Value-based care can feel like an overwhelming change in practice. To get started, focus your efforts where they’ll have the most impact – on your high-need patients who have critical gaps in care, never come in, or incur high costs. Here are three steps you can take:
1. Use Medicare annual wellness visits to assess risk and identify which of your patients may need more outreach from you and your staff to avoid poor outcomes and costly care.
2. Monitor that critical juncture when patients leave the hospital, also known as transitional care management.
3. Optimize your referrals, including when you refer (is it too soon, too late, or not necessary?), to whom you refer (are they using resources wisely?), and what you expect when you make a referral (are you getting what you need from them to optimize quality and costs?).
Adapted from “Finding the Bright Spots in Value-Based Care.”
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