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 Perfect^SM Dashboard
Designed with busy practices in mind, Practice Perfect^SM 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 Actions^SM 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 Actions^SM 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 VirtualHealth^TM 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 (VIP^SM)
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 Actions^SM. 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.