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10 TEN TEN TEN TE TEN NextGen Population Health Prevent Patients from Falling Through the Cracks in 10 Easy Steps

NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

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Page 1: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

10TENTENTENTENTENNextGen Population Health

Prevent Patients from Falling Through the Cracks in 10 Easy Steps

Page 2: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Proactive, automated patient engagement–anytime, anywhere.

Automate care management to improve population health.

AUTOMATEAutomatically reach out to, and

manage, your entire patient

community. Meet criteria for MU,

PCMH, and ACOs

TRACKTrack enhanced communications

and improved outcomes with

configurable reports and

dashboards.

IMPROVESee a significant return on

investment from increased payer

reimbursements and additional

treatment opportunities.

Watch an online demo | Call us at 855-510-6398

Ambulatory PracticeManagement

AnalyticsPopulationHealth

InteroperabilityInSight Reporting

Page 3: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Set it and forget it.Providers today need an automated patient engagement solution that is fully integrated with

their EHR and practice management systems. This integration enables providers to target

high-risk patient and work more efficiently and collaboratively across the organization.

Targeted outreach–why it matters.Providers need to deliver preventative care and the most appropriate intervention based

on the individual’s condition, health risk, and severity of illness. Proactive Population Health

management helps providers improve:

• Patient health

• Care quality

• Practice productivity

• Operational efficiency

• Revenue opportunities

Effective population health management drives collaborative care, which is at the heart of ACO, Meaningful Use (MU), and PCMH goals.

Page 4: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

1

Know population health goals.

Page 5: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Significantly improve

patient health outcomes

Deliver better care in lower cost settings using

population health tools

• Reduce avoidable ER visits and hospitalizations

• Lower hospital readmissions

Improve financial outcomes

• Maximize financial return for value-based care

• Earn preventative care incentives

• Better identify treatment opportunities

• Negotiate better risk/gain sharing terms with payers

Page 6: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

2

Find root causes.

Page 7: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

You need to manage your patient panel now more than ever.The US healthcare system has been broken for decades–

resulting in fragmented care delivery, unsustainable costs, and

poor access to quality care. Although the reasons are complex,

our changing demographics and patient non-compliance are

root causes of the problem, fueled by many factors:

Baby boomers (born between 1946 and 1964) are extremely high healthcare utilizers especially for “end of life” care

Increasing chronic disease and comorbid conditions

• Obesity

• Heart disease

• Diabetes

We’re transitioning to coordinated, collaborative, integrated, value-based care

• 40.3 million people age 65 or older in 2010; by 2050 projected 88.5 million; 8 in 10 seniors suffer from at least one chronic condition

• About 25 percent of seniors are obese

• 20 percent have diabetes

• 70 percent have heart disease

• Plus, there’s a projected physician shortage and issues of patient non-compliance with treatment

New diagnostic/treatments are now available to improve chronic conditions

Source: http://news.medill.northwestern.edu/chicago/news.aspx?id=222236&print=1

Page 8: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

3

Grasp the impact of patient non-compliance.

Page 9: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Patient non-compliance accounts for:

Source: Wu, S., & Green, A. Projection of Chronic Illness Prevalence and Cost Inflation. In RAND Corporation

11%OF ALL HOSPITAL

ADMISSIONS

41%OF NURSING HOME

ADMISSIONS

20%PRESCRIPTIONS NEVER

FILLED

30%PRESCRIPTIONS NEVER REFILLED

Contact with doctors and hospitals is sporadic and infrequent. Plus, health problems are often not addressed until the patient is in crisis.

By 2020, it’s projected

that 25% of the American

population will have multiple

chronic conditions.

Number of Americans with Chronic Diseases

Num

ber

of

Am

eric

ans

wit

h C

hron

ic D

isea

ses

(mill

ions

)

60

80

100

120

140

160

180

40

1995 2000 2005 2010 2015 2020 2025 2030

20

0

118125

133141

149157

164171

Page 10: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

4

Get the “lifestyle lowdown” on your patients.

Page 11: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Providers can help prevent chronic illness by encouraging lifestyle and behavioral changes.

Modifiable behaviors that affect chronic diseases:

Even healthy patients tend to cut corners. Ask your patients:

• When is the last time you had a preventative screening on time?

• How many doctors’ appointments did you cancel this year because you were too busy?

• Do you always take your medications as prescribed?

• Do you stop taking medication when you start feeling better?

• Do you eat properly?

• Do you exercise regularly?

• Are you getting enough sleep?

Patient engagement tools enable patient

participation in their own healthcare goals.

Lack of Physical Activity Poor Nutrition

Tobacco Use

questionsASK

Excessive Alcohol Consumption

Page 12: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

5

Tackle value-based payment models.

Page 13: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

How you get paid is changing.

Shifting from volume-based to value-based care puts the burden on physicians, predominately primary care physicians, for managing, improving, and reporting clinical outcomes. This means that reporting on these outcomes will affect how, and how much, providers are paid.

This is true regardless of whether or not you are:• Engaging in proactive patient

engagement for preventative care

• Keeping patients from falling through the cracks

• Engaged in quality reporting for ever-increasing measures and mandates

It’s your patient–and your responsibility– whether the patient is:• Compliant

• Non-compliant

• Chronically ill

• Sick short term

Page 14: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

6

Maximize quality reporting channels.

Page 15: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

If you don’t track it, you can’t report it! Generate more revenue with quality reporting.

In the new value-based environment, providers will be responsible for documenting and reporting their patient outreach efforts across the practice. Tracking and monitoring the health status of the entire patient population is the first step in managing chronic conditions. Ultimately, providers will need to segment or “stratify” their population based on similar targeted health conditions.

If you don’t report it, you can’t get paid.

Quick glance – population health management benefits:

• Optimizes clinicians’ time

• Enables providers to focus more on patients in the office

• Helps providers to proactively address chronic and preventive care

• Is a building block for pay-for-performance initiatives like PCMH and ACO

• Helps improve operational efficiency and compliance with follow-up visits

• Increases revenue from timely preventative care visits

Page 16: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

7Get your “ACO game” on.

Page 17: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Ask your patients:

When your population health solution is integrated with your Patient Portal, you’re well on your way to better care coordination and improved outcomes.

• Keep healthcare providers more involved and connected to patients, and vice versa

• Improve disease management

• Ensure patients are up to date with treatments—and easily schedule main-tenance visits by running quick reports by disease state

• Enable productivity improvements that save both time and money

• Lower the cost of healthcare through better care coordination and better quality outcomes

An ACO provides the actual frame-work for ongoing collaborative care across multiple patient touch points

And an effective population health management program is fundamental to ACO success and payer population-based risk contracts.

To meet ACO goals such as improving collaborative care, care coordination, and patient engagement for better health outcomes, leverage your population health efforts to align with your accountable care goals. Proactively reach out to your patient population to schedule recommended care using tools such as NextGen® Population Health.

Proactively reach out to your patient

population to schedule recommended

care, improve collaborative care, care

coordination, and increase patient

engagement for better health outcomes.

Population

HealthTIPS

Page 18: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

8

Leverage mid-level health practitioners.

Page 19: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

• Breast Cancer

• Multiple Immunizations

• Cervical Cancer

• Chlamydia

• Prostate Cancer

• Colorectal Cancer

• Tobacco Cessation Intervention

Some interventions don’t require a physician.

Many treatments can be administered by eligible nurses,

nurse practitioners, physician assistants, pharmacists, or other

non-MD medical professionals. You can also see more patients

with mid-level clinicians. Expand your time and resources for

patient care, while increasing staff productivity and efficiency.

Use mid-level clinicians for preventative screenings such as:

Page 20: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

9

Get the hang of data analytics.

Page 21: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Analyze patient data to identify potential treatment opportunities.

To minimize future costs, providers will need to

predict which patients are likely to get sick. Motivating

patients, especially your chronically ill population, to

comply with recommended treatment and preventa-

tive care is a universal challenge for most providers.

Implementing Population Health into your practice is just the beginning of improving patient outcomes. Practices using patient engagement reporting and analytics set the stage for more ad-vanced patient management capabilities. These include solutions such as risk stratification, risk scoring, predictive analytics, and improved value-based reimbursement opportunities.

We chose NextGen Population

Health to help us provide the

best care for our patients.

The ability to effectively

leverage our practice

management and clinical data

will help us identify treatment

opportunities and improve

quality outcomes.

Dr. Thomas Huth VP Medical Affairs

Reid Hospital & Health Care Services

Implementing Population Health into your practice is just the beginning of improving patient outcomes.

Page 22: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

10

Retool for patient “partnerships”

Page 23: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Elevate the patient/doctor relationship to new heights.

Because ACO delivery models are becoming more prevalent, providers are adopting new ways to connect, engage, motivate, and sustain meaningful patient engagement. As healthcare delivery evolves, (and designated caregiver) as a partner. This will require a major change in how patients, together with caregivers, use technology to better care for themselves,

maintain their health, and/or manage chronic conditions.

Make population health management work for you:

• Maximize financial return during transition

• Reduce “avoidable” ED visits

• See fewer avoidable hospitalizations and readmissions

• Deliver better care in a lower cost setting

• Deliver improved quality care outcomes

• Leverage patient management tools

• Get reimbursement for screenings

• Get paid for “non-visit contacts”

• See shared savings opportunities

• Address chronic and preventive care proactively

• Use PH as a building block for quality initiatives (such as PCMH)

• Improve operational efficiency and compliance for follow-up visits

• Increase revenue due to fewer missed opportunities

• Increase volume of inbound calls

Page 24: NextGen Population Health TENTENTENTENTEN · Elevate the patient/doctor relationship to new heights. Because ACO delivery models are becoming more prevalent, providers are adopting

Contact us at 855.510.6398 or

[email protected].

Take the Next Step

Copyright © 2014 NextGen Healthcare Information Systems, LLC. All rights reserved. NextGen is a registered trademark of QSI Management, LLC, an affiliate of NextGen Healthcare Information Systems, LLC. All other names and marks are the property of their respective owners. Patent pending.

NextGen Healthcare Information Systems, LLC | 795 Horsham Road, Horsham, PA 19044 | p: 215.657.7010 | f: 215.657.7011 | nextgen.com

EDU42-10/14

For more information, read our NextGen® Population

Health brochure at www.nextgen.com/Products-and-

Services/Ambulatory/Population-Health or watch an

online demo at nextgen.com.