Blog Post | April 3, 2017

Best Practices for High Risk Populations – Part Two

Part Two: Best practices for high risk populations

There’s Always More to Learn from Colleagues…and Happy to Share

Written By: Terri Maxwell Ph.D., APRN Chief Clinical Officer, Turn-Key Health and Matthew Harker MPH, MBA, Associate Director, Health Policy Hub, Duke Clinical Research Institute


It’s always gratifying to learn about market innovations.

My participation on a panel discussing alternative care models at the Best Practices for High Risk Populations Including Care Transitions and Palliative Innovations conference offered valuable information and guidance which I’ve shared in Best Practices for High-Risk Populations, Part One.

Here’s more!

Additional themes of the conference were to define and categorize the patient’s needs, not the setting, as the best means to determine post acute care needs. Progressive Medicaid programs such as those taking place at Passport Health in Kentucky are utilizing technology and analytics to meaningfully engage their members and link with outside community partners to help address the social determinants of health.  Concurrently, they are also providing a portal to coordinate their health care utilization across multiple touch points.

Jatin Dave, CMO, of New England Quality Care Alliance described various strategies to decrease variation in post acute care that represents a significant opportunity for Medicare savings and improved care quality. These are the result of an extremely fractioned part of our health care system that has not historically been aligned with hospital and physician groups driving most of the care decision making. He stressed that defining and quantifying patient needs and functional status is critical.

Here are some of the innovations from the alternative model panel:

Matthew Harker, a health policy expert from Duke, described payment model innovations that he is evaluating through a CMMI award on community-based palliative care delivery, and those that are being submitted by the AAHPM as well as CTAC.

John Burich, VP of Strategy and Growth of Passport Health Plan discussed how to make risk prediction work through tailoring reports and actionable activities in their “PayVider” consumer driven, provider led model.

Parag Bharadwaj, Chief of Palliative Care Medicine for Sentara Healthcare described the challenges inherent in using cost savings as the basis for program funding support in inpatient palliative models and ways to make the value proposition more compelling as it still remains a needed advocacy in hospitals.

And I described the importance of utilizing predictive analytics to proactively identify persons who would benefit from palliative care as opposed to waiting for referrals or using clinical trigger lists. I also highlighted the benefits of a non-medical community-based palliative care program model to achieve the triple aim in healthcare, which is a much needed movement to link care in post-acute settings, especially patients within the home setting.

If you haven’t read about our Palliative Illness Management model – better known as PIM™, here’s a link: “Over-Medicalized Care at the End-of-Life in the United States: Addressing the Economic and Social Consequences.”

Terri Maxwell Turn Key Health CCO

Terri Maxwell, Ph.D., APRN
Chief Clinical Officer, Turn-Key Health

Matthew Harker Associate Director Health Police Hub

Matthew Harker, MPH, MBA
Associate Director, Health Policy Hub within Health Services Research at Duke Clinical Research Institute

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