Registries Identify High-Risk Patients,
Support Evidence-Based Protocols

Obtaining a clear snapshot of a patient population is the first step in managing health outcomes in an accountable care organization (ACO), says Gregory Spencer, MD, FACP, chief medical officer with Crystal Run Healthcare. Registries are a major part of that, and at Crystal Run Healthcare, care managers use them to identify high-risk patients, implement evidence-based protocols, and coordinate care inside and outside the office.

We have used care managers for about seven years, said Dr. Spencer. Groups of nurses use our registries to identify high-risk patients and implement evidence-based protocols. We have used an EHR, and we use e-mail and Blackberries® extensively within our practice so that when we have a new development, we can get the word out quickly to mobilize people or alert them that certain things are happening. Registries are a major part of this: getting your list of people with a high-risk condition.

Our care managers are nurses that pull the list of patients from the registry using evidence-based guidelines, he added. They contact them, make sure they get certain things done that they need to have done, and smooth those efforts. They do care planning and then communicate with the patients outside of the office. We are also embedding a care manager at a few of our sites to try and catch patients while they are in the office as well.

The template we use is pretty basic, said Dr. Spencer. It keeps track of the patient's last test, and includes certain results so that if the patient has a question or is due for some lab work, the care manager can quickly order it. If it's not protocol-driven, they can send it to the physician for review or potentially do it themselves if we are able to cover it with a protocol. This is one way we use registries of patients who require referral tracking.

Again, workflow is the Achilles heel of some brilliant quality efforts. You don't want to destroy your workflow and patient flow, he explained. Not to say that you can't redesign your workflow if it is important, but this process can end in tears. Sometimes if the change is not well thought out, it has negative effects on workflow.

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable CareIn Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care Dr. Spencer examines the building blocks of population health management that drive improvements in healthcare quality and efficiency in ACOs while positioning healthcare organizations for core measure improvement and increased reimbursement.

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In this 40-page resource, Dr. Gregory Spencer, chief medical officer of Crystal Run Healthcare, demystifies registry use and shares patient registry best practices, including the following:

  • Redesigning internal processes so that a registry can be used most effectively;
  • Using registry data to identify gaps in care;
  • Steps to improve accuracy and completeness of registry data; and
  • The evolving role of patient registries in delivering accountable care.

Excellence in population health management can only be achieved through experience. CMS Physician Group Practice participant Dartmouth-Hitchcock has developed a competency in population health management that it deploys in ongoing ACO pilots with Medicare and Cigna and in an ACO pilot in development with Anthem/WellPoint.

In Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care, Dartmouth-Hitchcock senior medical director Dr. Barbara Walters shares how the pilots have demonstrated the value of an ACO by achieving efficiency, quality and cost targets.

She explains the following:

  • The shared savings and total cost of care payment methodology developed by Dartmouth and Cigna for commercial members attributed to Dartmouth;
  • The new roles and responsibilities within an ACO to efficiently manage the health of a population, including strategies for practicing at the top of license;
  • Developing a collaborative model of care that allocates resources to manage illness burdens, gaps in care and care plans of a defined patient population; and
  • Results from Dartmouth's ACO pilots with CMS and Cigna, including where Dartmouth has achieved better than market results for these programs.

To learn more or to order your copy today, contact HIN at 888-446-3530 or visit online at:

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