Data Analytics

The Population Health Analytics team maintains and utilizes a variety of solutions to create dashboards and reports for multiple stakeholders across the CIN and health system. The team aggregates, analyzes and interprets results from multiple data sources to help identify best practices, ideal outcomes, and program opportunities.

The Population Health Analytics team has a strong focus on accurate, real-time data access for physicians, care team members, and administration. During the past two years, the analytics team led the successful launch of HealtheIntent, a quality portal, with an access link embedded in Epic for providers, care team members, and administration to view near real-time BPP quality metric data and patient details. Additionally, the team created 24/7 access to the BPP citizenship metric performance dashboard within the Baptist physician’s portal for providers and practice administrators to review at their convenience.

Analytic Strategies

• Identify high-risk, high-cost patients

• Design provider engagement reporting

• Understand care gap patterns

• Evaluate care programs

• Group Performance Reporting Option (GPRO) – CMS submission

• Accurate documentation and diagnostic coding (ADDC)/Hierarchical Condition Categories (HCCs)

• Financial modeling for BPP shared savings distribution

• Evaluation of network sufficiency and optimization

To meet the care needs of the increasing patient population, the Ambulatory Care Coordination team now provides care for patients at home.The team comprises more than 50 team members who have recently been divided into eight regional, multidisciplinary teams with representatives from nursing, social work, health coaching, and respiratory therapy. With additional support from care coordinator assistants and intake specialists, they provide telephonic, virtual, and in-home visits to high-risk and rising-risk patients with multiple comorbidities.

Regional teams coordinate care for patients along the care continuum, including: patients discharged from the hospital, patients in skilled nursing facilities, assisted living facilities and longterm care, and patients in their home environments. Team members work at the top of their licenses, reference data to risk stratify patients and allocate resources appropriately.

Baptist Health’s recent transition to Epic allows for seamless coordination of care across the continuum, in addition to communication with Baptist Physician Enterprise providers, all of whom document in Epic.

Care Coordination Strategies

26

Nurse Care Coordinators

12 Care Coordinator Assistants and Intake Coordinators

10 Social Workers

Multidisciplinary Team-Based Approach

Care Coordination across the Continuum

3 Health Coaches

Data-Informed, Risk Stratification, Resource Allocation

Serious Illness Management and Advocacy (SIMA)

1 Clinical Educator

Goals of Care and Advance Care Planning

Social Determinants of Health and Health Equity

1 Diabetes Educator