Community Medical Group ® Sharp Community Medical Group Gregg Garner, D.O. Medical Director

Community Medical Group ® Quality Improvement Highlights P4P tracking and tying individual physician performance to financial incentives PCP Patient Management Model of compensation that ties best practices to revenue Chronic Care team that focuses on CHF, BP, Diabetes, COPD, CKD and contacts patients who do not seem to be compliant

Community Medical Group ® Quality Improvement Highlights Coumadin clinic We are contacting patients to have annual labs done if they are missing (HbA1C, LDL) and quarterly reports to PCPs on patients without the data Patient education initiatives to help them know what their numbers should be and encouraging follow up with PCP Encouraging HCC coding and CPT 2 coding

Community Medical Group ® Challenges Data collection and measuring results, particularly BP in offices not on EMR Physician buy-in Patient engagement Care coordination

Community Medical Group ® Lessons Learned Engagement of the PCP is vital to population management Alignment of incentives to physicians is critical to obtaining buy-in. Response rate for letters to patients educating them on need to have labs drawn has had a 15% response rate

Community Medical Group ® Future Objectives Collaborative with payers to obtain data at the point of care that brings relevant diverse information in a usable fashion – Active Health Initiative Reaching out to patient not seen by their PCP to establish care plans, and risk stratification, as well as taking our Diabetes Discussion Groups out into the field (doctor’s offices, meeting places), to reach more people. Working with different systems across SD in order to share relevant information for better patient care. IBM HIE Collaborative