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Care Process Improvement

Friday, March 11, 2016
2:00 p.m. – 3:15 p.m.

Cultural Change: On-Ramping to the Population Health Highway
Scott Foster, MD, System Medical Director Specialty Care, PeaceHealth Ketchikan Medical Center
Robin Virgin, MD, System Medical Director Primary Care,  PeaceHealth Ketchikan Medical Center
PeaceHealth entered a cooperative agreement with CMS to develop a population health framework that has drawn national attention for its success, including a 15% reduction in overall per member per encounter payments from CMS, and a 27% reduction in 30-day all-cause readmission rates compared to its local control group. This new program, made possible by a CMS Innovation award, is demonstrating the effectiveness of an integrated psychosocial and nursing approach for transition of care for patients leaving the in-patient environment. This session will outline key details to these care coordination methods and the appropriate infrastructure needed to put leaders on a good path toward a system strategy for population health. Topics will include leadership vision, data analytics development, care models, and business intelligence

Reaching for the Stars: Using Health Information Technology to Drive Performance Improvement on Chronic Care Measures
Robert A. Crossey, DO, President, Premier Medical Associates
Francis R. Colangelo, MD, Chief Quality Officer, Premier Medical Associates
Holly Kern, RN, Director of Quality Care, Premier Medical Associates
Premier Medical Associates has used Health IT registry capabilities and created transparent provider reports to improve performance to very high levels on various CMS Stars metrics.  Learn how the group has improved colon cancer screening rates from 62% to 79%, improved HgA1c outcomes for uncontrolled diabetics to well below the threshold set by Healthy People 2020, and implemented the evidence-based planks and transparent reporting of AMGA’s Measure Up/Pressure Down® program to achieve 77% high blood pressure control with a goal of hitting 80% in the near future.

Making the Transition:  Improving Coordination, Lowering Readmission, and Expanding the Care Team through Data-Driven Risk Stratification at Discharge
Jennifer McNay, MD, Vice President, Adult Primary Care, Mercy Springfield
Cindi J. Goddard, RN, BSN, MPH, Executive Director, Mercy Care Management
Like many healthcare organizations across the country, Mercy sought to improve its care delivery and overall performance in ambulatory readmissions.  Learn how Mercy leveraged Epic EHR functionality to develop a readmission risk calculator and an operational workflow engaging a number of roles within hospital and outpatient settings to manage the transition of the patients and communicate between care settings.  After just six months the results are promising.  Caring for over 5,000 eligible discharges, Mercy has achieved an overall readmission rate of 8.2%.  Patients who received the recommended therapy had a readmission rate of 7.2%, compared to a 12.3% rate for those not completing the care plan.  In addition, the 5,000 patients received a scheduled appointment 83% of the time.  This effort improved Mercy Springfield ACO’s performance in readmissions by 14.2%.

Wednesday, March 11, 2016
3:45 p.m. – 5:00 p.m.

Out of Chaos: Practical Steps to Mitigate Gaps in Care in an Ever-Increasing Complex World of Care Coordination
Philip Oravetz, MD, MPH, MBA, Medical Director, Accountable Care, Ochsner Health System
Mark Green, MBA, PMP, AVP, Transitions of Care, Ochsner Health System
In a world of increasing complexity, the healthcare industry often overlooks the necessity for basic care coordination. Patients are often asked to navigate complex or chronic episodes of care across a broad care continuum with limited assistance or guidance beyond clinical interventions.  Learn how Ochsner took a holistic view of the patient’s total care continuum to build a standardized/centralized approach to care coordination to positively enhance quality outcomes, and patient engagement and satisfaction.

Coordinated Care for Advanced Illnesses: Evolution to an Innovative, Integrated Model
Ira N. Hollander, MD, President and Chief Clinical Officer, North Texas Specialty Physicians
Natalie Wilkins, Administrative Director of Clinical Programs, North Texas Specialty Physicians
Care delivery to the chronically ill and those nearing the end of life typically is not coordinated or optimal. Contributing to the fragmented approach is the limited attention and support given to palliative care and advanced care planning. North Texas Specialty Physicians (NTSP) has long sought to bridge gaps in care for the chronically ill and those nearing the end of life. This session will detail how NTSP developed a comprehensive care model that encompasses extensivist care, palliative care, and advanced care planning, and the benefits that came from its commitment to fiscally responsible, well-integrated care for seniors.

Saturday, March 12, 2016
11:00 a.m. – 12:15 p.m.

A Population Health Journey: Transformation to Patient-Centered Care Delivery Model
Peter Schoch, MD, Medical Director of Quality, Informatics, Care Transformation and Population Health, SSM Medical Group
Jennifer Schultze, RN, Director, Ambulatory Care Coordination, SSM Medical Group
Jayceen Ensrude, Director, Quality and Process Improvement, SSM Medical Group
In 2011, the leadership at SSM recognized the need to redesign the way they delivered care to patients. This session will highlight SSM Medical Group’s population health journey, which includes the transformation to more patient-centered care, building a foundation for a robust care management program for the highest risk population, developing a comprehensive transitional care program, managing patients with chronic disease, successfully executing risk adjustment and stratification, and using innovative population health technology. You will come away with strategies that have been proven to yield positive clinical outcomes and significant cost savings.

Hypertension Control: Integrating At-Home Blood Pressure Monitoring into Workflows
Leisa Hills, RN, MSN, Director, Clinical Excellence, Community Physician Network
Barb Holloway, RN, CDE, Billings Clinic
A recent poll shows nearly half of American adults are extremely or very interested in being able to check their own blood pressure on smartphones or tablets. Further, as consumers seek additional involvement and control over their entire medical picture, new technology must evolve, making the data both available and actionable. The American Medical Group Foundation’s Measure Up/Pressure Down® campaign led a pilot project to integrate home blood pressure monitors into the workflow of four AMGA members. Learn best practice strategies and hear some of the lessons learned from two of these innovative participants-Billings Clinic and Community Physician Network.

Saturday, March 12, 2016
2:00 p.m. – 3:15 p.m.

Building a Statewide ACO and the Structure for Population Health
David Swieskowski, MD, MBA, Chief Executive Officer, Mercy ACO, Catholic Health Initiatives
Teresa Mock, MD, Senior Vice President, Mercy Clinics, Mercy North Iowa
Learn how Mercy was able to form, organize, and govern a successful, statewide clinically integrated network with more than 1,800 urban and rural providers serving more than 130,000 covered lives. This session will also cover how data and care management processes were standardized and delivered through a population health services organization model to improve care, allowing Mercy to demonstrate savings and obtain positive financial performance on every one of their value-based contracts.


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