Patient-centric interventions like population health management, health coaching, home visits and telephonic outreach are designed to engage individuals in health self-management—contributing to healthier clinical and financial results in healthcare's value-based reimbursement climate.

But when organizations consistently rank patient engagement as their most critical care challenge, as hundreds have in response to HIN benchmark surveys, which strategies will help to bring about the desired health behavior change in high-risk populations?

9 Protocols to Promote Patient Engagement in High-Risk, High-Cost Populations presents a collection of tactics that are successfully activating the most resistant, hard-to-engage patients and health plan members in chronic condition management. Whether an organization refers to this population segment as high-risk, high-cost, clinically complex, high-utilizer or simply top-of-the-pyramid 'VIPs,' the touch points and technologies in this resource will recharge their care coordination approach.

This 30-page resource compiles patient engagement strategies from such high performers as Memorial Hermann, Community Care of North Carolina, Yale-New Haven Health System, Intermountain Healthcare and others.

Accompanying each patient engagement profile are 2016 HIN Market Metrics on the top activation approaches, culled from responses from hundreds of healthcare organizations in regards to chronic care management, care planning, embedded case management, health coaching, population health management, and many more.

Describing their organization's patient engagement protocols in this report are the following subject matter experts:

• Danielle Amrine, transitional care business manager at the Council on Aging Southwestern Ohio;
• Vivian Argento, executive director, geriatric and palliative care services, Bridgeport Hospital;
• Debra Burbary, R.N., clinical quality assurance manager with Arcturus Health Care;
• Mary Folladori, RN, MSN, FACM, CMAC, system director of care management at the Memorial Hermann Physician Network and ACO;
• Carlos Jackson, Ph.D., director of program evaluation for Community Care of North Carolina, whose transitional care program was awarded the 2016 Hearst Health Prize;
• Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group;
• Tammy Richards, corporate director of patient and clinical engagement at Intermountain Healthcare;
• Amanda Skinner, executive director, clinical integration and population health, Yale New Haven Health System; and
• Alicia Vail, R.N. health coach, Ochsner Health System.

Table of Contents

• The Impact of Patient Engagement: 10 Trends to Know
  • HIN Market Metric: Impact of Patient Engagement Interventions
• Intermountain Healthcare's 6-Point Plan to Diminish Disengagement Divide
  • HIN Market Metric: Tactics to Identify Non-Engaged Patients
• Telephonic Care Team Behind Memorial Hermann's 74-Percent Patient Satisfaction Rating
  • HIN Market Metric: Top Chronic Care Management Delivery Modalities
• Sentara Hybrid Case Managers Target High-Utilizer, Top-of-the-Pyramid 'VIPs'
  • HIN Market Metric: Responsibilities of Embedded Case Managers
• CCNC's Award-Winning Home Visits for Clinically Complex Patients
  • HIN Market Metric: Population Health Management Modalities
• Arcturus Patient Relationships Flourish During Medicare Chronic Care Management Planning
  • HIN Market Metric: Barriers to Care Plan Adherence
• Council on Aging's Patient-Centered Health Records Avoid Breakdowns in Post-Discharge Care
  • HIN Market Metric: Components of a Data Analytics Infrastructure
• Yale-New Haven Face-to-Face Care Management for High-Risk, High-Cost Employees
  • HIN Market Metric: Care Sites for Embedded Case Management
• Bridgeport Hospital Handles Health Literacy Matters
  • HIN Market Metric: Top Patient Engagement Strategies
• Evidence-Based Health Coaching: Inspiring Accountability at the Patient Level
  • HIN Market Metric: Health Coaching Impact on Patient Engagement, Self-Management and Other Measures
• Patient Engagement Touch Points and Technologies
  • HIN Market Metric: Top Patient Engagement Tools