Population Health Transformation

The Population Health Transformation team serves as the bridge between BPP and CIN physician members to ensure value-based contracting goals are communicated and achieved. The team references reports generated by the Population Health Analytics Team to identify and share successes and opportunities with physicians and clinic team members to improve quality goals. Areas of focus include quality care gaps, accurate documentation, annual wellness visits, and avoidable utilization. The team also identifies and shares cross-continuum opportunities related to the BPCI Advanced.

BPP Initiatives a. Quality b. Patient Satisfaction c. Accurate Documentation

Primary Care Physicians

a. Care Gaps b. Office Workflows c. Epic

Quality Spotlight

Each month, the Population Health Transformation Team spotlights one valuebased quality measure. Spotlights include contract-specific quality measures, in addition to BPP-specific quality measures to ensure alignment of clinical care with BPP’s overall quality strategy. Monthly meetings with primary care stakeholders ensure consistency and long-term success.

Quality Improvement

In addition to stakeholder alignment, the team collaborates with stakeholders from across the health system to improve upon operational- and documentation-specific processes. Examples include accessing and interpreting data in HealtheIntent, documenting care gaps in Epic, and scheduling patients for annual wellness visits.