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Population Health Management in Action The common theme of the case below is po
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Population Health Management in Action
The common theme of the case below is population health management, IT and data management needs under value-based payment.
This case involves Bon Secours Virginia Medical Group, a large multi-specialty group practice located in Richmond, VA and serving 25,000 patients. Bon Secours has been a leader in transforming care delivery and was an early participant in the Medicare Shared Savings Program. The organization has since signed value-based contracts with several large commercial payers. Bon Secours’s strategy for its value-based care is its medical home initiative, designed to re-engineer practices by establishing physician-led care teams, care coordination activities, and shared clinical responsibilities across the care team. Nurse care managers are embedded in the care team. They assume a leadership role in patient outreach and in facilitating care and coordination.
To achieve Bon Secours’s goal of achieving quality outcomes and financial success, the organization has employed several health IT tools and capabilities including patient registries, risk stratification, automated outreach to discharged patients, and use of EHR/PHR records for which patients access clinical results and communicate with providers. Important challenges and lessons learned are discussed and include gaining physician buy-in for re-engineering practice workflow, paying for the transition to value-based care, and expanding implementation of PHM tools and strategies for measuring quality and performance.
I provided this case study as an example of how a large institution adopted population health management tools and strategies to address the preventive and chronic health needs of patient populations.
Please read chapter 4 prior to answering the discussion questions.
Please identify the elements of PHM that are important to managing care more effectively.
How is PHM engaging patients in managing their health and care?
Is it being done cost-effectively?
To what extent does social media play a role in PHM?