Population Health Management, 2021 Style

ABSTRACT

Using its experience with the MSSP and its Medicare Advantage (MA) capitation contract, Ochsner is engaging community physicians and physician networks to expand its reach. Two patient groups are prioritized those who are new to Ochsner and those with multiple chronic conditions that put them at high risk for health problems. In addition to a clinical assessment and medical reconciliation, the nurse practitioner can verify whether the patient has appropriate food, social support, and the durable medical equipment that will help him or her recover safely at home. A third at-home strategy is the use of a vendor, Ready, to reduce avoidable ED utility through on-demand at-home urgent care visits and short-term case management for ED frequent fliers.