationRussell B Leftwich, MD
Russell B Leftwich, MD Chief Medical Informatics Officer Office of ehealth Initiatives, State of Tennessee 1 Eligible providers and hospitals can receive incentives for meaningful use of certified EHR
More informationAlternative Payment Models and Health IT
Alternative Payment Models and Health IT Health DataPalooza Preconference May 8, 2016 Kelly Cronin, MS, MPH, Director, Office of Care Transformation, ONC/HHS HHS Goals for Medicare Payment Reform In January
More informationBob Davis, PharmD, FAPhA Professor and Chair, KPIC
Bob Davis, PharmD, FAPhA Professor and Chair, KPIC davisb@kennedycenter.sc.edusc edu South Carolina Primary Health Care Association September 19, 2015 Myrtle Beach, SC Disclosures Robert E. Davis declare(s)
More informationProviding and Billing Medicare for Chronic Care Management Services
Providing and Billing Medicare for Chronic Care Management Services (and Other Fee-For-Service Population Health Management Services) No portion of this white paper may be used or duplicated by any person
More informationExhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013)
Exhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013) 24 percent (52 ACOs) earned shared savings bonus 27 percent (60 ACOs) reduced spending,
More informationLow-Income Health Program (LIHP) Evaluation Proposal
Low-Income Health Program (LIHP) Evaluation Proposal UCLA Center for Health Policy Research & The California Medicaid Research Institute BACKGROUND In November of 2010, California s Bridge to Reform 1115
More informationThe New York State Health Center Controlled Network (NYS-HCCN)
The New York State Health Center Controlled Network (NYS-HCCN) A HRSA-Funded Project of the Community Health Care Association of New York State PCMH 2014 Must Pass Elements Qualis Health November 16, 2015
More informationMIPS Collaborative: Clinical Practice Improvement Activities April 19, 2017 Francis R Colangelo, MD
MIPS Collaborative: Clinical Practice Improvement Activities April 19, 2017 Francis R Colangelo, MD Outline of Presentation Introduction Overview of MACRA/MIPS Clinical Practice Improvement Activities
More informationPrimary Care Redesign: Perspective from the New York State Department of Health October 3, 2017
Primary Care Redesign: Perspective from the New York State Department of Health October 3, 2017 Marcus Friedrich, MD, MBA, FACP Chief Medical Officer Office of Quality and Patient Safety NYSDOH Marcus.Friedrich@Health.NY.Gov
More information21 st Century Care: Redesigning Pediatric Care at Denver Health
21 st Century Care: Redesigning Pediatric Care at Denver Health Designing Systems that Work for Children with Complex Health Care Needs Washington, D.C. December 7 th, 2015 Simon Hambidge, MD, PhD Chief
More informationValue-Based Payment Model Designs for Behavioral Health Services in Primary Care
Value-Based Payment Model Designs for Behavioral Health Services in Primary Care Using collaborative depression care management as a case study due to existing evidence, experience, and measures Robert
More informationHIMSS 2011 Implementation of Standardized Terminologies Survey Results
HIMSS 2011 Implementation of Standardized Terminologies Survey Results The current healthcare climate, with rising costs and decreased reimbursement, necessitates fiscal responsibility. Elements of the
More informationHealth Reform and The Patient-Centered Medical Home
THE COMMONWEALTH FUND Health Reform and The Patient-Centered Medical Home Melinda Abrams The Commonwealth Fund November 3, 2011 Grantmakers in Health Fall Forum Primary Care Foundation At Risk: Patient
More informationState Medicaid Directors Driving Innovation: Continuous Quality Improvement February 25, 2013
State Medicaid Directors Driving Innovation: Continuous Quality Improvement February 25, 2013 The National Association of Medicaid Directors (NAMD) is engaging states in shared learning on how Medicaid
More informationTHE QUALITATIVE AND QUANTITATIVE EFFECTS OF PATIENT CENTERED MEDICAL HOME IN THE VETERANS HEALTH ADMINISTRATION
THE QUALITATIVE AND QUANTITATIVE EFFECTS OF PATIENT CENTERED MEDICAL HOME IN THE VETERANS HEALTH ADMINISTRATION By Eric Stalnaker Sam Lovejoy W.K. Willis A. Coustasse Introduction The Patient Center Medical
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 informationEVOLENT HEALTH, LLC. Asthma Program Description 2018
EVOLENT HEALTH, LLC Asthma Program Description 2018 1 Evolent Health Asthma Program Description 2018 Table of Contents Section Page Number I. Introduction... 3 II. Program Scope... 3 III. Program Goals...
More informationMedicaid Payment Reform at Scale: The New York State Roadmap
Medicaid Payment Reform at Scale: The New York State Roadmap ASTHO Technical Assistance Call June 22 nd 2015 Greg Allen Policy Director New York State Medicaid Overview Background and Brief History Delivery
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 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 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 informationWhat is the QRUR? Understanding Your Annual Quality and Resource Use Report
What is the QRUR? Understanding Your Annual Quality and Resource Use Report What is the Quality and Resource Use Report? The Quality and Resource Use Report (QRUR) is a mid-year and annual report card
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 2/4/2018 The following program policies are applicable to all contracted providers and practices recognized
More informationBreaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery
Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Betty Shephard Lead VP, Care Management HealthCare Partners National Health Policy Forum October 19, 2012 HCP
More informationBuilding a Better Home: Transformation to a Patient Centered Health Home. Anna M. Gard, FNP-BC Association of Clinicians for the Underserved
Building a Better Home: Transformation to a Patient Centered Health Home Anna M. Gard, FNP-BC Association of Clinicians for the Underserved A Patient Centered Health Home is not a place but an approach
More informationPost-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016
Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver HEALTH FORUM AND AHA LEADERSHIP SUMMIT JULY 18, 2016 SAN DIEGO, CALIFORNIA Please note that the views expressed are those of the conference
More informationSIM Cohort 3 Application Instructions and Questions
SIM Cohort 3 Application Instructions and Questions Overview, Instructions & Resources: SIM Cohort 3 Application Overview: Thank you for your interest in the Colorado State Innovation Model (SIM) Initiative
More informationRevised for SIM Cohort 2, 2017
Colorado State Innovation Model (SIM) Implementation and Milestone Reporting Summary Guide for Primary Care and Bi-directional Health Home Milestone Activities Revised for SIM Cohort 2, 2017 1 Table of
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 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 informationImplementing Medicaid Value-Based Purchasing Initiatives with Federally Qualified Health Centers
Implementing Medicaid Value-Based Purchasing Initiatives with Federally Qualified Health Centers Beth Waldman, JD, MPH June 14, 2016 Presentation Overview 1. Brief overview of payment reform strategies
More informationPQRS and Alignment Opportunity: Concept to Operationalization March 1, 2016
PQRS and Alignment Opportunity: Concept to Operationalization March 1, 2016 Debe Gash/ VP & Chief Information Officer/ Saint Luke s Health System Anantachai (Tony) Panjamapirom/ Senior Consultant/ The
More informationHealth Center Strong:
Health Center Strong: Developing and Expressing Health Center Value Jonathan Chapman Director, CHC Advisory Services, Capital Link NHCHC National Conference and Policy Symposium May 18, 2018 1 Capital
More informationBCBSM Physician Group Incentive Program
BCBSM Physician Group Incentive Program Organized Systems of Care Initiatives Interpretive Guidelines 2012-2013 V. 4.0 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee
More informationReimagining PCMH Recognition
Reimagining PCMH Recognition August 2016 Michael S. Barr, MD, MBA, MACP Executive Vice President Quality, Measurement & Research Group Re-use without permission is prohibited 1 Where is PCMH in future
More informationMGH is an integrated service organization in central Maine serving approx. 190,000 individuals KRHA (PHO) 28 PC sites serve 115,000
1 MGH is an integrated service organization in central Maine serving approx. 190,000 individuals KRHA (PHO) 28 PC sites serve 115,000 KENNEBEC VALLEY COMMUNITY CARE TEAM JOAN ORR MCHES, MBA DIRECTOR ACCOUNTABLE
More informationArkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual
Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual 2017 This document is a guide to the 2017 Arkansas Blue Cross and Blue Shield Patient-Centered Medical Home program (Arkansas
More informationNCQA PCMH 2017 Standard Two 4/11/18. 6 PCMH Concepts within the standards
Candace Chitty RN, MBA, CPHQ, PCMH-CCE 1 6 PCMH Concepts within the standards 1. Team-Based Care and Practice Organization (TC). 2. Knowing and Managing Your Patients (KM). 3. Patient-Centered Access and
More informationPromoting Interoperability Performance Category Fact Sheet
Promoting Interoperability Fact Sheet Health Services Advisory Group (HSAG) provides this eight-page fact sheet to help providers with understanding Activities that are eligible for the Promoting Interoperability
More informationMission Health Care Network. April 2017
Mission Health Care Network April 2017 WHAT IS MISSION HEALTH CARE NETWORK? Mission Health Care Network is a Clinically Integrated Network including groups of doctors, the hospital and other health care
More informationGuidance for Developing Payment Models for COMPASS Collaborative Care Management for Depression and Diabetes and/or Cardiovascular Disease
Guidance for Developing Payment Models for COMPASS Collaborative Care Management for Depression and Diabetes and/or Cardiovascular Disease Introduction Within the COMPASS (Care Of Mental, Physical, And
More informationPost-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016
Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver HEALTH FORUM AND AHA LEADERSHIP SUMMIT JULY 18, 2016 SAN DIEGO, CALIFORNIA Please note that the views expressed are those of the conference
More informationEmployer Breakout Session Payment Change in Ohio: What it Means for Employers
Employer Breakout Session Payment Change in Ohio: What it Means for Employers Moderators Jeff Biehl, Health Collaborative of Greater Columbus Frank A. Johnson, Maine Health Management Coalition Who is
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 informationPOPULATION 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 informationIdentifying and Treating Your High Risk Patient Population. Beth Hickerson Quality Improvement Advisor August 15, 2017
Identifying and Treating Your High Risk Patient Population Beth Hickerson Quality Improvement Advisor August 15, 2017 HIGH RISK PATIENTS What and Why? What is a high-risk patient? High level of resource
More informationThe Transition to Version 5010 and ICD-10
The Transition to Version 5010 and ICD-10 An Overview Denise M. Buenning, MsM Director, Administrative Simplification Group Office of E-Health Standards and Services Centers for Medicare & Medicaid Services
More information