Focus is on innovation, leading to targeted strategies around care coordination and transitions, chronic care optimization and illness prevention, transformation of acute episodic care, and engagement of patients. Patient care can be incentive, virtual and in-person care integrated, and self-care emphasized. 0 Specific targets for redesign: largest impact by patient population, resource consumption, greatest amount of unjustified variation, evidence-based best practice and available metric outcomes, most Interest from clinical champions/consumers, observed outcomes farthest from expected performance.

D Clinical Business case: Target expected gains, process outcome metrics, and leadership accountability. Design teams work through clinical evidence definition, existing/future workflow, analysis of financial incentives, regulatory and estate reviews. Improvement methodology: using continuous Quality Improvement, Six Sigma, or Lean reengineering. 0 Practice Methodology: A Singer Health Plan RUN care coordinator in each practice site, predictive analytics to identify risk trends, focus on pro-active evidence-based care to reduce hospitalizing, promote health and optimize management of chronic disease.

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Home based monitoring, interactive voice-response surveillance, and support for end of life care decisions. A dedicated phone line to allow high -risk patients to contact their case managers directly. Practice based payments: To encourage physician engagement, Singer Health Plan provides monthly payments of $1,800 per physician. $5,000 per thousand Medicare members are paid to the practice to fuel their operations. In addition, an incentive pool is created based on differences between the actual and expected total cost of care for medical home enrollees (contingent on quality indicators).

To encourage team-based care/support, incentive payments are split between individual providers and the practice. Financial Incentives for Primary care: Comparison costs of practices using APPC model to those that do not and achieved savings (by reducing hospital admissions and unnecessary tests, they can get half $ back. The catch is that they only get the $ if they’ve met a whole checklist of quality measures for preventive care, chronic disease management and so on. Primary Care is rewarded for efficiency without sacrificing quality.