Amplifying DSRIP Care Manager Productivity and Effectiveness

Samir D’Sa, Principal, NY DSRIP Services, Earl Steinberg, MD, MPP, CEO, Chuck Baumgart, MD, Senior Medical Director, Melodi Brown, RN, MSN, CCM, Vice President, Care Management, xG Health Solutions, July 31, 2015

Care management is a key to success in Delivery System Reform Incentive Payment (DSRIP) because it directly influences patient health outcomes and use (for example, inpatient admissions, readmissions, and ED visits). Most PPSs envision use of diverse care teams composed of nurse care managers, pharmacists, social workers, care associates, and community health workers. Empowering a well-trained care team with workflow/documentation tools and robust analytics amplifies their impact and, by extension, delivers better patient and DSRIP outcomes.

Challenges: Off-the-shelf care management workflow tools are not the right answer. They are generally payer-centric and don’t readily support provider-directed care management or team-based care. For example, they are not always compatible with the documentation and care management process needs of an embedded care manager in a PCP office setting. Other care management tools are tightly coupled with a particular EHR and so do not readily support the needs of a regional PPS whose providers use several EHRs. Still others have no prebuilt clinical assessments or care plans with logical workflows—or worse, they contain lengthy, generic questionnaires that are siloed, rather than dynamic.

What to look for: Here are some important care management capabilities for DSRIP:

  1. Workflow: To be efficient and effective, care managers need clinically informed disease-specific assessments, care plans produced automatically based on the assessment results, clinical decision support, and algorithms that help the care manager prioritize his or her workload. The xG Care™ care management software platform provides all of these. xG Care uses branching logic so a care manager can ask the most efficient sequence of questions to get the job done. xG Care also uses a question library so a care manager is only prompted to ask a patient a particular question once, even if the question applies to more than one disease. The software inserts the nurse’s response wherever it is relevant automatically.
  2. Interventions: Reducing unjustified variation in clinical practice is essential—care managers should be prompted with the right set of interventions and care plan templates to create effective patient interventions. With xG Care™, we integrate a correspondence module with a library of auto-generated email/letter templates and educational materials, carefully worded and designed to influence patient behavior.
  3. Performance Management: Measuring the productivity and impact of each member of the care team helps supervisors get the most out of their team. xG Care has a preloaded set of case load, load balancing, productivity, and outcome metrics that support day-to-day management of the care team, promote team work, and provide a care management team scorecard for PPS executives as well as care management supervisors.
  4. Reporting: DSRIP wants an audit trail for the Dept. of Health. A care management platform that contains discrete data elements, workflows, queues, and documentation and that captures patient-specific care plans and management will meet this need and obviate the need for manual recordkeeping and retrospective searches for data to corroborate care management screening, outreach, and enrollment.


We look forward to engaging with you in a dialogue around your care management workflow and documentation needs.

Rocky Edmondson RN, BSN, MBA, CCRN
Senior Director, Bundled Payments, Care Redesign and Management Advisors, xG Health Solutions

Rocky Edmondson is the Senior Director of Bundled Payments for Care Redesign and Management Advisors at xG Health Solutions. Rocky has been involved in workflow redesign, program implementation, and analytic evaluation of Bundled Payment Programs across the country, and he coaches Hospitals, Health Systems, Post-Acute Providers, and Physician Groups on how to successfully implement care redesign in the Bundled Payment for Care Improvement (BPCI) and CJR Programs.

Rocky’s passion is helping people to understand the intricacies of Bundled Payment Programs. He has a talent for teaching people how to cut through all the noise and just do the things that matter to be successful in these programs.

Rocky holds an Associate’s Degree in Nursing from the University of Hawaii Maui, and a Bachelor’s Degree in Nursing and a Master’s Degree in Business Administration (MBA) from Boise State University.

Prior to joining xG Health Solutions, Rocky was the Southeast Region Director of Clinical Operations for Remedy Partners, overseeing program design, implementation and analytic evaluations for Bundled Payment Programs. Prior to embarking on a career in Bundled Payments, Rocky was a Registered Nurse for 18 years, working in a number of positions within Critical Care. Before becoming a Nurse, Rocky was an Institutional Broker at Merrill Lynch and advised a number of healthcare systems and large corporations on cash management strategies. In addition, Rocky has started several businesses and provided consulting for small business startups. Rocky served in the U.S. Marine Corps as a Recon Marine.

Janet Comrey RN, BSN, MHSA
Director, Population Health Solutions, Geisinger Health System

Janet Comrey, RN, BSN, MHSA has over 30 years of diversified nursing and leadership experience at Geisinger Health system and currently serves as Director of a small department embedded within Population Health. One of her key roles is managing the Bundle Payment for Care Improvement (BPCI) program since January 2014 earning an overall positive net payment reconciliation to date. Janet also serves as the coordinator for Project Achieve at Geisinger which is a national PCORI funded study related to patient’s perceptions of transitions of care.

Janet received her nursing education through Geisinger’s diploma program, her BSN through Bloomsburg University, and later earned her graduate degree from Marywood University. During her tenure at Geisinger she taught quality improvement methodology and facilitated improvement teams the Geisinger Quality Institute. She is currently enrolled in the Institute for Healthcare Improvement Advisory program.

Professional memberships include Sigma Theta Tau, Phi Kappa Phi, American Society for Quality.

Andrew Blackmon, MBA, MHS
Chief Sales and Business Development Officer

Chief Sales and Business Development Officer Andrew Blackmon, MBA, MHS, has more than 18 years of experience in healthcare product sales, marketing, and strategy.

Before joining xG Health, Andrew was vice president of sales for population health and risk management solutions at McKesson. He came to McKesson through acquisition of MedVentive, an early population health vendor. Before MedVentive, he served as vice president of enterprise solutions development at MedAssets. He is a past president of the Georgia chapter of HIMSS, and he has held strategy and planning positions at PricewaterhouseCoopers and Orlando Health.

Andrew has an MBA and a Master’s of Health Science from the University of Florida Warrington, College of Business, and a Bachelor of Arts degree in Psychology from Rollins College.

Holly Barbella, RN, MBA

Risk Coordinator, Geisinger Health System

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Earl P. Steinberg, MD, MPP
Chief Executive Officer

Earl P. Steinberg, MD, MPP, is a nationally recognized expert in healthcare quality improvement and serves as xG Health’s chief executive officer. Earl also is an adjunct professor of Medicine and of Health Policy and Management at Johns Hopkins University and a member of Blue Cross/Blue Shield Association’s National Medical Advisory Panel.

Before joining xG Health, Earl was executive vice president of Innovation & Dissemination, and chief, Healthcare Solutions Enterprise at Geisinger Health System.

Before joining Geisinger, he was senior vice president for Clinical Strategy, Quality & Outcomes at WellPoint, Inc., the largest commercial health insurer by membership in the US, and president and CEO of Resolution Health Inc. (RHI), a leading healthcare data analysis company that provides innovative quality improvement and cost reduction services to health plans, employers, pharmacy benefit managers, and disease management companies.

Before joining RHI, Earl spent six years as vice president of Covance Health Economics and Outcomes Services Inc., director of its Quality Assessment and Improvement Systems Division, and co-director of its Outcomes Studies Group. He also spent 12 years on the full-time faculty at Johns Hopkins University, where he was professor of Medicine and of Health Policy and Management and director of the Johns Hopkins Program for Medical Technology and Practice Assessment, and four years on the Federal Physician Payment Review Commission. He co-chaired the Institute of Medicine’s panel on Standards for Development of Trustworthy Practice Guidelines.

Earl has received many awards, including the Henry J. Kaiser Family Foundation Faculty Scholar Award in General Internal Medicine (1984), the “Outstanding Young Investigator” Award from the Association for Health Services Research (1988), and a Special Presidential Visionary Award from the National Kidney Foundation (NFK) (2004) for his work as the scientific director of the NKF’s landmark Kidney Disease Outcomes and Quality Initiative, which produced more than 250 clinical practice guidelines for management of patients with end-stage renal disease. He also is a fellow of both the American College of Physicians and AcademyHealth, and he has published more than 125 articles in peer-reviewed journals.

Earl received his AB from Harvard College (summa cum laude), his medical degree from Harvard Medical School, and a Master of Public Policy from the Kennedy School of Government. He performed his residency training in internal medicine at Massachusetts General Hospital.