While others wait for the healthcare industry to complete its transition to value-based reimbursement, Bon Secours Medical Group has already aligned itself with payment reform, leveraging its care team and providers and automating workflows to enjoy immediate rewards from its patient-centered approach.

Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes describes how this 600-provider medical group has primed its providers to employ a broad mix of team-based care, technology and retooled care delivery systems to maximize quality and clinical outcomes and reduce spend associated with its managed patients.

In this 25-page resource, Jennifer Seiden, administrative director, population health, Bon Secours Medical Group, and Lu Bowman, population health market program manager, Bon Secours Medical Group, share how a reframed approach to care transition management and chronic care management pays off in improved population health and decreased spend.

In Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes, Ms. Seiden and Ms. Bowman review the following:

• Medical home principles at the heart of BSMG's accountable care approach;
• Reshaping the care team to include EMTs, pharmDs, community workers, and others;
• Adopting a population health mindset that encompasses the full practice panel instead of just patients seen daily;
• Technologies to identify and manage patients 'below the waterline';
• Use of nurse navigators to manage care for high-complexity patients;
• The return on investment equation that builds a business case for team-based care and protects this valuable investment;
• Practical considerations for billing via Medicare's new Chronic Care Management codes—eligibility, reporting, exclusions, and others;
• Care coordination responsibilities in BSMG's advanced patient-centered medical home model;

Table of Contents

• Bon Secours Medical Group Workforce Development for Transitional Care, Chronic Care Management
  • Evolution to Value-Based Contracting
  • Medical Home Principles Form Care Foundation
  • Profiting from Healthcare's Transition to Value-Based Care
  • Stratifying Below the Water Line
  • Moderate- Versus High-Complexity Patients
  • Return on Investment Equation
  • Care Management Services
  • Billing with Medicare Chronic Care Management Code
  • Chronic Care Management Reporting
  • Care Team in Advanced Patient-Centered Medical Home
  • Results and ROI
• Q&A: Ask the Experts
  • Using EMTs in Team-Based Care
  • Educating Patients on Chronic Care Management Codes
  • Telehealth CPT Codes for Commercial Payors
  • Documenting Care Coordination
  • Role of SNFs in Bon Secours Continuum
  • Use and Benefits of Patient Registries
  • Remote Monitoring in Chronic Care
  • Using Respiratory and Physical Therapists
• Glossary
• For More Information
• About the Contributors