GE Healthcare Camden Group Insights Blog

Truth Be Told: What CMS Doesn’t Tell You About the Medicare Shared Savings Program

Posted by Matthew Smith on Sep 28, 2016 11:10:56 AM

By Megan Calhoun, MS, MSW, Manager, and Andy McNerney, Manager, GE Healthcare Camden Group

Secrets.jpgWhen the Centers for Medicare & Medicaid Services ("CMS") launched its Medicare Shared Savings Program ("MSSP") in 2012, CMS leveraged the upside, risk only-design and the opportunity to be a care model redesign champion. It also intended to lead the market in value-based care delivery as a way to entice ACOs to join the program. Four years and 539 accepted MSSP ACOs later, CMS released its most recent set of performance results for the 80 percent of ACOs that have survived the program.

While savings of more than $429 million and overall quality improvement sounds like cause for celebration, the real story begins by acknowledging that program success doesn’t come easily and requires hard and transformative work…just ask the almost 70 percent (n=272) of MSSP participants who failed to achieve a shared savings distribution. Even for those participants that did achieve program savings, it is likely that the set-up and operating costs associated with the ACO program threatened bottom line financial success…today. But care transformation is not just about today’s bottom line, is it? Program veterans, or those who have participated for more than one Performance Year, have shown that it takes years to truly make an impact on cost and quality. The rest of the story will be written by their continued success as they gain a strategic advantage and encourage other providers to invest in their own transformation.


If CMS Isn’t Telling the Whole Story, Define and Measure Your Own Success!

Participation in the MSSP is not only an opportunity to impact select quality metrics and recuperate some dollars lost as a result of reduced unnecessary utilization. It is a long-term strategic play to prepare for the not so distant future when up- and down-side risk taking will be the norm, not the exception. The data provided from CMS through the MSSP program is neither real-time nor risk-adjusted, making it extremely difficult for ACOs to assess their performance. In addition, the influx of participants makes it challenging to track and trend an ever-moving target. Furthermore, performance on quality measures is not released to the ACOs until Quarter 2 of the following performance year.

This leaves the ACO limited time to review performance, establish initiatives, and implement efforts to improve outcomes. ACOs need to develop a mechanism by which they can continuously monitor overall cost of care and performance on the established quality measures so that they are not relying on CMS to report on their progress. Instead, continuous process improvement and measurement needs to be the new normal in preparation for a time when CMS will not be the only value-based contract in place. The amount of shared savings achieved, the level of patient satisfaction, and the quality outcomes delivered at the end of each Performance Year should not be a surprise, but all too often it is!

The Focus On Quality Should Go Beyond MSSP Attributed Lives!

The overall quality improvement shown by the MSSP ACOs indicates a program-wide commitment to improved health outcomes that should be applauded. These measures focus on patient satisfaction, reduction in avoidable utilization, preventive care, and evidence-based protocols for at-risk populations. Successful performance on many of these measures requires substantial data aggregation and analysis and proactive outreach to MSSP ACO patients. Where many ACOs falter is by laser-focusing on only the MSSP population; those beneficiaries assigned to the MSSP receive proactive preventative care while other patients are overlooked.  While this can be a successful short-term strategy (particularly when resources are limited or information systems have not yet have matured), operationalizing it is a challenge and this approach will not position the organization for long-term success.

Quality outcomes initiatives should be inclusive of all patients, regardless of payer, to demonstrate that your model of care can be scaled and to attract similar shared savings arrangements beyond CMS. The bigger problem is that care delivery does not just change for a given population and organizations are realizing that other payers are benefiting from their performance improvement efforts, which causes barriers to engage these providers in value-based contracting because the organization is producing results that are benefiting the payer without the compensation.

In 2015, CMS set a goal of having 50 percent of Medicare payments made through alternative payment models by 2018. Providers have responded through strong participation in programs such as MSSP, Pioneer ACO, and Bundled Payments and indications are that value-based payments will become the standard. If your organization embraces a value-based world, then program participation can be a good step towards building the necessary muscle. But only if you make a full organization wide commitment to the cultural change required to support care model redesign and do so with a customized definition of success; because unsuccessful participation may be even more costly to an organization than no participation at all.

Organizations who don’t take the time to invest in the appropriate care coordination resources will find that they have spent money on ACO staff, slightly reduced inpatient utilization (and therefore revenue), and receive no shared savings distribution to offset these costs. This can be a very frustrating result, leading to dissatisfaction with the program and disillusionment with care coordination. So, jump in! But don’t leave the necessary people, data, or innovation behind. 

Calhoun.jpgMs. Calhoun is a manager with GE Healthcare Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. She may be reached at megan.calhoun@ge.com.


mcnerney.jpgMr. McNerney is a manager with GE Healthcare Camden Group. His primary area of focus is bundled payments strategy, design, and implementation. Mr. McNerney also specializes in system and service line strategic planning and new business development for a variety of healthcare organizations. He may be reached at andrew.mcnerney@ge.com




Topics: MSSP, CMS, MSSP ACO, Megan Calhoun, Andy McNerney

10 Myths of Population Health and Clinical Transformation

Posted by Matthew Smith on Mar 1, 2016 11:40:34 AM

By Daniel Juberg, Manager, and Megan Calhoun, MS, MSW, Manager, GE Healthcare Camden Group

Myths, Clinical Integration, Population HealthIt is a confusing time in United States healthcare. Healthcare organizations are faced with the new reality of value-based care and are identifying the necessary steps for success in an evolving healthcareenvironment. For many, this transformation is difficult, and fear of this change may hinder progress. However, at present, a lack of true understanding of the care processes, tools, and consequences of this transformative shift persists in the healthcare community, and with the public at large. The delivery and consumption of care is rapidly changing for both provider and patient, and not everyone is on the same page. Below are ten myths associated with clinical transformation and its ability to position an organization for success in a value-based world, along with the realities with which providers and organizations must face.

Myth #1:  The best care (or better care) is provided in hospitals.

RealityFor many years, the United States healthcare system has been very hospital-centric. Patients who were sick were directed to go to the Emergency Room or the hospital to get better, and physicians were paid handsomely for services provided in the hospital setting. This cycle has engrained within Americans (and within many physicians) that the hospital is the setting for receiving the highest quality of care. Patients will often even ask to be admitted to the hospital because they believe superior care will be provided there. Today, the healthcare system has begun to shift to improve and increase the suite of outpatient healthcare services to include ambulatory surgery centers, urgent care centers, retail clinics, even home-based care. The hospital is no longer the only place to go to receive care and, in fact, the best interventions will keep patients safely in their homes and out of the hospital altogether.

Myth #2:  All organizations should be negotiating value-based payment contracts.

Reality:  While value-based payments are a driver for clinical transformation, organizations should move at the pace of their market (and their own capabilities). Each market across the county differs in its pace in the shift from a volume to value-based environment. Organizations who are maintaining success in a primarily fee-for-service environment may not be ready for an immediate switch to value-based payments. Instead, these organizations should begin undertaking efforts to prepare for an eventual change to value-based contracting through improved medical management efforts and regular analysis on clinical outcomes and cost of care. This transition for some has had to be rapid, given the speed with which the market had adopted value-based payments. However, for many others who are not yet positioned for success in a value-based market, this transition should be gradual as the organization begins to develop the necessary capabilities; in a volume-based environment, these changes can still have positive outcomes through a focus on treating patients in appropriate care settings, thereby increasing capacity and access. Therefore, the focus for all organizations should be developing and implementing the clinical care model that is in sync with its payer contracting strategy.

Myth #3: Interoperability among information technology (“IT”) systems results in clinical integration.

Reality: As healthcare organizations begin to explore the clinical transformation needed to achieve clinical integration, the number one barrier frequently identified is the lack of interoperability among the health IT systems. Often, organizations may decide a complete IT overhaul is necessary (very costly) or that clinical integration is simply not possible and withdraw from the effort. However, highly integrated IT systems do not magically result in clinical integration. IT systems lack the clinical judgment that is necessary to provide high-quality, patient-centric care. IT systems cannot identify population health objectives and goals and design interdisciplinary medical management programs that aim to meet population health goals. It is the aligned vision for improving health outcomes among all care team members that results in clinical integration; IT systems can simply enable this type of care through real-time alerts, evidence-based clinical pathways, and historical and predictive trending of clinical data and notes. Interoperability should be viewed as a means, not as a deal breaker in its absence.

Myth #4:  Electronic Medical Records (“EMRs”) make physicians lives easier and provide better patient care.

Reality: Advances in technology have provided innumerous innovations to the majority of industries and society in general. While healthcare has been an undeniable benefactor, it is widely assumed that because electronic tools have made the public’s lives significantly easier, healthcare providers have experienced the same benefits and welcome all advancements. Healthcare IT, including EMRs, can provide the care team (e.g., the physician, medical assistant, nurse, social worker, or other care coordinator), with a wealth of knowledge about each patient. Tools exist that track and trend lab results, maintain and update a singular care plan, and provide point-of-care alerts to close gaps in care. Many organizations rely heavily on the information provided through these tools to provide patient-centered, high-quality care. However, it is not the information contained within these tools that has enhanced patient care; instead, it is the care processes and workflows that have been developed to ensure this information is meaningful and utilized that has enhanced care. Without clear care protocols or actionable reports, physicians can be frustrated by the vast amount of information presented to them and the myriad of tasks they must complete within multiple IT systems. Too much data contained in a myriad of health IT systems can actually result in less coordinated care between physicians and across care settings. It is the integration of this information, in a succinct form, into clearly defined care processes that enables the delivery of high-quality patient care and allows the technology to ease the burden on the provider, rather than add to it.

Myth #5: Population health management requires significant IT capital and increased staffing.

Reality: Additional capital to support informatics and staffing are a luxury and can improve efficiency and effectiveness of care management initiatives, but they are in no way a necessity for population health management. Population health management begins with a cultural transformation within the organization that is centered on a dedication to providing high-quality, patient-centric care. A clinical transformation subsequently occurs that leads to the development and establishment of refined clinical pathways and processes and often the redeployment of staff. IT tools can assist with these processes, but they should not drive the clinical transformation that needs to occur within the care teams. Similarly, the role of support staff (e.g., care managers, social workers, health coaches) does not actually increase; instead roles are assessed and redefined, as necessary, to ensure staff resources are deployed in a manner that is targeted to meets the needs of the population and the associated intervention. Too often organizations making this transition attempt to run before they can walk.

Myth #6: Clinical integration results in mass layoffs of staff.

Reality:  The Triple Aim® consists of three components: improved health outcomes, improved patient experience, and reduced overall cost of care. While it is imperative that all three of these tenets are taken into consideration for successful clinical transformation, providers frequently focus on the latter and associate it with cost and workforce reductions. Often, organizations are not over-staffed for population health management; instead, staff members are simply not working to the top of their license and are not always providing care to the right cohort of patients, at the right point in time, with the right care interventions to meet the patient’s needs. A reduction in staff will only increase the volume strain all staff is already experiencing. Instead, an assessment and redesign of clinical protocols should inform the medical management staffing. A re-deployment of staff may be necessary to ensure staffing levels are congruent with the acuity of the patient population, and additional training may become necessary to ensure all staff members are able to perform effectively and efficiently in new roles. In many cases, rightsizing can be replaced by adhering to clinical protocols and reallocating existing workforces.

Myth #7: Buying services that span the continuum is the only way to achieve clinical integration.

Reality:  The desire to purchase services that span the continuum stems from a need to be able to share clinical information, conduct warm handoffs between care settings, and keep healthcare costs and revenue under a single umbrella. However, just because an organization may own these services does not mean that these services are the highest quality, nor even utilized by other providers in the continuum. What is most important when developing a clinical integration model is the provision of high-quality, patient-centric care across the continuum. Services do not need to be owned to meet this obligation. Organizations should be looking, instead, to develop formal relationships with the most high-quality and value-based healthcare service providers. Referrers should have access to cost and quality metrics for all partner organizations and should utilize these results to drive care to the most appropriate providers. Preferred networks should be developed to enable care model development in conjunction with these partner organizations, all with the intent to provide patients with coordinated, seamless care transitions across care settings and, when appropriate, back to their home. There are several ways to achieve tightly aligned networks – organizations should be judicious when deciding if ownership over all components is the right strategy for them.

Myth #8: Maintaining universal physician satisfaction is a critical success factor for population health management.

Reality:  Physicians are critical to cultural and clinical transformation – this is an undeniable truth. However, not all physicians are well-educated about or in favor of clinical transformation to position them for success in population health. Some may be nearing the end of their careers, and this change may present a large burden. Placating to physician needs and preferences will not always bring about successful and unified change within an organization. Instead, try performance transparency. Initially, this may cause some discomfort among physicians; however, no physician wants to be the poorest performer, and this tactic may bring about the most rapid change in behavior. The enforcement of remedial action plans for physicians who do not follow established evidence-based protocols may also not be welcomed by all physicians, but will ultimately ensure that high-quality care is provided. While physician engagement is a critical element for success in population health management, it must be a mutual effort. Organizations that make the successful voyage to population health management need to weed out those vocally not on board, as well as those refusing to row in the same direction in their practices.

Myth #9: Patient satisfaction is the same as optimizing the patient experience.

Reality:  Despite what physicians may think, patients aren’t really rating physicians on whether they “always communicated well with them” or “always controlled their pain well.” The truth is that patient satisfaction has many components. Ultimately, patients are rating physicians on factors such as whether they got better and had timely access, which can ignore critical aspects such as the cost and appropriateness of care being provided. One prominent study contended that patients who reported being most satisfied with their physicians had higher healthcare and prescription costs and were more likely to be hospitalized than less satisfied patients. Could physicians who have patient satisfaction scores tied to their compensation be less likely to advocate against unnecessary requested treatments or less likely to raise concerns about lifestyle and behavioral modification issues?  Or could there be a correlation between high patient satisfaction scores and providers who actively tackle the hard-to-discuss issues the best? More research – and specifically innovative research – is necessary. Further complicating this issue is the new trend towards Yelp-style online public reviews influencing local perceptions of healthcare providers. As with any crowd-sourced review product, an issue arises when the public tends to only be inclined to offer their opinions when the service is exceptional, or the experience was considered an unpleasant one. Managing digital perceptions is yet another responsibility that consumer advancements and innovations have required of providers.

Myth #10:  Patient satisfaction will increase if physicians spend more time with each patient.

Reality: Patient satisfaction is about much more than the length of an appointment. Ultimately, patients are concerned about receiving personal, high-quality care at the time they need it. A patient will be satisfied with their care if they feel they can access it when they need it; for example, when a patient is able to schedule an appointment on the day and at the time they wish to see their physician or other provider and if their wait time is minimal.  Or, when a patient contacts their physician via a patient portal and receives a timely response. Furthermore, the patient wants to feel as though their physician is utilizing the appointment time to truly discuss their care, rather than reviewing old notes and labs and consistently typing on a computer; patients respond very positively to eye contact and listening skills as indicators that a physician is interested in a patient. A medical assistant or other office support staff can greatly assist physicians prepare for their appointments so that patients feel as though they are receiving the physician’s full attention, thereby bolstering the patient’s satisfaction with their visit.

juberg_headshot.pngMr. Juberg is a manager with GE Healthcare Camden Group and focuses on clinical integration, transactions, and strategic and business planning for healthcare organizations. He has extensive experience with the development of ACOs (financial planning and funds flow modeling), managing Medicare Shared Savings Program applications, and implementing clinically integrated networks. He is also experienced in master facility planning, CMMI Innovation Center grants, medical group valuations, and community needs projections. He may be reached at daniel.juberg@ge.com.

Megan.pngMs. Calhoun is a manager with GE Healthcare Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at Megan.Calhoun@ge.com.

Topics: Clinical Integration, Population Health, Regional Clinical Integration Networks, Daniel Juberg, Megan Calhoun, Clinical Transformation

Should You Consider the Accountable Health Communities Model?

Posted by Matthew Smith on Feb 22, 2016 1:53:44 PM

By Tawnya Bosko, DHA, MS, MHA, MSHL, Vice President, and Megan Calhoun, MS, MSW, Manager,                   GE Healthcare Camden Group

questions.jpgOver the past five years, CMS has developed numerous innovative models, grants, and initiatives aimed at providing high-value care to vulnerable populations such as Medicaid and Medicare beneficiaries. CMS recently announced its most recent model, a five-year test named the Accountable Health Communities (“AHC”) Model. The underlying premise of this model is the assumption that enhanced coordination between providers and community-based social service organizations for Medicaid and Medicare patients can help to achieve the central tenets of the Triple AimTM: higher patient satisfaction, lower overall costs of care, and better clinical outcomes. With the introduction of each new model, organizations often wonder whether they would benefit from participation. 

Questions to Ask

If your organization answers “YES” to any of the questions below, you may want to consider application for the AHC Model!

  • Do you have a high volume of Emergency Department “frequent fliers” due to poorly managed psychosocial issues?


  • Are healthcare services generally being mis-utilized due to the lack of sufficient psychosocial services?
  • Are there community-based organizations in your service area or surrounding neighborhoods that are not integrated into patient care plans or whose services are not fully utilized?
  • Does your payer mix consist of a high proportion of frail, underserved, or complex patients, such as Medicaid and/or Medicare patients or those dually eligible for Medicare and Medicaid?
  • Have you participated in or tried other care coordination initiatives (through CMS or otherwise) and been unable to successfully curb the cost curve?
  • Would you benefit from additional funding to integrate medical and behavioral care with social services?
  • Would your providers be open and willing to greater collaboration and coordination of care outside the four walls of current healthcare delivery sites?

It is clear that socioeconomic issues play a major role in the health of populations. According to CMS award recipients under the AHC model, referred to as “bridge organizations,” will oversee the screening of Medicare and Medicaid beneficiaries for social and behavioral issues, such as housing instability, food insecurity, utility needs, interpersonal violence, and transportation limitations, and help them connect with and/or navigate the appropriate community-based services.

If your organization struggles to manage the health of patient populations that have significant social support challenges, this program may be right for you. Up to 44 bridge organizations will be selected for the AHC model, which will deploy a common, comprehensive screening assessment for health-related social needs among all Medicare and Medicaid beneficiaries accessing care at participating clinical delivery sites.

Three Scalable Approaches

CMS has explained that the model will test three scalable approaches to addressing health-related social needs and linking clinical and community services – community referral, community service navigation, and community service alignment. Bridge organizations will inventory local community agencies and provide referrals to those agencies as needed. They may also provide intensive community service navigation such as in-depth assessment, planning, and follow-up until needs are

To measure the effectiveness of the model on impacting total cost of health care utilization and quality of care, the primary evaluation will focus on reduction in total health care costs, emergency department visits, and inpatient hospital readmissions.

Eligible applicants for the AHC model according to CMS are community-based organizations, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and not-for-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers.

Applications for the AHC model are due March 31, 2016.

Accountable Health Communities Model

bosko_headshot.pngDr. Bosko is vice president at GE Healthcare Camden Group and has over 20 years of experience in healthcare management and strategy. Her areas of focus and expertise include healthcare reform, market forces, and strategic analysis, specifically around hospital-physician alignment, emerging reimbursement and incentive models, performance optimization, payer strategy, and the intersection of health policy and delivery system transformation. Dr. Bosko is a nationally-recognized speaker on healthcare market trends and insights, focusing on the financing and delivery of care. She frequently presents at industry conferences and is the author of multiple articles for leading industry journals and publications on the transition to value-based reimbursement and health system strategy. She may be reached at Tawnya.Bosko@ge.com or 310-320-3990.

Megan.pngMs. Calhoun is a manager with GE Healthcare Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at Megan.Calhoun@ge.com or 310-320-3990. 


Topics: CMS, Triple Aim, Tawnya Bosko, Megan Calhoun, Accountable Health Communities

Moving from Utilization Management / Referral Authorizations to True Population Health Management

Posted by Matthew Smith on Feb 9, 2016 4:28:16 PM

By Tawnya Bosko, DHA, MS, MHA, MSHL, Vice President, and Megan Calhoun, MS, MSW, Manager,                   GE Healthcare Camden Group

population_health.jpgHistorically, many organizations managing care in a risk-bearing structure such as independent practice associations, medical groups, or related enabling entities such as management services organizations have primarily concentrated on utilization management, referral authorization, and claims processing, with attention to cost containment and ensuring all compliance standards are met. These functions have served as an "operational core," focused on getting the job done and meeting necessary requirements.

As they evolve, these organizations realize that simply "getting it done" will not suffice; they need to increase the focus on the clinical delivery process in order to affect the health outcomes of their populations.

To read this article in its entirety, please click the button below to immediately access CAPG Health.

  Population Health

Topics: Population Health, Risk-Based Contracting, Healthcare Analytics, Tawnya Bosko, Megan Calhoun

Navigating the Social Worker’s Role Within a Care Team

Posted by Matthew Smith on Oct 20, 2015 1:48:39 PM

By Megan Calhoun, MS, MSW, Senior Consultant, The Camden Group

Care TeamSocial determinants of health are a leading healthcare topic due to their association with costly and potentially avoidable events, including Emergency Room visits and hospital admissions. Living alone, experiencing loss, insufficient finances, a lack of caregiver support, or a limited education have all been shown to impact the occurrence of these potentially preventable events(1). Recent reimbursement changes emphasizing elements of the Triple AIM and value in healthcare are driving organizations to focus on minimizing these events by deploying care management resources aimed at meeting the social needs of patients.

Effective care management requires a highly specialized, interdisciplinary team focused on meeting the medical and psychosocial needs of a patient. With readmission penalties, reimbursement strains, and a shift towards patient-centric, coordinated care, organizations are looking to invest in care management teams that can effectively manage the patient across all settings of care and avoid unnecessary inpatient admissions. Social workers have specialized education and training that enable them to provide necessary social services and serve as an integral part of the care team; they possess skills to view the patient in the context of their entire situation, engage the patient in a plan of care, and reduce unnecessary admissions stemming from psychosocial issues. 

Engaging the Patient In a Care Plan

The key to any intervention is a patient’s engagement in the development of their care plan and subsequent adherence to the agreed upon goals. Social workers are trained in the skills necessary to develop rapport with patients and do not proceed with care planning or interventions until the proper foundation for this working relationship is built. Patience, compassion, and integrity are key components in this process along with a strong focus on meeting the patient where they are. Developing this relationship can be a fragile process and one that takes time; often, the patient just needs someone to listen to them. Medical social workers are often not under the same time constraints as physicians and nurses and can spend more time with their patients to fully develop this relationship. The goal of this process is to ensure that the patient feels fully supported as they strive to achieve their goals and that the care plan is created jointly between the interdisciplinary team and the patient. The patient will feel accountable for their self-management if they are engaged in the care planning process and feel as though their goals are achievable. The patient should feel comfortable reaching out with any questions or concerns and the social worker should make the patient feel as though all concerns are validated. Utilizing a social worker appropriately and to the top of their license can help alleviate time constraints on nurses, nurse practitioners, and physicians.

A Role Within Team-Based Care

It is widely accepted that psychosocial issues and a lack of appropriate social support are primary causes for care transition failures, readmissions, and lack of care plan adherence. In a team-based care management model, the perspective of the social worker helps to ensure that the patient remains at the center of the care plan and that interventions take into consideration the patient’s current medical, emotional, cognitive, and financial status. The biospychosocial approach employed by social workers to assess a patient may uncover social determinants of health status that get overlooked during a standard physical or office visit. Many of these issues stem from a lack of adequate resources and lead to costly, unexpected admissions and Emergency Room visits. A patient may be repeatedly presenting at the Emergency Room because bed bugs are preventing him from sleeping comfortably at home; he has been unable to pay the electricity bill; or, he does not know where else to get a free meal. A complete biopsychosocial evaluation will enable the social worker to determine whether the patient needs resource management and education, additional care management support from a clinical perspective, or mental health treatment. When needs are identified, arrangements can be made to connect a patient and their family to resources for medication funding, transportation, housing, warm meals, legal support, and a host of other  necessary supports that can make caring for a chronic condition easier. Through relationships with community-based resources, social workers can connect patients to less costly resources and services that are not typically included in the clinical plan of care but can be supportive, and at times even more effective. Barriers are identified and assessed and the social worker works continuously with the patient and his family to overcome these barriers. 

Evaluating Social and Medical Concerns

Social workers can expand a team’s view of the patient and thus the success of the care plan. They are taught to view the patient within an entire system, that is, within the context of their family, friends, resources, and community members; they evaluate a patient’s health in the context of the patient’s needs, expectations, rewards, and available support system. They put themselves in the patient’s role and assess how these interconnected systems are affecting the patient. For instance, many underlying problems for patients with chronic conditions and multiple co-morbidities are not medical in nature, but due to a lack of social support. Through the lens of a social worker, issues are uncovered which, if left untreated, could exacerbate medical conditions and drive unnecessary clinical costs. Often, non-traditional and non-clinical solutions are identified and implemented. For instance, the installation of an air conditioner may be all that is necessary to keep a chronic asthmatic out of the Emergency Room. Utilizing systems theory allows social workers to clearly see the interplay between social and medical concerns and address the real root of the problem. 

The use of social workers within an interdisciplinary team continues to be a model for success. Their work complements that of nurses, physicians, and pharmacists and helps to view the patient in his entirety, not just as a medical condition. 

Sources: Calvillo-King, Linda, Danielle Arnold, Kathryn J. Eubank, Matthew Lo, Pete Yunyongying, Heather Stieglitz, and Ethan A. Halm. "Impact of Social Factors on Risk of Readmission or Motality in Pneumonia and Heart Failure: Systematic Review." Journal of General Internal Medicine. 28.2 (2013): 269-82. Print.


Ms. Calhoun is a senior consultant with The Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at mcalhoun@thecamdengroup.com or 310-320-3990. 



Topics: Value-Based Healthcare Team, Care Team, Megan Calhoun, Social Worker

10 Key Indicators of Clinical Integration Success

Posted by Matthew Smith on Jun 23, 2015 10:14:10 AM

By Megan Calhoun, MS, MSW and Teresa Koenig, M.D., MBA, The Camden Group

ci_2-resized-600.jpgAs healthcare organizations are looking for strategic initiatives to transport them into the future, clinical integration is often the plan. Clinical integration is the answer for provider practices and/or systems that are ready to move into the “new normal.” However, clinical integration requires more than organizational realignment and a commitment to the Triple Aim. Developing an effective clinically integrated network demands commitment and investment in a complete clinical care model redesign focused on team-based, patient-centric care along with the necessary infrastructure to enable this change. Clinical integration requires several key components for success. When is an organization ready to take this next step toward clinical integration? Below are ten key indicators that an organization’s efforts are poised for success.

1.  Primary Care Geographic Coverage of the Target Market

When considering a clinically integrated network, the expansiveness of the primary care network is a critical component. In a clinical integration model, primary care is a pivotal access point to the system, and the primary care physician works alongside the patient to drive the care plan. Geographic coverage not only refers to an adequate number of primary care physicians, but also to the presence of extended hours sites, urgent care clinics, or telephonic triage services.  All of these access sites can assist in directing patients, who may otherwise access the emergency room inappropriately or not access care at all, to the right care at the right place at the right time. 

2.  Affiliation or Ownership of Services Along the Continuum

A fully integrated care model with services across the continuum is a central tenet for success. Gaps in coverage along the continuum can lead to insufficient knowledge transfer among physicians, poor hand-offs, and a high risk for complications during transitions in care. The delivery network must include ambulatory, acute care, and post-acute services through ownership or affiliation. Additionally, the network should be linked with community agencies that can provide psychosocial supports, preventive care, and education, as well as integrating these services into the care planning when necessary.

3.  Scalable Care Models and Information Technology (“IT”) Systems

A clinically integrated network must maintain an infrastructure that can adapt as the network grows. Patient workflows, care models, and staffing models must be developed such that they are scalable as the network continues to grow. Similarly, the IT systems in place to enable these work flows should be able to mirror the growth of the delivery network. Interoperability, cost, and ease of implementation should all be considered. The IT should support the needed care models across the continuum.

4.  Established Quality Improvement and Process Improvement

Clinical outcomes, patient satisfaction, and patient safety are critical to the success of the clinically integrated network. Value-based payment models utilize process and outcomes-based metrics to determine reimbursement. To continuously improve in these areas, a clinically integrated network relies on ongoing quality improvement initiatives with an established framework for process improvement. 

5.  Population-Based Reporting On Clinical Quality and Financial Outcomes

In order to educate members of the network on their performance, the network should have the capability to conduct analytics and reporting for both patient and population management. Clinical integration relies on clinical model transformation; clinical transformation can only occur with enough data to produce information that will drive this change. Physicians need information on their clinical outcomes, adherence to protocols, and value-based metrics. Transparency in these reports (including the financial results) is critical to physician behavior change. 

6.  Providers and Facilities Across the Continuum With Aligned Incentives and the Same Strategic Goal

In the past, physician and hospital incentives have not always aligned. Clinical integration requires a re-wiring of these incentives. Trust must exist between providers and facilities. In a clinically integrated network, all providers are working towards the same organizational goals. Providers must work together towards the Triple Aim and develop mutual respect – and rewards – for everyone’s involvement and input in this effort. 

7.  Established Evidence-Based Guidelines

Evidence-based guidelines are key to reducing variability among physician practice patterns. Established guidelines and protocols ensure that providers are following standards that result in the high-quality care – consistently across the network. Additionally, these guidelines eliminate unnecessary utilization of healthcare services. Evidence-based guidelines should be embedded in the technology tools that physicians utilize. Physicians must lead the charge in developing, utilizing, and monitoring adherence for the use of guidelines and protocols. Reports of non-adherence should be made available to the clinically integrated network’s leadership, and processes for remedial action need to be established for providers who routinely vary from the established protocols. 

8.  Regular Education for Providers and Staff

The healthcare environment is changing at a rapid pace. Clinically integrated networks must continually educate their physicians and staff on these changes. Rigorous training programs focused on standards of practice should occur regularly. Changes in reimbursement, care models, coding requirements, IT systems and capabilities, and organization-wide goals should be regularly distributed with timely education sessions. Care management staffs need significant training to ensure they are providing adequate support to providers and are working to the top of their license.

9.  Interdisciplinary Care Teams

To continuously improve quality and patient satisfaction, clinically integrated networks require interdisciplinary teams to provide care to their highest risk patients. The use of an interdisciplinary team could include the involvement of primary care physicians, specialists, care managers, social workers, pharmacists, dieticians, or any other ancillary provider. The team works together towards a single care plan for the patient. 

10.  Aligned Vision that Focuses On the “We” Not the “Me” 

Clinical integration requires significant cultural change. It is a mindset based on accountable care, where the entire care team is responsible for providing high-quality care. The vision for clinical integration must be ingrained in all physicians and staff as they work to achieve a common goal. No longer can physicians be worried only about their individual performance but rather the care of their patients across the continuum. The clinically integrated network needs to concern itself with its population of patients and how appropriate interventions and utilization of care can improve the health of the population. 


Ms. Calhoun is a senior consultant with The Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at mcalhoun@thecamdengroup.com or 310-320-3990.   


koenig_headshot.pngDr. Koenig is a senior vice president with The Camden Group who specializes in developing and designing clinical integration strategies, medical management programs, and value-based care delivery and payment models. She has worked with a variety of healthcare organizations, from individual physician groups and health systems to academic health systems and Fortune 50 companies, guiding them as they look for solutions to their specific challenges. Dr. Koenig is skilled in utilization and quality management, including setting metrics to help organizations deliver accountable care, as well as in the development of provider networks and incentive systems. She may be reached at tkoenig@thecamdengroup.com or 310-320-3990.   

Topics: Clinical Integration, Population Health, HealthIT, Care Continuum, Teresa Koenig MD, Megan Calhoun

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