Becker's Hospital Review

21 Executive Briefing xGCare uses predictive modeling and risk strati- fication to assess the population, and program also covers a vast range of clinical content and organizes information in a way that supports team-based care. Predictive modeling The first step we use in xGCare is predictive modeling to identify the highest risk, most complex patients. Factors that we consider include patient demograph- ics, clinical conditions, utilization and gaps in care. Risk stratification The second step of our population segmentation process relies on clinician judgment of a patient's status. Based on case managers' patient assessments, they can use real-time information on patients' condi- tions to make care management decisions. For ex- ample, say a patient is categorized as low risk. If they are not adhering to the medication and/or treatment regimen, or do not have access to other necessary resources, they can immediately be switched to a high-risk level and receive more intensive care man- agement services. A two-step risk stratification process helps leverage the power of predictive modeling with real time patient assessment information. Breadth of clinical content xGCare includes structured assessments for major chronic conditions, which then drive work flow, action plans, self-management plans and correspondence on an automated basis. Team-based care support Another important aspect of care management is coordination and communication among the whole clinical care team. The xGCare platform supports team-based care by organizing patients' information for various clinicians to view. Team members can see biometric data, claims information and recent assess- ments, giving the care team a 360-degree view of patients. Communication is a key requirement for team- based care, on which successful population health management depends. With effective communication, each clinical team member can operate at the top of his or her license, which ensures the team's time and clinical expertise is well spent. Easing the transition through education Population health management, the underpinning of value-based care, requires each member of the care team — including case managers, social workers, physicians and nurses — to obtain new knowledge and skills. Each needs "to know what to do to help the pa- tient. To do that, they have to be trained adequately so they can be proactive, not reactive," says Joey Sevi- son, RN, vice president of population health manage- ment at xG Health Solutions. The incorporation of new practices and process- es into clinicians' and other workers' workflow is a significant adjustment that requires time and educa- tion. xG Health's learning solution, xGLearn™, helps healthcare organizations accelerate training for both clinical and nonclinical staff to better prepare them for population health management. xGLearn combines coaching and online content produced by Geisinger and xG Health experts with immersion in a healthcare facility where experienced staff are working. "The combination allows nurses and others to learn so they can hit the ground running — so their critical decision-making skills are really honed and they are ready to roll in the clinical environment," says Ms. Sevison. The training program, most of which is online, is highly interactive. Students watch videos of experts addressing real-life challenges and complete short quizzes related to what they've seen. Various inter- active scenarios help trainees make decisions and define priorities for an individual or group of patients. The virtual patients who trainees treat via xGLearn present behavioral and social issues to better reflect real-life cases. Trainees — through xGLearn — have the chance to utilize best practices for care management from ex- perts at Geisinger who have devised those practices over decades. "The nice part is when experts share what works, and importantly, what doesn't work — it saves others from the pain and suffering of discovering that on their own," says Ms. Sevison. "Anyone can go online and find a care management training course and hope it will help. However, you really have to ask certain questions before investing in online education. Will the program be relevant to what you're trying to accomplish? Will trainees walk away actually knowing something different?" Optimizing EHRs with supplemental technology EHRs have become the mainstay of hospitals' and health systems' patient medical records. However, there is room for improvement. Four in 10 healthcare professionals do not think EHRs are sufficient for coordination, according to the

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