Primary Care First (PCF) participants need to pay attention There is a renewed emphasis on advancing primary care. Primary care serves as the front door to the overall healthcare system, and early and accurate diagnosis can lead to fewer hospital admissions – a metric that has become especially important during the pandemic. With the January 2022 launch of Primary Care First Cohort 2, it is important to review what steps healthcare organizations should take to ensure the best outcomes. To be successful, PCF participants must pay special attention to three aspects: tracking the beneficiary population, obtaining physician buy-in, and ensuring timely access to performance metrics. 1. Tracking Beneficiary Population Tracking patients participating in the PCF program is necessary to build patient navigation processes and monitor care outcomes. However, this can be challenging for many providers as internal EMR solutions do not provide complete data across the entire continuum of care f...

Can ACO REACH help CMS and providers achieve the unmet goals of prior alternative payment models? If so, a stronger focus on equity, provider leadership, accountability through risk and evaluation may make the difference. Announced Feb. 24, ACO REACH — Accountable Care Organization Realizing Equity, Access, and Community Health — is CMS' newest voluntary APM. Robust resources and capabilities will be needed to navigate its requirements. As highlighted in a recent CMS webinar , ACO REACH is the first APM to launch following a Strategy Refresh by the Center for Medicare and Medicaid Innovation. ACO REACH aligns with the CMMI objective of driving accountable care to improve cost and quality and will replace the current Global and Professional Direct Contacting program, effective Jan. 1, 2023. CMMI encourages current GPDC participants and new entrants to apply, noting that selection criteria and performance monitoring will be more stringent. This blog highlights key differences bet...

Download our white paper, Using Social Risk Scores to Predict Unnecessary Healthcare Utilization .  All forward-thinking hospitals understand the role of social risk in providing effective, equitable and efficient care. In many ways, hospital objectives align with those of social risk assessment. Both help to distinguish acute from long-term needs, identify underlying contributors to poor outcomes and, wherever possible, help minimize or completely prevent more serious interventions. Six social risk factors and their drivers Social risk is a measure of vulnerability as defined by specific social determinants of health (SDOH) . DataGen uses the following six SDOH categories. Social Determinants of Health Category Defined by Individual risk drivers Community risk influencers Digital Access, affordability and literacy Competency Resources Finance Strength, resources and r...

CMS has introduced more than 50 innovative care delivery models designed to drive health system transformation over the last decade. Only six of those produced significant savings; of those, only four met the requirements to be expanded. As the second 10-year period of the program gets underway, which includes $10 billion in new funding, CMS’ Center for Medicare and Medicaid Innovation is considering numerous changes to improve the overall success of these programs and, in turn, drive overall gains in care outcomes and health equity. When evaluating what has worked in the past and what changes are needed moving forward, it is important to review what success looks like for Alternative Payment Model programs.  CMMI relies on three benchmarks to measure levels of success The gold standard: improving quality of care while simultaneously reducing expenditures. Improving quality of care without impacting expenditures. Reducing expenditures without impacting quality of ...

In the first part of this blog, we discussed the “Discover” phase of working with community-based organizations to address social determinants of health. Next, we’ll discuss the other steps in the Discover-Plan-Act cycle. In planning SDOH strategies, hospitals and health systems, guided by their Community Health Needs Assessments, are often best able to identify and convene key partners to address SDOH. The CHNA process brings neighboring healthcare providers and community-based organizations together to: learn from one another; gain commitment; share expertise; understand public policy efforts; and leverage technical and hands-on assistance. But, are these efforts sufficient? The recent HealthLeaders Social Determinants NOW Summit highlighted the conversations needed to identify, solve and scale collaborative SDOH programs with CBOs. The summit showed the importance of identifying, expanding and improving existing CBO wish list programs. In other words: leverage, scale, improve and...

Read the next blog in our series,  Part 2: How to supercharge social determinants of health (SDOH) outcomes. Partnership has always been essential to achieve healthcare's aims. And where there's a will — and a pandemic — there's a way. To find the way , hospitals and community-based organizations must partner in new ways to incorporate social determinants of health into patient care improvement efforts. Rich new SDOH data sets can supercharge the design, implementation and evaluation of SDOH initiatives as providers are expected to assume more responsibility for outcomes related to non-clinical factors.  The impact of social determinants of health  The pandemic resurrected a statistic that has been around for some time: 80% of health outcomes are based on social determinants, with only 20% dependent on clinical care.  People naturally understand it is harder for someone to manage their diabetes without access to affordable, healthy food. Through the federally-requir...