Practice Transformation Coach

JOB SUMMARY: Supports Clinical Services and Operations Team in their effort to monitor outcomes and create ongoing performance improvement initiatives at DVACO. Will be working across DVACO and with multiple CINs and ACO Members, and multiple EMRs. Work as a member of the DVACO Team to study and monitor care processes in a quality infrastructure and use data to drive ongoing performance improvement throughout DVACO. Must be able to coordinate, interpret, and translate performance data, and critically review metrics; data should permit evaluation of opportunities to implement change and monitor ongoing results of clinical quality outcomes. Collaborate with DVACO Leadership team on ongoing opportunities for improvement in Clinical Operations, Quality, Risk Reduction, Patient Outcomes; this may be in response to regulatory, payer, entity & health system requests as it relates to clinical quality. ESSENTIAL ACCOUNTABIITIES: Acts on a consistent basis to support the Mission, Vision and Values of DVACO. Support DVACO goals, strategies, and mission as directed by the Leadership team/ Manager Of Practice Transformation Primary administrative and project manager support for practice transformation using principles of PCMH and the NCQA application process, including managing overall timeline, facilitate scheduling of practice meetings, coordination of educational webinars, and formulation/dissemination of meeting minutes, assist with design of corresponding data reports, verification of application details, coordination and facilitation of uploading survey documents, etc. Will serve as a key member of the DVACO team to help transform the practices into allowing them to excel at providing excellent patient experience, and quality medical care. Will help practices to be well-positioned to meet requirements of CPC+ (Comprehensive Primary Care Plus) and the CMS MIPS (Merit-Based...

Population Health Medical Director

Reporting to the CEO, the Population Health Medical Director will be the primary owner of physician engagement strategies and tactics. They will be responsible for developing, deploying, and championing a transformational clinical strategy for improving population health outcomes, quality and experience of care, and cost of care for the populations served by DVACO in an environment which is rapidly moving towards significant downside financial risk. This position supports population health and clinical aspects of payer relations and contracting, provides clinical oversight of all care management and care transformation initiatives. Education: M.D. or D.O., Board Certification in Internal Medicine or Family Medicine (preferred) • Master’s Degree in Business Administration, Health Administration, Public Health or related field or equivalent related experience. Licensures & Certifications: Unrestricted PA medical license required, up to 20% FTE of ongoing clinical practice desirable Experience: At least 5 years of experience in leadership-level position with a proven track record in population health, with a strong preference for managing outcomes in a complex risk-bearing entity including a variety of populations (e.g. Medicare, commercial, employer-based) Direct experience with the Medicare Shared Savings Program (or equivalent) is strongly preferred. Experience with care models that support bundled/episode payments is a plus. Demonstrated ability to lead groups of physicians through change, with and without direct authority, using influence, trust, and thought leadership. Strong clinical background with at least 5 years in direct clinical practice, preferably in primary care. Experience in targeting programs at population health segments (e.g. chronic/complex illness versus health promotion) and measurement of program effectiveness. Proven strong leadership, business, communication, organizational, analytical and relationship skills. Proven experience in successfully facilitating...

Care Coordination, Clinical Analyst

JOB SUMMARY: The DVACO Clinical Care Analyst assigned to Care Coordination will work directly with the Manager of Care Coordination to positively influence the quality outcomes and reporting metrics in the Care Coordination environments of care. The essential accountabilities of the job description will be applied to the Care Coordination environment working specifically but not exclusively with our Care Coordination staff and our Pod partners to manage patient referrals and report out on care coordination activities. The Care Coordination Clinical Care Analyst will work with Wellcentive, Patient PING platform, Formsite, Microsoft Excel and Access and other similar tools yet to be defined to meet the essential accountabilities. Healthcare knowledge and prior experience working in the hospital or physician practice is preferred. Works as part of the DVACO Clinical team to collect, process, integrate, analyze and present data; provide tools, descriptions, answers and guidance for projects to improve clinical quality and financial success for the ACO and its participating partners. Manages and meets reporting deadlines for assigned deliverables and ad hoc reports. Role will provide administrative, project management and care coordination/transitions of care support to the team. ESSENTIAL ACCOUNTABILITIES: Administrative duties. Managing relationships includes electronic, phone, and in person communication often with direct consultation with clinical staff to help manage the DVACO patient population. Arranges subcommittee meetings (schedules, produces documents, and compiles meeting notes) to support the DVACO clinical initiatives. Serves as technical support to clinical staff in trouble shooting issues with care coordination and information management software. Collects data from disparate partners and from various sources including the care coordination software, to produce daily, weekly and monthly reports to...

Care Coordinator RN

JOB SUMMARY: The RN Care Coordinator (Health Coach) is a Registered Nurse who facilitates patient continuity of care with the healthcare team. Under the clinical direction and oversight of the Primary Care Physician, the Care Coordinator coordinates care for high risk/complex patients by collaborating with the patient, family, physician, nurses, and other members of the healthcare team to identify needs and expedite appropriate, cost effective care. S/he assists in the development of the patient’s care plan and collaborates with the Primary Care Physician to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. The Care Coordinator will serve as the patient’s primary conduit to the primary care provider as they help coordinate necessary services both within and outside the practice, coordinating care from a variety of sources—physicians, specialists, home care providers, rehab centers, pharmacists, etc. They will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. ESSENTIAL ACCOUNTABILITIES: Contact ACO members to determine if there is a need for case management intervention based on guidelines, protocols and timeframes established for the applicable clinical program. Provide care coordination according to program descriptions including member education, follow up on a timely basis and eliminating barriers to care. Conduct comprehensive assessments that include the medical, behavioral, pharmacy, and social needs of the member. Review data for services the member has received and identify gaps in care based on clinical standards of care. Based on assessment of members needs and...

Catching up with Katherine Schneider, M.D., M.Phil., FAAFP, CEO of DVACO in an interview with Population Health News

Population Health News: How does population health integrate with accountable care? Katherine Schneider: My motto is that ACOs are all about the “C” part of the acronym. If we don’t change the care model at an individual level, then we will not achieve improvements in outcomes, which include the health of a population, the care experience and smarter spending. I also view population health as a set of tools that we are integrating into the delivery system for data-driven quality improvement and care coordination. It is a viewpoint that expands beyond the four walls and timespan of a provider visit to include what happens to/for/by people 24/7, 365 days of the year regardless of where they are. Population Health News: How do you embed chronic disease management in a delivery system? Katherine Schneider: While I get annoyed when people say it’s all about the incentives, it certainly is a foundational prerequisite to have meaningful incentives aligned with better chronic disease care processes and outcomes. But you also have to teach providers new skills and give them tools. I like to use the analogy of surgeons learning to use laparoscopes decades ago. Last but not least, you need to address what should be embedded directly in a delivery system. Successful “embedding” really means transformative disruption of historical workflows of clinical practice, such as redistributing tasks to multidisciplinary teams working at the maximal scopes of their licenses. If this level of change is required of clinicians, then ensure that the rest of the system is also expected to change to support better outcomes (i.e., benefit designs which promote adherence to chronic...