The following projects, currently in process through Ascension St. Mary’s PHO, were strategically selected to support: patient attribution growth, improved patient care and satisfaction outcomes through innovative approaches to care delivery, and integrated use of health technology in the ambulatory care practice setting. Most of the strategic initiatives currently in process through Ascension St. Mary’s PHO are tied to payer incentives. Successful outcomes for these projects support the mission and vision of Ascension St. Mary’s PHO.

Memorial Healthcare & Ascension St. Mary’s PHO Affiliation:

Ascension St. Mary’s PHO extended network participation to Memorial Healthcare, in Owosso, effective January 1, 2022. Ascension St. Mary’s PHO’s affiliation with Memorial Healthcare will continue to have positive impacts to both the physician network and attributed lives.

Teleretinal Initiative:

This initiative will introduce digital communication solutions for diabetic retinal eye examinations at the point of care in the primary care physician office. Care teams perform the eye exam with a handheld device (RetinaVue camera). Digital images are sent automatically from the primary care physician (PCP) to the ophthalmologist for reading and returned to the PCP within 24 hours for appropriate follow up. Screening compliance improves as testing access is provided at patient site of care with PCP. The RetinaVue camera was gifted to Ascension St. Mary’s PHO PCPs for testing integration at the practice unit site.

Expanded Ascension St. Mary’s PHO Infrastructure to Support Physician Practice Units:

Ascension St. Mary’s PHO staff is expanding staffing resources to engage in clinical transformation activities related to population health management, adoption and use of health information exchange, and expanded care teams with the Ascension St. Mary’s PHO physician practice units.

Remote Patient Monitoring for Patients with Diabetes:

The goal of this initiative is to improve overall diabetic care management through patient interaction, literacy and engagement using digital monitoring tools for high risk diabetic patients. The program will specifically focus on providing a digital device to engage the patient to better understand their disease state, know what symptoms to monitor, how biometric data can be used to monitor health, and how healthy habits (patient goals) help mitigate chronic symptoms and improve biometric data. Ascension St. Mary’s PHO is hiring a full time diabetic patient coordinator to support the physician practice units in pre-work activities for outreach and follow up of diabetic patient care management.

Michigan Collaborative Type 2 Diabetes- Blue Cross Blue Shield of Michigan Initiative for Diabetes Management:

This program with Blue Cross Blue Shield of Michigan (BCBSM) focused on controlling Type 2 Diabetes for eligible BCBSM patients. The intent of the program is to utilize enhanced data sharing for medication education and improved use of medication. The program provides significant cost sharing opportunities for patients who work towards compliance with their prescribed medications, utilize continuous glucose monitoring devices, and adopt appropriate dietary and weight loss strategies.

Improvement Plan:

1. Prescribing GLP1 agonists and SGLT2 inhibitors

2. Expanding use of continuous glucose monitoring devices

3. Offering low-carbohydrate diabetes diet options for patients with obesity and diabetes, supporting weight loss strategies.

Clinician & Group-Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) Patient Satisfaction Survey:

Ascension St. Mary’s PHO sponsors the Clinician & Group-Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) patient experience of care survey for PHO-affiliated Primary Care Physicians and Specialists. The survey is used to measure patient experience of care and help health care organizations identify areas of needed improvement. Providing a survey is a requirement to engage in multiple payer program initiatives that provide incentive dollars. Ascension St. Mary’s PHO is in the process of rolling out the survey to all physician practices over the next 6 months.

Social Determinants of Health Technology:

The Social Determinants of Health (SDOH) is a standardized data collection and aggregation initiative aimed at increasing SDOH screening by Primary Care Physicians during annual wellness visits. In order to address social needs, providers must be able to identify patients with social factors that could affect health care outcomes and connect with community organizations. Physician Organizations are incentivized to build their technology infrastructure to facilitate capturing, storing and aggregating SDOH data.