Key Highlights
- The program saved $1.46 million in the year since implemented
- Patient engagement – measured through “no-shows” and compliance – improved
- Provider engagement increased
Genesys PHO, a Michigan-based physician hospital organization and partnership between primary care physicians and investors Ascension and Henry Ford, serves about 120,000 patients. Recently, the organization began working to improve outcomes using risk stratification to improve provider performance.
Working with analysts and leveraging the risk stratification tools in the Milliman MedInsight VBC platform, nurses embedded within various practices were able to identify high-risk patients, even those without recent doctor visits. With teamwork, continuous feedback, and physician engagement, the program has improved care coordination and adoption across teams. It is a collaborative approach that has also driven enhanced patient engagement and fewer missed appointments, resulting in measurable ROI within one year.
“All our caregivers care about our patients and they really want to make a difference. That was the driving force of that program. Having the tools and right information just made their jobs easier.”
Samantha Lewis, Genesys PHO Manager of Healthcare Business and Population Health Analytics
Identifying the problem
The primary challenge was optimizing data management and engagement with Milliman MedInsight to allow providers to focus more on direct patient care.
- Providers prefer direct answers to streamline workflows and maximize patient care time.
- Inconsistent EHR problem lists and reliance on Microsoft Excel/PDF workflows hinder efficient data use.
- Improved integration and visibility of behavioral health data are needed for comprehensive care.
Analyzing the data
Population health analysts, using EHR and claims data, provide lists to embedded clinical staff.
- Data pulls include BMI, HbA1c, diagnoses, and chronic condition flags.
- Quarterly patient lists are provided to nurses in Microsoft Excel or PDF format.
- Metrics like patient contact hours, ED visits, hospital admissions, and specialist touches are analyzed for
productivity and ROI evaluations.
Developing solutions
The solution introduced cleaned data, risk stratification, and embedded nurses in practices.
- Reports were developed that included risk stratification, clinical flags, and relevant lab results.
- Analysts worked with practice managers and nurse care managers to provide relevant data.
- Continued support includes expanding the diabetes education program initiated with specific flags for
prediabetes and diabetes.
Implementing the plan
Implementation was a phased approach, starting with high-cost, low-quality providers, allowing for feedback and improvement in clinical reports.
- Risk stratification was rolled out to all providers within nine months, with nurses embedded in practices and quarterly patient lists provided for follow-up.
- Within nine months, the program was rolled out to all providers.
Realizing results
The program resulted in significant cost savings, improved patient management, and increased provider engagement.
- The program saved $1.46 million in the year since implemented.
- Patient engagement, measured through “no-shows” and compliance also improved.
About Genesys PHO
Founded in 1995, Genesys PHO is a physician hospital organization focused on improving the health of the community with integrated services and innovative care management programs. As a partnership between primary care physicians and Ascension Genesys Hospital, the network also includes 100 primary care physicians, several hundred specialists, stand-alone imaging centers and physical therapy centers.
Learn more: genesyspho.com
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