Keys to Success in Value-based Care Systems

By Carlos Jackson, Ph.D. and Paul Mahoney, Community Care Physician Network

2022 Alliance sponsor feature article courtesy of Community Care of North Carolina

The movement to value-based payment systems occurring simultaneously with a pandemic and, in North Carolina, sweeping changes to Medicaid, has made for an incredibly challenging environment for medical practices, particularly independent practices. This new environment requires new workflows and new approaches to managing patient panels.

The good news is that, working together, independent practices can still thrive in this new environment. In supporting the more than 900 practices in the Community Care Physician Network (CCPN), we’ve identified four critical keys to success, highlighted in the graphic below. At CCPN we work with practices where they are, share best practices pioneered by similarly-situated practices and help them find practical solutions to daily challenges.

CCPN exists to help member practices thrive financially, provide high-value care, and enable providers and patients to maximize their satisfaction with the practice of medicine. CCPN is governed by practicing, community-based physicians.

We have found that for many practices, the most challenging piece of this puzzle is making the best use of data. Practices are awash in data, but can they parse it intelligently to pull out what is actionable, and identify the information critical to hitting the metrics that drive present and future revenue?

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CCPN has made significant investments in tapping into the potential of EHR clinical data without practice staff needing to devote significant time in making sense of it all. Through new tools and innovative partnerships, we have built an infrastructure to help our network practices identify opportunities to close care gaps, improve quality and patient engagement and ultimately hit metrics that satisfy payer bonus arrangements, generating significant additional revenue critical to the long-term financial viability of the practice.

Practice PerfectSM Dashboard
Designed with busy practices in mind, Practice PerfectSM is a Tableau-based business intelligence tool that distills complex information from multiple data sources, identifying actions you can take right now to boost quality and improve performance. Recommended ActionsSM are an efficient and unique way of viewing worklists taking multiple patient and practice factors into account in order to help you prioritize long lists of care gaps.

The dashboard synthesizes claims, hospital visits, and individual risk scores to prioritize patient needs, as well analyzes the cost, utilization, and disease burden of a practice’s Medicaid patient panel. The dashboard also provides monitoring of performance on contract measures to inform practices of their progress on meeting contract measures. Users can quickly create targeted patient lists to determine where to best focus resources and improve performance. Additionally, Recommended ActionsSM integrate with clinical and scheduling data, as well as ADT and immunization feeds from outside vendors, for more actionable and up-to-date guidance. The dashboards are organized in a way to not overwhelm the provider and offer just enough information to help them be successful.

VirtualHealth™ Provider Portal
The VirtualHealthTM Provider Portal connects practices with their CCNC Care Management team – partners for improving patient outcomes. This provides secure access to Medicaid patient care management documentation, comprehensive needs assessments, and care plans. Through the portal, clinicians can make referrals to care management and enjoy secure communication with patient care teams. Clinicians can view patient history from claims, pharmacy, and hospital data – keeping them “in the know” regarding what care patients are receiving from outside their practices.

Value-based Informatics Program (VIPSM)
CCPN has significantly upgraded technology that supports practice success under value-based contracts across all payers and populations – at no additional cost to our CIN practices. We pull clinical data from practice EHRs to measure quality more easily. This greatly helps practices generate bonus payments from insurers. Our system also gathers appointment data to help practices better capitalize on Recommended ActionsSM. We alert practices to care gaps and opportunities to improve the accuracy of RAF scoring. We do this by joining EHR data with claims data for a more comprehensive view of patient care that yields improved insights. These tools also reduce administrative burden on practice staff. We are also piloting some in-line prompting tools that will provide practices with real-time alerts at the point of care. We believe that putting information in the hands of providers at the right time is one of the keys to success in value-based contracting.

While the environment for primary care practice won’t get easier anytime soon, help is available from your peers and CCNC. Together, we can help you find a path to financial strength and greater satisfaction with the practice of medicine for you, your staff, and your patients.

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Community Care Physician Network (CCPN)
CCPN is a physician-led, clinically-integrated network that helps independent primary care physicians deliver high-quality, cost-effective care. CCPN priorities are helping practices thrive financially, provide high value care, maximize provider and patient satisfaction, and take charge of their own destiny.

Lisa Hooks, MBA, Named NCMGMA/Medical Mutual Administrator of the Year


(L-R): Steve Parker of Medical Mutual, 2018 Administrator of the Year Lisa Hooks and NCMGMA President Sandra Jarrett

Lisa Hooks, Executive Director for Mt. Olive Family Medicine Center (MOFMC), was named the 2018 NCMGMA/Medical Mutual Administrator of the Year during the North Carolina Medical Group Management Association’s Annual Conference (NCMGMA) awards banquet on Thursday, May 10th. The event was held at Harrah’s Casino and Resort in Cherokee, NC.

The Administrator of the Year award honors a medical practice administrator who has demonstrated exceptional leadership and management proficiency, and who has helped enhance the effectiveness of health care delivery in North Carolina. Sponsored by Medical Mutual Insurance Company, the Administrator of the Year Award also provides the recipient with a stipend for continuing education at a state or national Medical Group Management Association (MGMA) meeting or professional development through ACMPE.

Lisa Hooks has served as the executive director of Mt. Olive Family Medicine Center (MOFMC) for almost 20 years. Under her leadership, MOFMC is consistently recognized as one of the best family medicine practices in North Carolina. For the past three years, MOFMC has been recognized as the “Best Medical Practice in Wayne County” by the Goldsboro News Argus and was recently awarded the Practice of the Year Award from NCMGMA.

Some of Lisa’s standout achievements include: MOFMC received the Level III Patient-Centered Medical Home designation; she helped develop MOFMC’s Chronic Care Management Program and Concussion Clinic; and during the 2017-18 fiscal year, Lisa wrote for and was awarded with $448,879 of grant money for MOFMC.

Lisa is the Professor (Adjunct) for Health Care Management at the University of Mount Olive and is involved in several professional and community organizations, including the Mt. Olive Chamber of Commerce, the Coastal Administrators Advisory Committee for Medical Mutual, and the Medicaid Committee and Blue Cross Blue Shield Committee for the North Carolina Medical Group Management Association.

Approximately 200 people attended the Annual Conference in Cherokee this past weekend. This year’s conference featured nationally-recognized speakers, general and breakout sessions led by industry veterans and an exhibit hall showcasing the latest healthcare management products and services.

Mt. Olive Family Medicine Center, Inc. Receives 2017 Annual NCMGMA Practice of the Year Award

Mt. Olive Family Medicine Center was named the 2017 Practice of the Year at the North Carolina Medical Group Management Association’s (NCMGMA) Annual Conference, held May 7-9, at the Westin in Charlotte, NC with over 275 people in attendance. NCMGMA’s Practice of the Year Award recognizes a medical group practice that makes significant contributions to its community, patients and staff through volunteer work, fundraisers, staff wellness programs, community clean ups, and community screenings and education.

“Mt. Olive Family Medicine Center truly signifies all that our Practice of the Year Award stands for.” says Fran Sembert, NCMGMA’s 2005 President and current Governance Committee Chair. “The practice continues to grow and change to meet the needs of the population they serve and the community benefits from the education that is now provided directly to teachers, guidance counselors, coaches and parents. This resource is now local to their patients, many of whom have transportation issues and financial restrictions.”


(L-R): Andrea Murphy, Lisa Hooks, Ashley Long and Joey Long

The Practice of the Year Award, sponsored by First Citizens Bank, provides a $3,000 check to a charity chosen by the award recipient. This year’s funds will be given to the Mt. Olive Family Medicine Center, a 501(c)3. Lisa Hooks, Mt. Olive Family Medicine’s Executive Director confirmed the additional funds will allow for more baseline concussion testing for local public school athletes with a goal of providing free testing to all athletes regardless of their economic status. Up until the summer of 2015, if a patient suffered a concussion, they would have had to drive 60 miles to receive neurocognitive testing

During the conference, attendees attended educational sessions centered on the theme “Leading through Change” and heard from presenters such as Robert Laszewski from Health Policy and Strategy Associates, Skip Weisman from Weisman Communication Resources, North Carolina Medical Society, Parker Poe, and MSOC Health.

The North Carolina Medical Group Management Association (NCMGMA) Association gives the professional administrator a rich source of information and contacts for professional growth. Since our founding in 1971, we have grown to more than 850 members strong, representing medical practices across North Carolina. Our membership includes executives and managers of private group practices, academic medical centers, integrated delivery systems, and companies that support medical provider organizations. Learn more at

About Mt. Olive Family Medicine Center
Operated by a volunteer uncompensated Board of Directors from the service area of the practice, Mt. Olive Family Medicine Center is a designated Rural Health Center as declared by the NC Office of Rural Health and Resource Development. We are dedicated to the health and well-being of the residents of Wayne County and the surrounding areas. It is our goal to identify and minister to the medical needs of the family unit-not only to provide quality, comprehensive medical care, but also to institute health education, urgent care, wellness and preventative medicine.