Leveraging Data
We create value for our members by collecting and sharing data to help them better manage patient populations.
As a Clinically Integrated Network (CIN), we deliver evidence-based, patient-centered care — leading to improved health outcomes & reduced Total Cost of Care (TCOC) for our patients. We leverage data to implement new strategies to address gaps and measure outcomes in our network.
Value-Based Care (VBC)
FPAN partners with payers in VBC arrangements that reward improved healthcare outcomes and decrease the TCOC.
Data Sources
- Payer Contracts: We receive claims data from commercial and government payer contracts and work to integrate this information with real-time clinical data to coordinate patient care.
- Network Members: Our CIN members share quality and patient experience data to support collaboration and improve patient outcomes.
Reporting
As members of Fairview Health Network, we provide primary care clinics information to manage patient populations, gap closures, patient experience, and shared savings. We use enterprise applications such as Power BI, and Salesforce to deliver reporting.
Transitions of care
We work to reduce the number of avoidable hospital readmissions and improve the movement of patients from one level of care to another. Efforts include:
- Automated discharge reports from all M Health Fairview hospitals.
- Report inpatient and emergency department visits to Fairview Health Network primary care clinics.
- 48-hour follow-up calls and seven-day primary care physician visits.
Telemonitoring monitoring
We participate in M Health Fairview’s remote monitoring program, providing 30-day post-hospital surveillance for Medicare fee-for-service enrollees with congestive heart failure, chronic obstructive pulmonary disease (COPD), and other chronic conditions. Patients can enroll at no cost after discharge from a network hospital.