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Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care
Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care
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The Accountable Care Organization (ACO) model is dedicated to achieving the Institute of Healthcare Improvement's 'Triple Aim:' improving population health, enhancing the patient experience and slowing increases in healthcare costs.

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care examines the building blocks of population health management that drive improvements in healthcare quality and efficiency in ACOs — while positioning healthcare organizations for core measure improvement and increased reimbursement.

One such building block is an effective patient registry, which provides usable, actionable data — a true snapshot of the patient population being served and for which the organization is accountable. A registry also keeps organizations on track with recommended care and identifies ways to improve outcomes.

In this 40-page resource, Dr. Gregory Spencer, chief medical officer of Crystal Run Healthcare, demystifies registry use and shares patient registry best practices, including the following:

  • Redesigning internal processes so that a registry can be used most effectively;
  • Using registry data to identify gaps in care;
  • Steps to improve accuracy and completeness of registry data; and
  • The evolving role of patient registries in delivering accountable care.
Excellence in population health management can only be achieved through experience. CMS Physician Group Practice participant Dartmouth-Hitchcock has developed a competency in population health management that it deploys in ongoing ACO pilots with Medicare and Cigna and in an ACO pilot in development with Anthem/WellPoint.

In Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care, Dartmouth-Hitchcock senior medical director Dr. Barbara Walters shares how the pilots have demonstrated the value of an ACO by achieving efficiency, quality and cost targets.

She explains the following:

  • The shared savings and total cost of care payment methodology developed by Dartmouth and Cigna for commercial members attributed to Dartmouth;
  • The new roles and responsibilities within an ACO to efficiently manage the health of a population, including strategies for practicing at the top of license;
  • Developing a collaborative model of care that allocates resources to manage illness burdens, gaps in care and care plans of a defined patient population; and
  • Results from Dartmouth's ACO pilots with CMS and Cigna, including where Dartmouth has achieved better than market results for these programs.

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care also presents new market research on the use of registries for population health management from the 2011 Healthcare Intelligence Network Health Registries for Quality Improvement Survey.

Table of Contents

  • Patient Registries: Cornerstone in Creating Accountable Care
    • 4 Reasons to Use Registries
    • Which Data Should Registries Gather?
    • Rules for Registry Data Entry
    • Workflow Improvement
    • Identifying Gaps in Care
    • Payback from Registry Use
    • Registries and Care Managers
  • Leveraging Population Health Management To Meet ACO Efficiency Metrics
    • Building Blocks of an ACO
    • Understanding the Population
    • Transforming the Nurse's Role in the ACO
    • Focus on Admissions, Readmissions
    • Dartmouth-Hitchcock Lessons Learned
    • Moving from Public to Private Payor Partnerships
  • 2011 Benchmarks in Registry Use for Quality Improvement
    • Current and Planned Use of Registries
    • Percentage of Patients Included in Registries
    • Targeted Conditions and Populations
    • Primary Registry Responsibility
  • Q&A: Ask the Experts
    • Results from Registries
    • Registries for Internal Provider Comparisons
    • Templates in EMRs
    • Training Staff in Registry Use
    • Using Registries to Identify Gaps in Care
    • Lessons Learned in Meaningful Use
    • Plans for CMS Pioneer ACO Program
    • Feedback on CMS's Proposed Rule on ACOs
    • Patient Care Team Roles in an ACO
    • Practicing at Top of License
    • Super Registries
    • Care Management Reimbursement Formula
    • Improving the Patient Experience
    • Skill Sets for Embedded Case Managers
    • Physician Response to Data Sharing
  • Glossary
  • For More Information
  • About the Speakers
Video
Publication Date: September 2011
Number of Pages: 40
ISBN 10: 1-937229-17-3 (Print version); 1-937229-18-1 (PDF version)
ISBN 13: 978-1-937229-17-7 (Print version); 978-1-937229-18-4 (PDF version)
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