WHERE THE BRIGHTEST MINDS in health and IT meet.

Prioritizing Care Coordination for Patients Who Need It Most

February 20, 2017 — 01:30PM - 02:30PM EST
Orange County Convention Center
Session ID: 


Medical Home Network (MHN) is a 501(c)3 that integrates disparate providers to create a seamless network upon which providers can effectively connect, communicate and collaborate around patient care for effective care coordination. MHN have improved value and outcomes with a team-based model of care, technology platform and success building provider-alignment has advanced the delivery of medical, behavioral and social services in one of the largest Medicaid settings in the country. This session will dive into MHN’s dynamic and predictive risk stratification methodology using not only historical claims but also real time behavioral and social determinant data, which is proven to be predictive of subsequent utilization and cost of care. We present analyses demonstrating the validity of the approach and the impact that can be identified at a patient level. We will facilitate a discussion on effective care coordination and developing a high impact, value-based integrated delivery system.

Learning Objectives: 

  • Compare risk stratification methodologies to understand strengths and weaknesses
  • Assess the value of predictive risk algorithms versus traditional claims-based strategies to identify patients most in need of care coordination resources
  • Demonstrate the benefits of incorporating psychosocial determinants into patient risk stratification
  • Discuss how attendees are currently approaching the prioritization and coordination of patients and how they would ideally like to do so
  • Identify best practices for incorporating predictive patient risk stratification into care coordination to identify and activate patients most in need of assistance


Nurse, CNO, CNIO
Physician, CMO, CMIO




in health and IT meet.