Care Transformation Center Blog

The insights, tools, and resources you need to take on population health management

The first step for medical home-specialist collaboration

Amanda Berra September 2, 2015

As a next step in patient-centered medical home (PCMH) model evolution, we see progressive organizations building connections and partnerships with specialists as ongoing collaborators in patient care. But achieving perfect PCMH-specialist collaboration will not be easy—especially for less integrated organizations—as there are a number of sizeable barriers in the way.

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The care management staffing question you're not asking

Rebecca Tyrrell August 31, 2015

As organizations continue to build or refine cross-continuum care management models, the perennial question is: What is the right ratio of care managers to patients?

The answer is influenced by a number of factors, including the patient population type under management, scope of care management responsibilities, and access to and availability of other types of staff such as social workers or non-clinical specialists.

The related, but less frequently asked question is: Where should that care manager be deployed?

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For Mercy's chief clinical officer, it's about large-scale population health

Dennis Weaver, MD, MBA August 27, 2015

Mercy Health, the largest provider in Ohio, has managed a high level of change over the last few years—transforming from a federation of hospitals to an integrated, regional system. The system has moved into population health management by setting up an ACO, clinically integrated (CI) network, and a population health services organization (PHSO).

I sat down with Chief Clinical Officer, Brent Asplin, MD, MPH, who oversees Mercy Health’s physician network and clinical imperatives. Read on to learn about how they’ve embraced new payment models, why physician engagement needs to happen locally, and what’s next on the horizon for Mercy Health.

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A top ACO's approach to depression screening

Tracy Walsh August 26, 2015

As we’ve mentioned in previous posts, primary care providers are often the first to recognize depressive symptoms and formally diagnose a patient with depression. When initiating conversations around depression management, primary care providers should be comfortable and prepared to broach the following topics:

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Does your leadership model help or hinder your population health efforts?

by Chrissy Wild August 24, 2015

Two of the biggest challenges to scaling the care management model include designing a flexible leadership model and effectively deploying staff. Introducing a new leadership model aligned to population health strategy requires breaking down silos and navigating politically sensitive decisions around accountability, scope of ownership, and reporting relations.

Population health-driven organizations recognize the need to organize system-wide care management resources to promote efficient and effective use. But in many cases, care management roles have developed organically in siloes without an enterprise strategy guiding expansion or integration. Coordination between care management programs supporting care transitions and chronic disease management is also often highly variable.

Here's how organizations across the country have begun to shift their model to improve cross-continuum care coordination and efficiency.

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Three reasons why CI networks are falling short

Dennis Weaver, MD, MBA August 21, 2015

When my team began setting up clinically integrated (CI) networks for our health system clients, the main goals were to align with physicians that were otherwise out-of-reach, broadly improve clinical performance, and to secure some form of accountable payment contracts.

While these are still the core components of any CI network, today’s market-driven evolution from volume to value requires a greater focus on population health management than before—and the most successful networks are making this a priority. But we’ve found three reasons why other CI networks haven’t been able to optimize operations to successfully manage population health.

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Two common patient engagement technology questions—answered

by Eric Sun August 19, 2015

For many providers, patient engagement ranks as a top priority to help improve quality of care and reduce overall cost of care. Yet given limited resources, not all patients can receive in-person or even telephonic support from health care staff.

In a recent webconference, the Population Health Advisor team reviewed emerging web-based technologies that health care organizations are using to scale their patient engagement efforts. We evaluated four main platforms—the virtual health coach, patient social network, condition-specific forum, and provider-hosted online community—on several factors including which patients they work best for, the platform’s potential for patient behavior change, and the degree of investment they require.

During the webconference, attendees asked a number of questions about these technologies. I’ve included a few questions and answers below.

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The biggest trade-offs for popular remote patient monitoring models

by Meridith Weiss August 18, 2015

We recently profiled how four leading care management programs that remotely monitor congestive heart failure (CHF) patients identify and recruit patients to their programs.

Beyond enrollment strategies, providers need to know the answers to two questions to determine their remote management approach: Which devices will you use to monitor patients? And who will analyze incoming patient data?

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