Overview
Adventist Health, leveraging the Bridge platform's Med Econ capabilities, has launched a real-time, AI-powered dashboard to empower stakeholders with actionable medical economics metrics, patient-level insights, and financial performance indicators. The initiative supports medical directors, financial analysts, care coordinators, and QA teams in making data-driven decisions and optimizing operational oversight.

Challenges
Prior to implementing Med Econ, Adventist Health encountered several obstacles. They had fragmented data sources, which limited visibility into key performance indicators (KPIs), patient-level data insights, and financial reconciliation. Additionally, the lack of dynamic filtering and drill-down capabilities in their previous state analytics made it difficult to analyze trends by organization, payer, line of business, or contract. Lastly, they were in need of secure, HIPAA-compliant data handling and audit logging to ensure regulatory adherence as risk-bearing contracts grew.

Solution
The Bridge platform empowered Adventist Health with a unified data view by aggregating claims, eligibility, membership, and patient registry information for comprehensive analysis. Bridge introduced interactive KPI panels featuring dynamic filtering across organization, payer, line of business, and contract dimensions. Financial summaries and reports, including profit and loss reports, specialist comparisons, high-cost patient identification, and childcare services analytics, provided deeper operational insights. Additionally, the platform generates contextual, model-driven narratives that highlight expenditure patterns, risk score trends, and projected savings.

Background
On Belay Health Solutions is a physician-founded Managed Service Organization and Accountable Care Organization (ACO) located in Boston, MA, that is committed to reinventing primary care through solutions that empower care teams and strengthen practices. On Belay supports practices across 22 states, serving populations through the CMS MSSP and REACH programs, Medicare Advantage, and manages care for over 42,000 lives through Bridge. This storyline highlights how On Belay leveraged Bridge's Care Management tools to improve outcomes across the entire population.

Problem
Before implementing Bridge, On Belay's care managers relied heavily on Microsoft Forms and manual workflows, which led to significant inefficiencies. Duplicate documentation was common, and tracking key Care Management KPIs proved difficult. Fragmented systems limited their ability to analyze and act on critical data for both internal performance tracking and strategic decisions. Additionally, executing and monitoring Transitional Care Management (TCM) workflows was a challenge due to the lack of centralized tools.

Solution
To address these issues, The Garage collaborated with On Belay's leadership to build a customized Bridge solution. This included their most-used assessments and additional fields for tracking patient outreach and interactions. In July, On Belay's Care Managers began using Bridge to support their Transitional Care Management (TCM) program. With integrated ADT feeds, Care Managers could view recent discharges, document patient outreach, and complete TCM assessments all in one place.

Outcomes
Bridge has empowered On Belay to streamline care management processes, centralize data, and meet internal and external reporting goals. Most notably, they achieved a 68% decrease in the No Activity Rate and a 13% increase in Follow-Up Rate, which is clear evidence of the platform's impact on improving care coordination and operational efficiency.

Background
Cibolo Rural Health Network exists to ensure that high-quality, affordable care remains accessible across rural America. Serving more than 140 facilities across five states (North Dakota, Minnesota, Ohio, Montana, and Nebraska), Cibolo supports a population of over 5 million people. Through its High Value Networks (HVNs), Cibolo helps providers deliver coordinated, patient-centered care while navigating the rising complexity of cost pressures, workforce shortages, and limited access to services.

Situation
Rural healthcare faces growing challenges, including limited access to care, rising costs, and a severe workforce shortage. Critical clinical issues Cibolo faced included incomplete data, which hindered decision-making, and incomplete coding, resulting in reduced share savings. While they actively work to aggregate patients, command payer attention, and negotiate vendor discounts, they recognized the need for a more robust solution that would further empower rural providers amidst complex healthcare pressures. To further their mission and truly equip rural providers with the necessary tools, they initiated a search for a unified platform. This platform was envisioned to provide their HVN participants with advanced analytics, robust care management capabilities, and the infrastructure to improve outcomes across the rural communities they serve, building upon their existing collaborative framework.

Solution
Cibolo Health selected The Garage's Bridge as their population health management platform for this initiative, supporting data sharing and interoperability across their networks. Despite challenges in accessing timely and complete external data, The Garage quickly configured the Containers app to seamlessly integrate data from Health Gorilla, Experian, and Cibolo Health Partners. This integration provides actionable intelligence at the point of care, enabling rural care teams to make informed decisions. The app also creates a unified patient worklist and triage interface, bringing together clinical, social, and administrative insights into a single dashboard. It offers crucial clinical insights to close care gaps and provides prompts for improving coding accuracy, empowering care teams with necessary intelligence precisely when needed.

Outcomes
Within 4 weeks, the utilization of the Containers app has saved the HVNs an estimated 15-20 hours per week per care team member that they previously spent manually gathering and consolidating patient data, thanks to Bridge's data capabilities. Having this data at hand has improved patient outcomes through timely, contextualized engagement and has effectively supported population health by aligning interventions with risk and need, driving additional ROI, and shifting resources to patients most likely to benefit from care coordination.

Background
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. They have over 38,000 employees dedicated to their mission of inspiring health, wholeness, and hope for their patients.

Situation
As part of their mission, Adventist Health participates in multiple ACOs and risk-based value care contracts, serving a population of approximately 250,000 patients across various specialties and primary care providers. Participating providers consist of the Adventist Health Physician Network, as well as Independent Affiliate participants. Although AHPN participants have had access to dashboards to review advanced analytics for their patient populations, Adventist Health began searching for a platform that would provide advanced analytics for its independent affiliate practices in one unified location for the first time. Without a unified source of truth for all participants, this resulted in missed opportunities for efficiency, savings, and better patient outcomes.

Solution
By partnering with The Garage and adopting Bridge, our platform has enabled Adventist Health to drill down to the granular level detail of advanced analytics for cost of care, utilization, savings, and many other metrics across ACO and VBC contract participants. Bridge can provide risk models and stratification processes across multiple contracts, providing actionable insights to support our shared commitment to high-quality, cost-effective care. Bridge has integrated with multiple EMRs, as well as Health Gorilla, to deliver a robust level of clinical data completeness to Adventist, its participants, and users.

Outcomes
Within less than a year, Adventist Health and The Garage have commenced and participated in a strategic and collaborative journey involving the onboarding of 6 IPAs at a rapid pace, on one unified platform. We have worked hand in hand on new developments for Utilization Management and Recovery, focusing on more efficient cost and reimbursement management. Within the first year, we transformed Adventist's problem of experiencing fragmented data into a foundation of transformation for their value-based care models. Our partnership isn't just about providing dashboards of data; it's about building a connected care ecosystem that empowers providers to improve their outcomes of cost savings and patient care, while continuing our joint mission with Adventist to change healthcare for the good, one community at a time!

Background
Miami Jewish Health (MJH) is a not-for-profit organization with a legacy spanning over 85 years, dedicated to providing healthcare and living options for older adults. Based in South Florida, MJH employs over 900 professionals committed to delivering high-quality, compassionate care and services to the population we serve. A cornerstone of MJH's services is Florida PACE Centers (Program of All-Inclusive Care for the Elderly) - a comprehensive, federally funded initiative through the Centers for Medicare & Medicaid Services (CMS). PACE is designed to provide coordinated medical and social services to frail, community-dwelling older adults who are eligible for nursing home care but wish to remain living independently.

Serving over 1,200 participants across Miami-Dade and Broward Counties, Florida PACE Centers empower seniors to maintain independence and thrive within their communities while championing healthy aging and quality of life.

Situation
Evolving from its origins as a nursing home, MJH has become a leader in senior healthcare and living options which include independent and assisted living, affordable senior housing, a 32-bed hospital, a state-designated memory disorder clinic and clinical research site, integrated rehabilitation, a home health agency, and a growing focus on PACE. As MJH deepened its commitment to the PACE model, the organization needed a scalable, data-driven solution to support operational efficiency, improve patient outcomes, and ensure financial sustainability.

The leadership team envisioned MJH becoming a PACE-focused equivalent of an Accountable Care Organization (ACO), with a strong emphasis on population health, cost management, and quality of care. However, they faced several operational barriers, including the manual preparation of KPI reports, which consumed nearly a week each month for two full-time staff members. These inefficiencies limited visibility into performance data and delayed action on key initiatives. To move forward, MJH required a platform that could automate analytics, support proactive care planning, and fuel strategic decision-making.

Solution
To address these challenges, MJH partnered with The Garage to implement BRIDGE, a comprehensive population health platform designed to unify and activate data across their ecosystem. BRIDGE integrates data from multiple databases and sources-memberships data, medical & pharmacy claims, and clinical records-into a centralized system, providing real-time visibility and actionable insights.

At the heart of the implementation was the development of the PACE Quality KPI Dashboard-a dynamic, automated dashboard tailored to MJH's PACE program. Previously, compiling essential metrics was a manual process that took two full-time team members nearly a week each month. With the Dashboard, MJH now has access to up-to-date performance data refreshed weekly, allowing leadership and the PACE Interdisciplinary Team (IDT) to make faster, more informed decisions. The automation has significantly improved operational efficiency, freeing up staff to focus on delivering high-quality, person-centered care.

Supporting this transformation, The Garage also integrated BRIDGE with the Florida Health Information Exchange (FLHIE) to provide real-time ADT (admission, discharge, transfer) notifications. This capability enhances care coordination by alerting the IDT to critical patient events in real time, enabling quicker interventions and better continuity of care for participants.

Together, these innovations have empowered MJH to drive operational excellence, strengthen outcomes, and position their PACE program for scalable, sustainable growth.

Outcomes
The implementation of BRIDGE enabled MJH and Florida PACE Centers to transform how they manage and deliver care. By automating data aggregation and analysis, MJH can make faster, more informed decisions that drive better outcomes and organizational growth. BRIDGE provides advanced analytics and deep visibility into their PACE patient population-offering insights into clinical distribution, utilization patterns, cost trends, risk stratification, and care gaps.

These capabilities allow the care team to identify high-risk individuals, prioritize interventions, reduce avoidable hospitalizations, and enhance overall program efficiency. Using the tools in BRIDGE, MJH can better track performance against quality benchmarks, monitor social determinants of health, and align care delivery with value-based goals-key factors in improving outcomes and achieving long-term sustainability in a PACE model.

Most importantly, by automating manual processes such as reporting and performance tracking through the PACE Quality KPI Dashboard, staff can focus on what matters most: providing compassionate, personalized care that supports aging adults in living healthier, more independent lives.

Background
Desert Mountain ACO is an accountable care organization dedicated to improving the lives of its growing patient population. Currently serving over 7,500 patient lives, Desert Mountain ACO prides itself on offering coordinated care that prioritizes care quality, accessibility, and lower costs while simultaneously improving care outcomes. Looking ahead to 2025, they anticipate a significant expansion, with its patient population projected to double in size.

Situation
Desert Mountain ACO recognized the urgent need for a data partner that could deliver deeper actionable insights. Their objective was clear: empower providers with meaningful information to identify and capitalize on the greatest opportunities for improving care delivery, particularly for patients with the most critical needs. Despite evaluating various platforms, they discovered that existing solutions lacked the depth and precision necessary to make meaningful changes.

Solution
After extensive evaluations, Desert Mountain ACO chose The Garage as their expert solution due to Bridge's tools and capabilities to unlock data-driven strategies and its abilities to transform insights into impactful, patient-centered outcomes. Guided by Desert Mountain ACO's direct feedback, The Garage crew developed a comprehensive, unified data view that was tailored to capture and present the most relevant data points. Having this centralized resource equips their ACO administrators with the insights needed to drive informed, actionable conversations with their care providers.

Outcomes
By streamlining access to critical information, Bridge has empowered Desert Mountain ACOs administrators to prioritize and address the most impactful areas of care. This has enabled their care team to improve patient outcomes and significantly boost the overall performance and operational efficiency of the ACO.

Background
Monida Healthcare Network is a not-for-profit Physician Hospital Organization (PHO) founded in 1996 and consists of over 750 physician and ancillary providers, as well as 8 hospitals, serving residents of Montana and Idaho. Monida is dedicated to creating value for its customers, payers, employers, and communities by fostering collaboration and addressing the unique challenges of rural healthcare. Guided by their mission to navigate the complexities of healthcare, Monida's vision is to help it's members transition to value based care by engaging both its hospitals and providers in implementing programs that improve population health, control costs, and elevate healthcare quality for the communities they serve.

Situation
Committed to improving rural healthcare, Monida sought a robust platform that addressed the critical challenges rural healthcare faces. They needed to partner with payers to improve patient outcomes and implement reimbursement strategies that reward care teams who reduce high-cost care utilization, such as ER and inpatient care. The solution also needed to enable the real-time identification of wellness visit due dates on a rolling calendar basis, accurate identification of patients without visits in a defined lookback (leveraging CCDA and claims data), and collate claims and clinical data to identify patients with open care gaps.

A key functionality needed with this solution was a reliable mechanism that shared clinical data with payers, to efficiently create care gap closure and result in financial reimbursement for quality performance across diverse, overlapping contract metrics. Additionally, the platform needed capabilities to identify rising-risk populations through a defined logic and populate a care management grid for proactive care interventions. Maintaining a patient-centric model was critical to facilitating efficient care delivery across the continuum of care. This approach needed to include Transitional Care Management, streamlined primary care communication, and effective referral management to close specialty care referral loops. Additionally, the platform needed to accurately filter information by organization, location, contract, practice, and provider.

Solution
To support Monida in advancing its mission and aligning with its strategy and vision for improving population health, The Garage's platform Bridge was selected in 2022. Utilizing Bridge, Monida addresses key healthcare priorities and challenges while staying true to their mission. Bridge has empowered Monida to focus on the people, processes, and technology by providing a unified population health management solution to serve as its backbone to achieve the Quintuple Aim: lower costs of care, better care for the patient, improved health of communities, sustainable service models for care teams, and equitable access to care for all. This approach, achieved through the combination of integrating Monida's network with Bridge's infrastructure, drives operational efficiencies, improves decision-making capabilities, and implements scalable, patient-centric care models that addresses the unique needs of the rural communities they serve.

Outcomes
Using the Bridge platform and its data warehouse, Monida has improved their care management initiatives, amplified their provider and patient outreach outcomes, and has the ability to expand partnerships with other entities to create a broader impact. Bridge embodies an "EASY Button" philosophy, simplifying complex processes and empowering Monida to deliver effective and accessible value-based care (VBC) services, while increasing organizational productivity, reducing unnecessary costs, and improving overall contract management efforts.

Background
On Belay Health Solutions is a physician-founded Managed Service Organization and Accountable Care Organization (ACO) located in Boston, MA, that is committed to reinventing primary care through solutions that empower care teams and strengthen practices. On Belay supports practices in 18 states, serving populations through the CMS MSSP and REACH programs, Medicare Advantage, covering a combined 39,000 lives, as well as commercial contracts with Aetna and BCBS. This storyline highlights the rollout of our Care Management tools in Bridge, purposefully crafted to empower Care Management teams with the tools they need to deliver more coordinated, patient-centered care.

Situation
As a growing startup, On Belay required standardization of care management processes - including workflows, patient identification, assessments, and care planning, for the 2024 calendar year. They needed to increase efficiency, monitor and track outcomes, and ensure they had a strong care management program to support an increase in provider contracts. In the first half of the year, On Belay successfully defined and implemented improved workflows and introduced some standardized processes. However, they still operated across several disparate systems to complete work. As a result, they approached The Garage, asking if they had the capacity to customize the Grid application to meet their needs.

Solution
The Garage was willing and able to assess On Belay's needs, provide valuable recommendations, and support the necessary configurations. By partnering with The Garage, On Belay has successfully implemented several key features to support its care management initiatives. These features include embedded assessments, enhanced transitions of care through On Belay's own ED and IP post-discharge assessments within a "recently admitted" grid, and the ability to track patients effectively. Additionally, On Belay has incorporated ad hoc reporting, and its care management team has significantly reduced the number of systems required to perform their work. They plan to eliminate additional systems in Q4 of 2024.

Outcomes
By partnering with The Garage, On Belay successfully reduced the number of disparate systems being utilized, ultimately leading to increased efficiencies. They have achieved standardization across workflows and enabled increased transparency and communication across care teams. This has allowed better visibility into the work of multidisciplinary teams managing enrolled patients. Soon, On Belay will have the ability to report care management activities from a single system, further streamlining company operations.

Background
NEXT Healthcare Solutions is a leading physician enablement organization that owns and operates ACO MSSPs, REACH ACOs, Medicare Advantage MSOs, and Commercial Value-Based Care contracts. They have established a robust presence in the healthcare landscape with over 140 practices, 700 practitioners, and a network of more than 139,000 patients. Headquartered in Trinity, FL, NEXT Healthcare Solutions has consistently earned prestigious accolades and recognition since its founding in 2012. Their success is anchored in three core pillars: Autonomy - supporting independent practices to maintain control; Thrive - fostering growth through value-based care for both practices and patients; and Protect - leveraging the strength of their network to shield practices from financial risk.

Situation
NEXT Healthcare Solutions sought a comprehensive and unified platform to support the operations of their three ACOs: West Florida ACO, Central Florida ACO, and Space Coast ACO. Their primary goal was to streamline data integration across these entities, enabling advanced analytics to drive better decision-making and optimize patient outcomes. They also sought a platform to improve care management efforts and empower care teams with real-time insights and coordinated care strategies. Additionally, they needed a solution capable of tracking and reporting quality measures in compliance with Medicare's Clinical Quality Measure (CQM) requirements, ensuring that each ACO could meet regulatory standards while delivering high-quality, value-based care.

Solution
The Garage successfully implemented its comprehensive Bridge platform for NEXT Healthcare Solutions in just four weeks, exceeding expectations for speed and efficiency. This all-encompassing solution included over 139K patient lives, including over 27K ACO lives, a testament to the platform's robust capabilities. Additionally, the Bridge platform processed over 2.4 million claims for 325 physicians across 104 practices, including both CMS claims and Florida HIE data.

Outcomes
Bridge has empowered NEXT Healthcare Solutions with the ability to effectively track High-Cost, High-Need (HCHN) patients, providing valuable insights into their care patterns and helping identify opportunities for intervention. Bridge has also enabled Transitional Care Management (TCM), allowing care teams to coordinate and manage the complex needs of patients transitioning between different care settings from hospital to home more efficiently. With Bridge's powerful quality tools, NEXT Healthcare Solutions has an enhanced ability to close care gaps, ensuring patients receive timely and appropriate care based on individual needs. Overall, Bridge empowers NEXT Healthcare Solutions with the tools needed to have a streamlined, proactive approach to care, improving patient satisfaction and operational performance across their ACO network and value-based contracts.

Background
Electronic transmission of claims data between SOMOS and payers offers a consolidated view of individual patients, while supplemental data (i.e., retinal eye exams or blood pressure) helps their physicians submit information they may have missed when submitting claims, enriching their data sets by providing additional clinical insights. The comprehensive picture of the care and services delivered utilizing this supplemental data enhances HEDIS^® measures and facilitates quality gap closure. Incorporating centralized supplemental data simplifies data attainment and saves time, money, and resources while simultaneously improving the data at hand for HEDIS^® reporting and patient analytics. As a result, health plans and providers are empowered to deliver high-value care, identify closed care gaps, and meet essential quality targets crucial for value-based programs.

Situation
SOMOS, the largest provider-led IPA in New York with more than 2500 physicians, serves 650,000+ lives across 5 boroughs. Optimus Analytics, which powers SOMOS's IT and is the data intelligence arm, assists with multiple risk VBC arrangements along with all data needs. SOMOS needed a streamlined solution that established connections with over 250 individual EMRs, aggregating, normalizing, cleaning, and standardizing this data prior to packaging and transmission to Healthfirst, Emblem, Anthem, United and many other local and national plans, to meet supplement reporting requirements and its benefits.

Solution
The Garage/SOMOS Genome Data Warehouse, a testament to our commitment to efficiency, was built in 2022 to gather CCDAs and Reports from individual EHRs spanning the SOMOS network. This warehouse automatically refreshes each weekend, aggregating data in a uniform way with a Master Patient Index. With this warehouse at their fingertips, SOMOS and Optimus can pull clinical data reports for supplemental reporting to payors and any in-house analytics from the central repository. This streamlined solution has saved substantial time and stress and prevented the inclusion of inaccurate patient data, leading to organizational success. It has eliminated the time-consuming, costly, and sometimes troublesome process of manual data aggregation from hundreds of practices. Today, the Genome Data Warehouse incorporates 396 total integrations and 2,278,341 lives for SOMOS.

Outcomes
While these plans have no effective way of vetting the statistical impacts of supplemental reporting, given parallel claims and other supplemental data sources such as HIEs, SOMOS continues to attribute supplemental reporting as an integral part of business success. By partnering with The Garage to bear the responsibilities of directly integrating each EMR, SOMOS/Optimus have eliminated the costs of eCW direct fees and reallocated personnel costs equivalent to 4-5 new FTEs to support these integration requirements.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Background
Community Care Physicians (CCP) is the largest independent multispecialty medical group in New York's Capital Region, whose focus prioritizes addressing each patient's needs, regardless of age, who seeks primary care, specialty care, urgent care, and wellness services. This physician-led, patient-focused local organization's overarching goal is to improve the health of communities, prioritizing personalized care and community well-being as core principles.

Many CMS-sponsored and payer-sponsored programs require extensive reporting from participating practices, with CMS and other payers offering performance-based incentives for measures such as patient experience, clinical quality, and utilization, which affect the total cost of care. However, a major barrier to accurate, timely reporting is the lack of uniformity in EMR systems across practices, as disparate systems isolate necessary data for efficient reporting. Consolidating practices to a single EMR can cost up to $70,000 per physician and result in a 50% reduction in adjusted income within the first seven months after EMR implementations, prompting many organizations to seek alternatives.

Situation
With CCP's previous method for submitting HEDIS^® Supplementary files no longer being viable, they were at risk of financial losses in late 2023. After assessing its unique business needs, and its desire to mitigate this risk, CCP partnered with The Garage for this initiative to develop a solution that would meet its HEDIS^® and claims reporting requirements. Previously. CCP's process was manual and labor-intensive, requiring them to retrieve gap lists from various payer portals, analyze and compare against EMRs, and manually upload or fax records. On the payer side, there was also a manual process for reviewing documentation and the subsequent approval or rejection in the HEDIS^® logic. This consumed valuable time, was prone to human error, and resulted in disjointed workflows, disrupting efficiency. Recognizing CCP's urgency, The Garage's data engineering team collaborated closely with CCP to design and implement an automated submission process, streamlining file ingestion and comparison and eliminating the cumbersome manual procedures.

Solution
Due to CCP's partnership with The Garage, HEDIS^® supplementary files are now managed through an automated process that is repeated on a monthly basis. All gap list files from payers are automatically retrieved via SFTP, eliminating the need for manual logins to patient portals. Each gap list file is then compared to data from the EMR in the Bridge platform, and any clinical data supporting gap closure is automatically compiled into a supplemental submission file tailored to the payer's specific requirements. These files are uploaded monthly to the payer's SFTP, automatically processed, and applied to the payer's HEDIS^® measure logic.

Outcomes
Implementing this automated process for HEDIS^® supplementary files has resulted in approximately 200,000 data points being submitted. A time study done by The Garage has indicated that this process has saved 60-80 person days due to this process, reflecting the efficiency gained from the automation.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Background
Community Care Collaborative of Pennsylvania and New Jersey LLC (CCC) operates as an Accountable Care Organization (ACO) and works in tandem with the Innovative Health Alliance (IWA), a clinically integrated network. CCC/IWA oversees patient populations covered by eight distinct Medicare Advantage and Commercial plans. CCC coordinates care for more than 18,000 beneficiaries in the PA & NJ regions through the ACO Medicare Shared Savings Program and nearly 60,000 total members.

Situation
Ten durable medical equipment companies may have cost the Traditional Medicare system close to $2-3 billion in potentially fraudulent payments, though CMS has not yet confirmed this. As part of its participation on the Benchmarking Committee late in 2023, the CCC was given a heads up of the potential fraud and began its research. Furthermore, the National Association of ACOs (NAACOS), as part of their advocacy for their ACOs, reached out to CCC in early February 2024 about research conducted by the Institute for Accountable Care, calculating individual ACO spending on urinary catheter billing codes (A4352 and A4353) in 2022 and 2023 to quantify an increase in billing. CCC's 2022 Catheter Payments showed as $297,339, whereas 2023's Catheter Payments reported an astounding $2,166,189, showing a $1,868,851 difference and a 629% increase in billing when comparing 2022 to 2023, as well as 17,732 Unique Beneficiaries in 2023.

This surge in claims data information prompted an investigation into potential Durable Medical Equipment (DME) Fraud. CCC contacted CMS to address the heightened expenditure and was subsequently requested to provide additional information and data points. These included identifying provider/supplier names suspected of fraudulent activity, associated NPIs or Provider Transaction Access Numbers (PTANs) suspected of involvement, the timeframe in which the alleged fraudulent claims were made, a short description of the purported fraud and its detection methods such as Claim Type and CPT/HCPCS codes), as well as any available evidence detailing financial impact to their ACO, or a list of ACO assigned beneficiaries for whom claims were submitted by the fraudulent providers/suppliers.

Solution
CCC reached out to The Garage seeking assistance in acquiring the information requested by CMS. The Garage promptly supplied the required information in a Data Warehouse (DW) and offered guidance on which data points to focus on when compiling a PowerBI dashboard and report to be submitted to CMS. Additionally, a Garage Senior Data Analyst conducted a peer review of the SQL query developed by CCC's data team, ensuring output accuracy with necessary corrections.

Outcomes
Leveraging the structured data availability provided through The Garage's data warehouse in addition to The Garage's Senior Data Analysts peer review conducted on CCC's Data Team's findings, the corroborative evidence provided indicating potential fraud flagged by the analyst. With only 2 months of runout, CCC determined a Potential Shared Savings Loss amounting to $2.8M to CMS and $2.0M in shared savings payments to the CCC, over 25% of projected total shared savings earned. Additionally, CCC is building out an entire suite of PowerBI visualizations to monitor for fraud monitoring and detection based on this experience that will be used in their processes in all CCC/IAW value-based contracts. The financial outcome remains to be seen. According to their CMS Coordinator, CCC has provided CMS with more detailed information than other ACOS. With this additional information, CCC is hopeful CMS will exclude these expenses in their final accounting.

Background
Forward Leading IPA (FLIPA) is a network of 21 member organizations serving 27 counties across upstate NY. Its member organizations include 13 community health centers (FQHCs), 7 behavioral health organizations, and a rural health network. FLIPA believes in the purpose shared across its member organizations: to serve our communities better by connecting community health centers, behavioral health organizations, and community-based organizations to develop innovative solutions to drive successful outcomes.

Situation
Medicaid enrollment increased fourfold¹ at the start of the pandemic, primarily due to the continuous enrollment provision. Federal regulations that were suspended for the public health emergency during the pandemic were reinstated and New York State Medicaid recipients were required to recertify and reenroll in the program starting in July of 2023. Statewide communication campaigns were implemented to connect with Medicaid enrollees at risk of losing coverage since many individuals were unaware of this change in required recertification. FLIPA needed a way to support communication to individuals with upcoming recertification deadlines to help ensure that eligible participants were aware of the need to enroll.

Solution
FLIPA leveraged Garage's Communicator Application - an all-in-one, HIPAA-compliant text messaging service that enables easy, secure, and fast SMS campaigns or one-on-one conversations with patients. This application gave FLIPA the ability to send text message campaigns to thousands of Medicaid patients, urging them to recertify and re-enroll and providing information on how to do so.

This Communicator campaign established three phone lines dedicated to the three FLIPA member organizations participating in this initiative. Communications are dispatched monthly, targeting patients whose Medicaid coverage is nearing expiration. The campaign emphasizes a clear call to action for patients, underscoring the criticality of maintaining uninterrupted coverage. The message includes a recertification website and phone number along with a reminder that their health center enroller is also available to help with the recertification process.

Outcomes
The use of Garage's Communicator application provided a highly efficient additional layer of communication to the target population in a way that eliminated the administrative burden of alternative 1:1 communication pathways such as individual phone calls or mailings. In the first 5 months of this ongoing campaign, FLIPA has outreached to over 7,000 individuals with a 19% subscription rate, resulting in over 1,300 people actively interacting with the recertification message.

Background
Middletown Medical is a multi-specialty physicians group serving over 110,000 lives in Orange, Sullivan and Ulster Counties in NY. Middletown has 10 value-based-care risk contracts within Medicaid and Medicare line of business. Due to quality, financial, and overall performance responsibilities with such contracts, Middletown requires an analytics infrastructure that can cohesively and accurately present quality, utilization, and performance metrics to Middletown executives. While the goal is to achieve shared savings dollars in risk arrangements, Middletown holds its priority responsibility in guiding Middletown physicians to achieve this high-performance care through our partnership in a data-first, digital-first strategy.

Situation
Middletown Medical is dedicated to reducing hospital admissions and emergency room (ER) utilization as part of a broader effort to lower costs, enhance patient outcomes, and boost revenue. CEO Darcy Shepard initiated research into the use of remote patient monitoring to bring about impactful changes in the organization's patient care strategies. As Middletown strives to be a community-led and family-integrated practice, it sought a solution that would facilitate meaningful collaboration among staff, engage families and patients, establish trust in accuracy, and foster deeper physician-patient relationships. Several factors were considered when planning the rollout of this program, including the need to connect with the Hispanic community and the importance of supporting patients who may feel isolated by ensuring they always feel connected.

Naturally, the program required accurate and timely patient data, as well as an intuitive application that could handle everything from clinical reading alerts and device management to compliance tracking and billing reports to ensure its smooth and successful implementation. Given Middletown's five-year history of using the Bridge platform to manage all electronic medical records (EMR) and payor contracts, integrating remote patient monitoring into existing tools was a clear and logical choice.

Solution
The Bridge has launched SYNC, an advanced remote patient monitoring (RPM) and device management application designed to facilitate home-based care, real-time monitoring, and success in value-based care. Some of its key components include:

• Enrollment Tracker and Activity Timelines
• Daily Briefing on current active patients, Device Compliance, and Eligible for Billing
• GRID expansion with SYNC: Integrated care RPM into care management workflows to streamline care processes. This includes device ordering, patient onboarding, and readings repository and trends.
• Device Inventory Management: Stock management, changing assignments, and device ticketing
• Care Alerts: Real-time alerts for various flags across Blood Pressure, Pulse Oximetry, Weight, and Glucose levels
• Data Transmission Alerts: Be notified when patients are becoming non-compliant.

The initial population chosen for roll-out were those with Hypertension, COPD, CHF and Diabetes across 1 assigned Primary Care Providers.

The application is adopted by a designated RPM team with a ARNP Lead for clinical oversight and various state medical assistants and case management specialists for patient education, onboarding support, and encouragers of compliance.

Outcomes
The SYNC application was rolled out in various stages throughout 2023, introducing enhanced features and scaling patient lists. To date, over 431 patients consented for remote patient monitoring (RPM).

For patients who have been actively engaged in RPM for at least three months, we have observed significant improvements in their health metrics. Specifically, we have seen a remarkable 46% improvement in systolic blood pressure readings, with over 50 patients transitioning from Stage 2 Hypertension (140+/90+) to normal or elevated levels. Additionally, for patients enrolled in glucose monitoring, we have observed a 50% improvement in glucose levels, with one patient's glucose levels decreasing from 203 to 130.

Across blood pressure monitors, pulse oximeters, glucometers, and weight scales, Middletown is achieving a 60.4% device compliance rate, far surpassing the national average.

We are excited to continue monitoring the financial and utilization impact this program has on the patients. Stay tuned for updates in 2024!

Background
CCC Community Care Collaborative of Pennsylvania and New Jersey LLC (CCC) operates as an Accountable Care Organization (ACO) in collaboration with the Innovative Wellness Alliance (IWA), a clinically integrated network. Together, CCC/IWA oversees patient populations covered by eight distinct Medicare Advantage and Commercial plans. The collaborative efforts of CCC and IWA are strategically aligned with a shared mission: to empower healthcare practices and providers to collaboratively enhance the health outcomes of individuals and populations. This is achieved through a commitment to quality, accessibility, and efficiency, utilizing data-driven and patient-centered models of care.

Situation
CCC has been engaged with the Garage platform for over five years, working collaboratively to enhance various aspects of healthcare practices. This partnership has focused on boosting utilization within the build, with a specific emphasis on closing Care Gaps, increasing Annual Wellness Visits, and conducting follow-up calls for Transitions of Care. The integration of applications such as Care Gaps, De-risk, Insights, and TCM has played a pivotal role in supporting CCC's initiatives.

In 2023, CCC expanded its utilization of technology by incorporating Bridge for care management. During the second and third quarters of 2023, a dedicated care manager, responsible for high-risk patients, was introduced to Bridge's GRID application. Once acclimated to the platform, the care manager leveraged GRID logic to identify high-risk patients, enabling a focused approach to care planning and documenting progress, as well as addressing patient follow-up needs.

Simultaneously, CCC involved a registered pharmacist in utilizing GRID to monitor high-risk patients, document changes, and communicate updates with primary care providers. The pharmacist could efficiently review patient information within the GRID application and seamlessly share updated documents through the Messenger Application within the platform. This integrated approach underscores CCC's commitment to leveraging technology for comprehensive care management and enhanced communication among healthcare professionals.

Solution
By harnessing the capabilities of the GRID application within BRIDGE, both the care manager and registered pharmacist have successfully extended outreach beyond patients. The Message Center functionality has proven instrumental in transmitting essential documentation to healthcare providers, ensuring they have access to the latest and most accurate information.

Furthermore, the care manager has adeptly utilized PHP and GRID to identify ACO-attributed Medicare beneficiaries. This strategic use of technology enables CCC to streamline the process of the Skilled Nursing Facility 3-Day Waiver, alleviating the requirement for a traditional 3-day inpatient stay before admission to the skilled nursing facility. This approach not only enhances efficiency but also aligns with CCC's commitment to optimizing healthcare processes and improving patient care outcomes.

Outcomes
Through the Care Manager's diligent efforts, patient engagement has commenced with GRID stratified cohort selections, and comprehensive care plans for traditional Medicare patients have been successfully developed since August 2023. This strategic initiative has empowered the Community Care Collaborative to proactively prevent hospital admissions by facilitating direct transfers to Skilled Nursing Facilities under the CMS 3-Day Waiver. We are enthusiastic about further developing this workflow and expanding outreach to assess the statistical and data-driven impact on utilization and clinical outcomes.

Background
Healthix is a large New York health information exchange funded by the NYS Department of Health. They are committed to securely exchanging patient data to improve the quality and efficiency of care. Healthix receives clinical information from over 8,000 facilities - from large hospital systems to small doctor practices as well as behavioral and community-based organizations and more. With a patient's consent, this information is shared among providers to improve clinical outcomes and enhance value-based care delivery.

Situation
Given the accelerated pace of adoption for value-based care models, the focus on health equity, and the coming additional federal investment in New York's delivery system, the Healthix team wanted a way for their providers to leverage the data they hold in order to pinpoint priority patients quickly and effectively. They have actionable data to highlight patients with recent inpatient and emergency admissions and discharges, but they sought an easy-to-use mechanism to bring those insights to the forefront of care. They were looking for a straightforward solution that was easy to implement to ensure providers only got the information most critical to them for the patients that needed it most.

Solution
With Garage's industry-leading logic for identifying priority patients, a customized version of The Garage's point of care solution, Blazespeaks, was built to aggregate all the patient data and bring the most critical patients to the provider's attention. Most importantly, the tool is a web browser extension which gives physician's the flexibility to be in their EMR while still being able to see the priority patients. With all the pertinent patient information at the physician's fingertips, it eliminates the need for the physician to dig around for all the necessary patient information so they can jump right into action. Healthix providers can now see patients with Recent Admissions, Inpatient Discharges and Emergency Discharges. Once accessed, the clinical team has a breakdown of conditions and medical histories for the patient such as medications, encounters, results from labs and imaging, advanced directives, procedures, and any other pertinent documents for this patient.

Outcome
This technological innovation has been a breakthrough in enabling access for priority patients. In a few weeks' time, one of Healthix Participants team of providers, registered nurses, and clinical support staff has shifted priorities on 70 priority patients and provided care to ensure their health needs are met and keep them happy, healthy, and at home.

Background
Votion (formerly Better Health Group/Select Physician Partners) operates in 11 states and has over 600 primary care providers across five Accountable Care Organizations. As a leading value-based healthcare network, Votion continues to demonstrate its commitment to the growth and advancement of improved healthcare delivery. While Votion enables innovative relationships with providers and payers, Votion works with the Garage in tandem on all business initiatives that require digital-and-data forward solutions, aiming to improve patient outcomes and achieve increased savings and high-performance care through our partnership.

Situation
With Votion's plan for continued growth, there is a critical need to engage physicians to address value-based performance requirements such as closing care gaps and appropriate documentation of chronic conditions. Votion needed a solution to accomplish this at scale and avoid time-consuming and worksheet-based workflows. With over 120 practices with different dynamics and staffing models, it became clear that an aggregate software application that presents timely information and is easy to use is required. Votion and The Garage set out to release a solution with a priority focus on improving risk scores with proper documentation and closing care gaps to achieve positive clinical outcomes, shared savings, and high STARS scores. New practices joining Votion's ACOs needed to have quick and easy access to the tools available to support their success and quickly onboard to a standardized process to start closing gaps immediately.

Solution
The Bridge's Container application was chosen to support this initiative. Combining all critical action items for the patient is done in a unified singular interface allowing a singular and streamlined workflow. Depending on practice staffing and workflows, the Container can be used at pre-visit planning or at point-of-care. Furthermore, the Container integrates daily the practices EMR appointment schedule, allowing a reconciliation against today's schedule to list all unmet care gaps, undocumented HCCs with ICD10 descriptions, and other important variables like status on AWV completion. Because the Container reflects the most recent aggregate data across various data sources such as claims, lab, pharmacy, and EMR data, there is no time wasted by the clinical staff to gather all relevant data sources needed to enable action.

Outcome
The Garage and Votion launched the Container application in late winter of 2023, with 64 practices having attended trainings so far. When comparing the first half of 2022 versus the first half of 2023 redocumented rates based on claims data, we are seeing a capture rate increase from 17% to 33% respectively. We are excited to demonstrate the success rates of HCC redocumentation and closure of care gaps when comparing the first half of 2022 to 2023. The Garage and Votion are using select practices selected as evaluators of Bridge to provide continuous feedback on the value of the platform.

Situation
Finger Lakes Community Health (FLCH) was founded in 1989 to serve New York Finger Lakes region's seasonal agricultural workers. Today - as a leading Federally Qualified Health Center in Upstate New York, FLCH serves seven sites and more than 30,000 lives. FLCH strives to build a healthy community by providing health services and becoming a leader in health education and technology innovation.

Problem
FLCH needed a cost-effective and efficient way to increase patient engagement tied to access to care initiatives. Staff burden through call centers is time-consuming and often ineffective in getting responses. Mailers have become an outdated way of receiving patient callbacks. The pandemic has brought FLCH into a digitally driven path where texting is a common and often accepted form of patient engagement.

Solution
The Garage's Communicator tool was added to FLHC's outreach strategy. Six phone lines were activated for Medical, Dental, and Population health initiatives in English and Spanish. This allows FLCH to engage with its large population through campaigns that can reach large cohorts while simultaneously saving massive call center and administrative burdens. The convenience of texting has not only allowed FLCHs diverse rural and agricultural population to more proactively respond but build a communication path between providers and patients that is digital-driven and patient-focused. With a heavy focus on access to care, FLCH has been focused on medical appointment initiatives.

Outcome
This technological innovation has given the breakthrough FLCH needed to enable access for patients in rural areas far from hospitals or urban medical centers. Since going live in the late summer of 2022, over 400 patients have subscribed for ongoing communication with over 4000+ messages sent/received. Most communicator campaigns relate to increasing patient engagement for visits and other timely reminders, but culturally this ease of texting has become a way for patients to reach out on other matters, such as medication refill requests or changing onsite visits to virtual due to same-day emergencies.

Background
Collaborative Health Systems (CHS) is a Management Services Organization covering a national market of various path ACO Entities, Medicare Advantage and Commercial markets, covering over 180,000 beneficiaries across 26 states. CHS's care management strategies include centralized and decentralized care managers, social workers, and other clinical resources. With goals to minimize hospital admissions and emergency room visits, reduce the cost of care, and improve clinical outcomes and services available to the patients, CHS has had to be nimble in its strategies. They ultimately found that using the power of advanced data integrations and aggregation in Bridge could allow them to ease the daily burdens of care management while building focused outreach to the highest-need-highest-cost patients.

Situation
Due to multiple-payer contracts, an extensive growing network and a wide breadth of patient population needs, CHS's clinical teams needed to evolve their care management strategies so that their team members are driven to focus populations where the most significant impact can be made. CHS has utilized the Bridge Platform's GRID application to drive care management activities, with its first version of the product released in 2019. While initial versions of GRID were successful, they found the broad criteria released in earlier versions to be overwhelming to team members. CHS and The Garage embarked on an effort to create highly specified GRID eligibility criteria that more closely aligned with the work performed by CHS's care management team. Care managers were also required to interact with multiple platforms outside of GRID for areas such as identifying social needs categories, referring to social services in their area, and documentation for productivity tracking.

Solution
CHS's Care Management strategy development in GRID has been multi-factorial, involving workflows for interdisciplinary teams working together to provide comprehensive care that addresses each patient's unique needs across large geographic areas.

• GRID Initiatives: Since its initial release, the team has designed 21 unique initiatives for patients to fall into GRID and include criteria to expire based in timing of the patient timeline and closure of initiatives based on user action taken in the platform. The goal is to keep the patient eligibility as narrow as possible in order to drive care management to the patients where the most significant impact to quality-of-care goals and cost reductions could be realized. As data integrations became more robust, the CHS team is experiencing Bridge's data-first approach to ensure initiatives are more clinically relevant and in alignment to quality initiatives that are heavily weighted across all payer contracts.
• GRID Risk Level Stratification: Historically, triaging to appropriately assign the required care source to the level of risk the patient carried quickly became overly burdensome to the care management team, requiring extra workup time and delays in triage before patients could be appropriately assigned to a care resource. We introduced an extra layer of stratification, further distributing patients between 'Low', 'Medium', 'Medium-High', or 'High' risk categories when they meet criteria that includes a number of chronic conditions, overall spending, and a number of ER/IP discharge events. This has reduced the administrative time spent triaging and ensures the care team members are working with patients appropriate to their license level.
• Experian Integration: The CHS care team members found themselves with data gaps to appropriately identify social determinants of health needs due to assessment line of questioning and time required to develop trust with a patient. Through Experian Health Platform, an integration brought in individual patient category scores in four distinct buckets - Access to Care, Access to Medication, Food Insecurity, and Housing Instability. This data has never been accessible to care team members and is now aligned with their standard workflow to determine if the patient will have any barriers to care or higher needs throughout their care journey.
• FindHelp (formerly Aunt Bertha) Integration: FindHelp is a tool that lists various support services within a particular geographic area available to patients, with the ability to refer patients to specific services for assistance, including but not limited to: financial assistance programs, food pantries, counseling services, medical care, transportation, and other free or reduced-cost help. Access to FindHelp through Bridge allows staff to refer patients to necessary service(s) to reduce barriers to ongoing treatment and medical care. Because FindHelp is integrated into GRID, care teams are saving the manual effort of using multiple portals and saving notes externally for day-to-day care management activity.
• PCA Tracker and Productivity: With the high volume of care management activities performed in Bridge's Grid application, the CHS team critically needed to track productivity and metrics around its custom workflows. The Garage team built a custom-designed PCA Tracker (Care Management Tracker) where every care resource touchpoint, including successful/unsuccessful outreach attempts, timeliness of initiative completions, care plan work, HRA updates, total touchpoints, and missed opportunities, can all be tracked. This empowers the conversation and initiative around even work distribution.

Outcome
Today, a staff of over 100 care resources use Bridge, with an average of 70 care resources in the tool five days a week. Among all workflows outlined above and more, an average of 415 touchpoints occurs daily in GRID! In 2023 alone, over 8900 unique patients have been outreached to, over 800 cases have been closed/completed for patients who fall under HighRisk categorization. Since the implementation of the social intervention plan more than 200 referrals have been placed to community benefit organizations.

While every day impacts the individual patients that are served, when looking at historical performance from 2021 to 2022, we saw a 44% reduction in IP/1000, and PMPM rate reduction of 16.6%! We are excited to continue providing necessary solutions to the incredible CHS care management teams in order to manage efficiently & effectively more than 8,100 current open cases.

Situation
Finger Lakes Community Health (FLCH) was founded in 1989 to serve New York Finger Lakes region's seasonal agricultural workers. Today - as a leading Federally Qualified Health Center in Upstate New York, FLCH serves seven sites and more than 30,000 lives. FLCH strives to build a healthy community by providing health services and becoming a leader in health education and technology innovation. FLCH was an early adopter of Telehealth technology to instill continued access to care for those who cannot get to a clinic, remote training, specialist consultations, remote diagnostics after hours, and so much more.

Problem
In advocating and scaling virtual care units, FLCH was using Zoom. This created various workflow barriers, increasing the administrative burden on staff and patients. First, a patient has to install the application, which presents challenges in tech literacy skills, not knowing App Store passwords, or other difficulties with setting up a new application. Furthermore, patients had to enter a password for Zoom meetings, which created a time burden for staff to copy and paste these details from Zoom into the eClinical Works appointment section and then text the patient. With the Zoom licensure cost, FLCH had to share accounts between providers. As every encounter was an individual session to a single account, getting a patient from a check-in to a provider to a checkout process was inefficient, if not impossible.

Solution
A custom Virtual Care center was designed that imitates a real-life patient experience. Most importantly, the Virtual Care Center is browser-based, offering expanded access to FLCH's network. Entry into this virtual space requires minimum patient effort, and is also bilingual in Spanish. Virtual rooms separate patients into a receptionist area where they are checked in with the necessary steps. Only then can a patient be moved to one of the six serving locations or a care management/behavioral health support staff member. The clinical and physician roles can interact with the patient individually or three-way if a translator, specialist, or ancillary service provided is needed. After all clinical components of the encounter are complete, the patient is sent back to check out, schedule their follow-up, and tackle any next steps, such as getting details on a referral or verifying a prescription.

Outcome
This technological innovation has been a breakthrough in enabling access for patients in rural areas far from hospitals or urban medical centers. In May 2023 alone, more than 200 encounters occurred between the Behavioral Health and Medical department. A physician survey showed that in contrast to previous tools, the experience with the Virtual Care Center powered by Garage is 5/5. Not only is this solution bringing efficiency to clinical workflows, better patient experience, and increased patient engagement, but it also allows FLCH to expand its access by implementing this virtual care program in its Mobile Clinic that provides care directly to workers at farmworker housing. This allows patients with transportation barriers and connectivity issues to enter a Mobile Clinic and connect with providers and specialists across the FLCH network.

Background
Community Care Collaborative of Pennsylvania and New Jersey LLC (CCC) is an Accountable Care Organization. With Innovative Wellness Alliance (IWA), a clinically integrated network, CCC/IWA manages patient populations of eight different Medicare Advantage and Commercial plans. Strategically, CCC and IWA drive a joint mission to empower practices and providers to collectively improve the health of individuals and populations by ensuring quality, access, and efficiency using data-driven and patient-centered models of care.

Situation
CCC/IWA sought an innovative solution to unify critical contract performance areas of focus and provide a single source for the list of "priority" patients based on defined eligibility criteria and a custom in-house scoring system for 69 practices overseeing 65,000 lives. CCC/IWA administrators had to aggregate multiple operational goals and KPI's manually, have central staff members run monthly reports, and send individual reports to each practice. The Garage was presented with a request to build a consolidated dashboard that can timely generate a patient work lists that took into account the performance metrics from payor contracts and a stratified priority logic to ensure the right patients were seen at the right time.

Solution
Garage and CCC/IWA spent a few months building the algorithm, which ascribes various point value(s) for every ED visit, open care gap for priority vs. nonpriority measures, and multiple other elements. The total is then calculated to become an "in-house risk score" and patients are sorted from highest to lowest in the Priority Patient List in the Members application as a work list initiative.

The targets of focus selected were:

• AWV capture of 100% by the end of the year. This is tied to revenue optimization.
• Outstanding coding opportunities capture a target of 85% by the end of year. This is tied to better clinical outcomes and revenue.
• Closing potential / identified care gaps in specified quality measures at 90% by end of the year. This is tied to benchmarked goals to achieve performance success for savings.
• A custom CCC/IWA consent collection called "Form Completion" at 100% by the end of the year. This is tied to a major revue bonus.
• History of ER/IP visits in the last rolling 12 months. This is tied to potential medical literacy deficits and social determinants of health issues, and utilization management.

This work initiative, combined with other clinical statistics such as patient cost and PCP utilization allows users to take a more informed course of action. The Members Priority Patient List empowers users to evaluate patients from various data inputs and ultimately drives interventions based on the CCC/IWA population stratification design and focus.

Outcome
Implementing the Priority Patient list in the Members application provides practices in risk arrangements and easy and centralized access to a focused target list regardless of clinical user and situation. The Priority Patient implementation saves CCC/IWA's team the manual effort and time of doing this by payor, line of business, and practice each month, allowing the staff to focus on what they do best - empower practices to grow and succeed. We are looking to revisit later in 2023 to evaluate the success of performance against benchmarks across all categories.

Background
Shores Quality Partners (SQP) is a Clinically Integrated Network that serves approximately 40,000 attributed patients in New Jersey, spanning Medicare, Medicaid, and commercial populations. SQP is committed to creating access to high-quality healthcare services while striving to ensure that its diverse and large population gets access to timely and much-needed care.

Problem
Network leakage has become a serious issue for SQP. With growing healthcare conglomerates in the geographic service area, it has become imminent that SQP keeps patient care in-house and identifies ways to serve its patient population better. One way they can do this is by adding specialists to their service network. Without the ability to track patient movement and cost, SQP cannot find the correct patterns and course to provide network coverage or identify when adding more providers is not advantageous. Alternatively, SQP is unaware of when it's best to simply work with others to negotiate pricing on referred patients.

Solution
The Garage was tasked with using all available data to analyze leakage from SQP claims data against their roster network. Because of the comprehensive data sets we receive, the Bridge platform was able to aggregate, normalize, review, and identify all movement in and out of SQPs network. Combined with cost and diagnosis data, this has allowed the SQP team to see where they can make the most significant impact in supporting their network and identify room for improvement.

Outcome
With a full breakdown of where patients are going in and out of the network, SQP has been empowered to easily analyze network utilization and referral patterns. This has helped identify where the biggest area of opportunities exists to control leakage and close the gap in needed services in the network. Ultimately, practices can be equipped with transparency to where members are receiving specific care and take necessary action to help lower overall costs and increase quality scores.

Background
Honest Medical Group is a Nashville-based privately-owned organization that partners with leading physician groups to transform the standard of care and care delivery for its populations. By partnering with provider groups, Honest provides financial backing, administrative staff, clinical support teams, and infrastructure processes, so physicians can truly put their patients first. As an Independent Practice Association, Medicare Advantage Organization, and Value-Based Care entity, Honest aims to advance the provider and patient experience, improve care, and reduce healthcare costs for Medicare populations.

Situation
With Honest Medical Group's growth and expansion through joint ventures with various physician groups, there was a demand for a population health platform partner who is data-driven and data-smart while innovative in digital strategy solutions for all aspects of population health management. Honest has multiple business lines and units to head each business line's functions. The units are tasked with implementing workflows for operations and tracking KPIs to meet business goals. It is critical for Honest to be able to manage specific requirements for various Value-Based Care (VBC) populations and Medicare Advantage Special Need Plans (SNPs), as well as streamline clinical support staff workflows. Honest needed a fit-all-needs population health platform partner to provide agnostic business and operation solutions.

Solution
Honest Medical Group partnered with The Garage in late 2022 to carry out its population health operation and business goals. Since kick-off, the Garage teams have been moving quickly in building a foundation for success with Honest's key stakeholders and teams. The Garage is committed to providing Honest with a tailored population health platform to support Honest's goals of achieving high-quality, coordinated care services and reducing healthcare costs. The Garage implemented the following tools and project management strategies to support high-paced expectations:

• The Garage uses Asana to organize requirements, track enhancement requests, and plan deliverables, providing the Honest team access and visibility to prioritize necessary items for operation and business objectives.
• The Garage Customer Success team communicates real-time openly and directly with Honest's teams and critical stakeholders via direct communication paths, bridging the physical divide and allowing for better collaboration.
• A collaborative User Acceptance Testing process has been implemented, allowing end-users to ask questions and receive instant feedback for their testing activities. This empowers users to become familiarized with functions and how the platform works as we roll out for production.

Outcome
In the partnership with Honest, The Garage's Customer Success team is an excellent indirect asset along with Honest's internal teams. Working in tandem, the Garage crew prioritizes deep dives into understanding what Honest teams want and expect from a population health platform to help reach operational and clinical goals. Building collaborative business workflows that can produce measurable outcomes while creating better experiences for providers and patients continues to be a critical component of our partnership. This experience has set a foundation for our future in tackling the needs of Honest's network.

Situation
Valley Health Alliance (VHA) is a group of large, self-insured employers spanning the Colorado region. Under the Community Care Alliance (CCA) umbrella, VHA employers are able to work with doctors and administrators with regional hospitals and primary care provider networks to craft healthcare goals that could both improve employee's healthcare outcomes and lower costs. To effectively build and manage the VHA program, CCA needed a cost-effective way to run quarterly attribution based of a custom logic algorithm for assigning patients to each of the six separate employers and take those patients through a risk stratification model to assess shared savings and distribute funds flow. CCA also needed the quarterly risk scores to be easily available to the program's participating providers.

Problem
CCA was using an actuarial firm to run the quarterly attribution and calculate patient risk scores. Although the firm did a great job, it was a very costly approach and the format of the report they sent was cumbersome to understand and distribute. It required manual administrative effort on the CCA staff to clean, package, and send out the data on a quarterly basis, which was time consuming and stressful.

Solution
Garage took the VHA Program's attribution logic and the preferred HCC Risk Stratification model to build these capabilities into CCA's Bridge data set up system. After vetting Garage output against the actuarial firm to review quality of logic implementation, the outcomes passed with flying colors giving CCA the opportunity to end their relationship with the actuary and rely on Garage for this critical business need. Garage runs the VHA Program's attribution and risk scoring on a quarterly basis for CCA leadership.

Outcome
CCA uses the report Garage produces to populate patient risk lists and summary reports for the involved employers and participating practices. The file produced by Garage has cut down CCA's internal report generation time from 11 hours to 2 hours. Soon the information will be built entirely in Garage and CCA's internal report generation time will drop to approximately 30 minutes. Participating Providers will also have 24/7 access to their attributed patient's risk scores.

Background
The Community Care Collaborative of Pennsylvania and New Jersey LLC (CCC) is an Accountable Care Organization (ACO) formed by Doylestown Health, Holy Redeemer Health System and their associated clinically integrated networks: Doylestown Healthcare Partnership (DHP) and Innovative Wellness Alliance (IWA). Strategically, CCC and IWA drive a common mission to empower practices and providers to collectively improve the health of individuals and populations by ensuring quality, access, and efficiency, using data - driven, patient - centered models of care. CCC serves approximately 30,000 MSSP beneficiaries and IWA serves an additional 54,000 value - based lives across eight payer lines of business (Medicare Advantage and Commercial) and one employee plan.

Situation
On the journey to find a population health platform, CCC presented a major business need of the selected partner to be able to host a data warehouse that will prevent CCC from building everything from scratch. That would include data cleaning, table design, payer mapping, modeling, normalization of data, maintenance. This would alleviate a huge cost and resourcing burden for CCC as doing it in house would require hiring of technical experts and data scientist. Average industry cost of such a data warehouse would by upwards of $100,000 and more. Garage agreed to this need and delivered a data warehouse in Summer of 2020.

Solution
The requirement and business needs of the data warehouse span greatly for CCC. As the data warehouse is connected to CCC's PowerBI system, it is used for monthly dashboarding used at presentations, and ad hoc request for custom and complex analyses. The last few months the data warehouse has been the anchor for CCC to analyze, study, and prepare to apply for and ultimately manage a 340b pricing contract for its Holy Redeemer Network. The data warehouse helps identify members, physicians, and specialists that could benefit from participating in the program and empowers CCC to conduct conversations to achieve success in this opportunity. With 340b pricing, CCC could see almost 35% savings (reduction) in Part B drug cost just their ACO alone! Being able to analyze pharmacy data with such intricacy is required in order to educate physicians on why this is beneficial for them and the organization from a financial revenue standpoint, while maintain clinical integrity and good patient health outcomes.

Outcome
There are numerous ways the data warehouse is used aside from the 340b current scenario. Among these are:

• Provides insights on the attributed lives (especially new and removed members) of each practice/payer combination to negotiate their contracts
• Enables CCC to identify the InSystem Utilization and define achievable targets for their practices
• IWA uses the data warehouse to come up with various pricing models that provide benefits to practices as well as members
• Helps the CCC to perform well in terms of quality and savings

In addition to all data analysis and insight projects, the data warehouse has offered transparency to CCC & IWA on potential data gaps from payers. Critical elements of claims such as NDCs and DRGs allow for informative business analytics, and if they payer misses the delivery of such elements allows Garage and CCC to work in collaboration to study, understand and optimize the data set to achieve the highest degree of data quality as allowed. We all know there is no such thing as perfect data but knowing what is imperfect - is one step forward towards empowering yourself as a business so decisions aren't made on gaps of data access

Background
According to the Agency for Healthcare Research and Quality (AHRQ), nearly 20% of Medicare fee - for - service beneficiaries discharged from the hospitals are readmitted within 30 days. At least 70% of those re-admissions are preventable and add up to a staggering $26 billion in cost per year. Aside from the financial burden on the healthcare system, what is more worrisome is the human cost factor. Frequent admissions and re-admissions pose a tremendous threat to patient safety and their overall health. Transition of Care (TCM) programs can help combat inconsistent care continuity and improve patient outcomes.

Situation
Freedom Healthcare Alliance (FHA), a South Carolina based Accountable Care Organization (ACO), has set a North Star goal to reduce ED utilization and re-admissions to improve their patients'health and reduce the cost burden for CMS. However, the FHA care team needed a way to view admission and discharge information in an organized and efficient manner. The administrative burden of manually logging into portals to pull down alerts, aggregating and recording outreach results in spreadsheets was too frustrating and time consuming.

Solution
Partnering with The Garage, FHA sought to connect with surrounding hospitals' ADT feed to receive real-time admission and discharge notifications in a centralized platform. FHA established a TCM program and a centralized team of nurse care coordinators to follow up with patient's post-discharge via these direct feeds. The Garage's population health platform, Bridge, provides the ability to access a centralized view of patient activities and a TCM workflow that is intuitive and efficient. This is important for the FHA's team as the care coordinators need to reach out to patients within 48 hours and ensure the patients receive the necessary care during their transition out of the hospital.

Outcome
FHA has successfully monitored "high-rate emergency department (ED) utilizers", and reduced ED utilization, admissions, and as a bonus - captured TCM revenue. In 2021, compared to all MSSP ACOs, FHA was able to demonstrate a reduction in emergency department visits by 5% and inpatient hospitalizations by 29%. The result is FHA accomplishing a greater reduction in utilization compared to other all other MSSP ACOs.

Background
Health Care Dynamics International (HCDI) is a healthcare services company headquartered in Maryland that committed to health care quality improvement and transformation. Through their work, HCDI has partnered with providers, payers, and government organizations to provide specialty services that translate policy to practice with a specific focus on Population Health, Social Determinants, Managed Care and Diabetes Center of Excellence. Since 2020, the Garage has been working with HCDI as their platform to empower work in the areas of care gaps, social determinant analytics, and even contact tracing.

Problem
Working with a large payer, HCDI was contracted to evaluate 42,000 members with potentially open care gaps. The work includes engaging the patient through an outreach program to determine if care gaps had been closed in other venues, update records accordingly, and work to close gaps where necessary. Before they began working with the Garage, HCDI had been employing a cumbersome spreadsheet system to manage their care gaps work. The process was not as efficient as it could be, requiring hours of manual tracking each week, and could not effectively report on activity and productivity of the HCDI team

Solution
When HCDI began working with the Garage, it became clear that care gap management was a pain point. The Garage configured its care gaps application, an embedded component of the Bridge population health management platform, to track seven payer-specific measurements for the full panel of 42,000 patients. An attestation workflow specific to the project was configured to ensure a simplified process of tracking closed measures, and a suite of reports was developed to track productivity and enable reporting back to the payer. Catera Davall, Team Lead for this work at HCDI said, "The Garage improved my care gaps workflow by simplifying input and providing a member view that makes it easy to see all the applicable measures in one place. No more toggling between spreadsheets! The new workflow has given me back time to focus on outreach to more members."

Background
Dr. Lokesh Reddy of Lokesh G. Reddy Physician PC is a primary care practitioner in Westchester, NY as a member of Collaborative Health System's (CHS) Hudson ACO. At the end of March 2020, Dr. Reddy was challenged to pivot his practice's care delivery model as the threat of COVID-19 grew exponentially in the state of New York.

Situation
Prior to the COVID-19 pandemic, Dr. Reddy had not delivered care via telemedicine and had focused on seeing patients in person within his office. To ensure that his patients continued to receive the care they needed and to mitigate the financial impact of COVID-19 on his business, he looked to Ignite Lite through his relationship with CHS to assist in pivoting his patient-facing interactions to be based on telemedicine.

Solution
The Garage released Ignite Lite in immediate stand-up and release time in the early onset of the COVID-19 pandemic. Dr. Reddy and his office staff were quick to utilize the tool to make the transition to telemedicine as seamless as possible for his patients and his office staff. The Garage worked closely with Dr. Reddy to introduce additional features he required to be successful in the use and the adoption of Ignite Lite for his patients and himself.

Outcome
With a commitment from the Garage and his office staff, Dr. Reddy was able to quickly pivot his care delivery model in a critical time of need to ensure his patients were taken care of. Moving forward, Dr. Reddy plans to continue the use of telemedicine as a new medium to interact with his patients and Ignite Lite is his choice of tool to grow with in this new healthcare environment.

Addendum Update: As of November 2021, Dr. Lokesh Reddy is no longer with CHS. Garage continues to support all providers in CHS to the extent needed to support the transition to telehealth services.

Background
Chronic Care Management (CCM) is an important factor in value-based payment models such as the ACO (Accountable Care Organization) MSSP model. CCM programs are designed to help providers manage select beneficiaries with two or more chronic/ongoing conditions. These programs allow providers to promote quality across the entire care continuum, prevent gaps in treatment, and maintain the health of patients with chronic conditions. CCM is crucial to improve patient outcomes, increase patient satisfaction, and ultimately help ACOs achieve shared savings.

Situation
Select Physicians Association (SPA), a multi-state ACO with close to 20K attributed Medicare lives, perfectly proves the value of CCM and care coordination. Numbers speak louder than words in this case: In 2021, looking at all-cause Inpatient Admission Per 1,000 Person Years rate, SPA consistently trended lower in each quarter than the average rate of all MSSP ACOs and National Assignable FFS Beneficiaries population. Notably, in Q2, SPA achieved an 11% lower rate than all MSSP ACOs and a 20% lower rate than the National Assignable FFS Beneficiaries population. Going back to even 2020, with the ongoing adoption of Garage's care management tools, SPA was able to generate CMS savings of $10.1 million while achieving a quality score 97.5% quality score.

Solution
Critical to SPA's successful CCM program is using an advanced population health technology that can effectively parse and aggregate immense amounts of clinical data, identify eligible patients, and offer the necessary tools for providers to close the gaps in care. Most commercial EMRs do not have the technology or sophistication required for supporting CCM at scale.

Garage's population health platform, Bridge, automatically identifies patients with chronic conditions across the population. Providers can then use the Ignite app, which is included in Bridge, to enroll eligible patients, perform telehealth services, and bill for CCM. Ignite is a one-stop-shop application that allows providers to interact with patients, document medications, create care plans specific to each patient, and generate billing reports with accurate CPT codes based on time spent with the patient for reimbursement.

Outcome
SPA ACO provides its participating practices with Garage's Bridge platform, enabling them to provide quality care at a lower cost for patients with complex needs. Mary Alfieri, Care Coordinator at SPA's participant practice, states: "I truly believe that CCM has made a difference in the health of our patients that are enrolled in the program. Regular patient interaction is beneficial on many levels. Patients have a point of contact in the office that they know is aware of their medical needs as well as their medical history. When I call, the patients go right into their updates whether they have anxiety issues, depression issues, fluctuations in their blood pressure and I can help them resolve the issue whether that is to bring them in for an appointment, speak with their provider, refill medications, whatever the need. Just today I was on a call reconciling a patient's medications when I realized that they had a new medication. Not only was I able to add that to the list, ensure that there were no interactions with their current medications, but I also found out that the specialist that prescribed the medication was not on the list of specialists in the chart. I was able to send a request for records and then send them over to the primary care provider so that they were aware of the changes in the patient's health plan." The CCM services described by Mary are crucial elements of primary care that drive better patient outcomes, increase patient satisfaction, and decrease overall health care costs.

Background:
Shore Quality Partners (SQP) is an Accountable Care Organizations and a Clinically Integrated Network (CIN) made up of independent, contracted, and employed physicians together with Shore Medical Center serving a population of 45,000 in New Jersey. Shore Quality Partners allows community physicians to remain independent while forming a cooperative model that responds to local and national healthcare reform and competitive pressures. SQP is designed to help its participants improve patient care through quality and cost improvements, such as supporting its members in MSSP GPRO Quality reporting to ensures its members are successful.

Problem:
As an ACO, SQP needed a data aggregation and entry tool to meet the demand of CMS Quality Reporting. In December 2021, just a month away from kick off ACO Quality Reporting season, SQP wanted to leave from their current vendor and start with The Garage but needed to make sure we could have a reporting tool up and running in time. On December 8th, 2021, SQP met with Garage to review this critical need and identify if it would be feasible to configure a platform in a timely manner with no barrier in quality and function.

Solution:
With Garage's focus on SQPs situation, we were able to fully build, quality control, and release a Care Gaps application with full QPP reporting workflow questions and required outputs, alongside a loaded ranking file, within 6 weeks. This gave the SQP team a full ACO Quality Reporting attestation tool allowing them to start and finish reporting in the time needed.

Outcome:
With a later start in the year than other ACO's, SQP team of just two end users were able to finish reporting within record time. SQP preliminary results register 3-4% higher in scores compared to the previous reporting year.

Situation:
Brownville Family Health & Wellness Center (BMS) is a Multi-Service Family Center of 48 years that has advocated and served the community of Brooklyn, NY. As an FQHC, ACO participant, and PCMH, BMS holds demanding compliance and processes to succeed in population health management.

A major core of BMS is their Health Home agency status. Without the right providers and services, it is hard for people to get well and stay healthy. New York State's Health Home program was created with these people in mind. The goal of the Health Home program is to make sure its members get the care and services needed. This may mean fewer trips to the emergency room or, less time spent in the hospital. It could mean getting regular care and services from doctors and providers. Or, finding a safe place to live, and a way to get to medical appointments.

Problem:
To quality for Health Home, one must have two or more chronic conditions, or one serious and persistent mental health condition. BMS's Athena EMR does not integrate claims data, creating a gap of knowledge on a larger patient cohort that could be suffering from multiple chronic condition by diagnosis from external to BMS specialists and providers, or even the emergency room. BMS needs a way to know who these patients are and outreach to screen, determine the benefit, and register them into BMS's Health Home program.

Solution:
Bridge's "Chronic Care" Frequently Accessed Report found in Insights aggregates all claims data to determine patients with two or more chronic conditions. Because some of these patients might not exist in BMS's EMR due to either being new patients or lack of previous engagement, BMS staff can access phone number and address details to support that outreach. The dates, locations, and details of the chronic condition diagnosis are listed to give BMS staff transparency, allowing an outreach attempt to obtain records and have better context when engaging with the patient.

Outcome:
The Chronic Care report provided BMS 192 patients who were eligible for health home. Upon review of every patient against state Health Home enrollment it was determined that many were not engaged, allowing the BMS team to attempt outreach, education, and process to enroll the patient. Long term implications of such success allow BMS to lower cost of this patient cohort, manage the patient's quality of life from disease management to medication support, and ultimately achieve positive health outcomes.

Background:
Valley Health Alliance (VHA) is a group of large, self-insured employers spanning the Colorado region. Under the Community Care Alliance (CCA) umbrella, VHA employers are able to work with doctors and administrators with regional hospitals and primary care provider networks to craft healthcare goals that could both improve employee's healthcare outcomes and lower costs. To effectively build and manage the VHA program, CCA needed a cost-effective way to run quarterly attribution based of a custom logic algorithm for assigning patients to each of the six separate employers and take those patients through a risk stratification model to assess shared savings and distribute funds flow. CCA also needed the quarterly risk scores to be easily available to the program's participating providers.

Situation:
CCA was using an actuarial firm to run the quarterly attribution and calculate patient risk scores. Although the firm did a great job, it was a very costly approach and the format of the report they sent was cumbersome to understand and distribute. It required manual administrative effort on the CCA staff to clean, package, and send out the data on a quarterly basis, which was time consuming and stressful.

Solution:
Garage took the VHA Program's attribution logic and the preferred HCC Risk Stratification model to build these capabilities into CCA's Bridge data set up system. After vetting Garage output against the actuarial firm to review quality of logic implementation, the outcomes passed with flying colors giving CCA the opportunity to end their relationship with the actuary and rely on Garage for this critical business need. Garage runs the VHA Program's attribution and risk scoring on a quarterly basis for CCA leadership.

Outcome:
CCA uses the report Garage produces to populate patient risk lists and summary reports for the involved employers and participating practices. The file produced by Garage has cut down CCA's internal report generation time from 11 hours to 2 hours. Soon the information will be built entirely in Garage and CCA's internal report generation time will drop to approximately 30 minutes. Participating Providers will also have 24/7 access to their attributed patient's risk scores.

Background
According to the Agency for Healthcare Research and Quality (AHRQ), nearly 20% of Medicare fee-for-service beneficiaries discharged from the hospitals are readmitted within 30 days. At least 70% of those re-admissions are preventable and add up to a staggering $26 billion in cost per year. Aside from the financial burden on the healthcare system, what is more worrisome is the human cost factor. Frequent admissions and re-admissions pose a tremendous threat to patient safety and their overall health. Transition of Care (TCM) programs can help combat inconsistent care continuity and improve patient outcomes.

Situation
Freedom Healthcare Alliance (FHA), a South Carolina based Accountable Care Organization (ACO), has set a North Star goal to reduce ED utilization and re-admissions to improve their patients' health and reduce the cost burden for CMS. However, the FHA care team needed a way to view admission and discharge information in an organized and efficient manner. The administrative burden of manually logging into portals to pull down alerts, aggregating and recording outreach results in spreadsheets was too frustrating and time consuming.

Solution
Partnering with The Garage, FHA sought to connect with surrounding hospitals' ADT feed to receive real-time admission and discharge notifications in a centralized platform. FHA established a TCM program and a centralized team of nurse care coordinators to follow up with patient's post-discharge via these direct feeds. The Garage's population health platform, Bridge, provides the ability to access a centralized view of patient activities and a TCM workflow that is intuitive and efficient. This is important for the FHA's team as the care coordinators need to reach out to patients within 48 hours and ensure the patients receive the necessary care during their transition out of the hospital.

Outcome
FHA has successfully monitored "high-rate emergency department (ED) utilizers", and reduced ED utilization, admissions, and as a bonus - captured TCM revenue. In 2021, compared to all MSSP ACOs, FHA was able to demonstrate a reduction in emergency department visits by 5% and inpatient hospitalizations by 29%. The result is FHA accomplishing a greater reduction in utilization compared to other all other MSSP ACOs.

Background
Finger Lakes Independent Provider Association (FLIPA) is a network of 18 member organizations across a 23-county area of upstate region of New York State, often in under resourced communities. FLIPA is comprised of eleven community health centers including Federally Qualified Health Centers (FQHC) and FQHC Look-Alikes, six behavioral health organizations, and one rural health network. FLIPA is the first IPA in New York State that brings together primary care, behavioral health, and social determinants of health services as part of a holistic approach to improving community wellness. Engagement is key to improving wellness for individuals in FLIPA's network. By scheduling annual visits with patients, complications and risk factors can be identified before becoming greater problems. FLIPA providers serve a largely Medicaid-enrolled patient population with high rates of social determinants of health barriers. Many of these barriers, including homelessness and housing insecurity, poverty, low health literacy, limited access to the internet, and having a primary language other than English are well-known barriers to engaging in annual visits and other preventive health care. However, these barriers also pose challenges to typical health center-to-patient communication that can support engagement such as email, online health portals, or sending reminders in the mail. Anthony L. Jordan Health Center (Jordan Health), one of FLIPA's FQHCs, was tasked with engaging individuals who had not utilized any Medicaid services in over 12 months; one of FLIPA's Population Health goals that is also tied to an incentive payment.

Situation
At the beginning of 2021, nearly 18% of patients in FLIPA's network were considered part of this cohort of patients who had not received any Medicaid service in over 12 months. FLIPA recognizes that, over the long term, engaged patients typically have better outcomes at a lower cost. However, continually sending letters and making calls that are not successful at engaging patients is an overwhelming task for health center administrative staff with limited resources. Also, as our world has shifted to one where texts are a more convenient way for patients to engage, Jordan Health was looking for a tool to optimize and streamline engagement efforts to make better use of staff time and be more successful at reaching patients.

Solution
FLIPA added The Garage's Communicator tool to its Bridge Population Health Management platform and implemented it at Jordan Health. Supported by FLIPA, Jordan Health staff were able to accurately identify a cohort of patients who had not received Medicaid services in over 12 months, and seamlessly deploy Communicator to reach out to that group. Patients were efficiently sent text messages to remind them of scheduling and attending upcoming appointments. Staff were able to send texts via the Communicator in large batches and communicate with patients in real time, greatly reducing administrative time. Nearly every patient owned or had access to a cell phone with text functionality, so this simple outreach made a big difference in connecting with patients in a way that maximized convenience, access, and efficiency.

Outcome
Supported by FLIPA data analytics, partnership with payers, and the Communicator tool, the Jordan Health team was able to drive down their rate of patients who had not received services in over 12 months from 25.35% (January 2021) to 16.01% (December 2021). By efficiently connecting with patients in a way that is accessible and convenient, Jordan Health is able to engage individuals in their own wellness and to focus on what matters most: providing more members of its community with affordable and accessible care.

Background
Tyler Downing joined Western Health Alliance (WHA) in 2017 as the Director of Data Innovation. Through 2019, WHA included Colorado's San Juan ACO, and Rocky Mountain ACO known as Community Care Collaborative (CCA). The macro-objective Tyler set out to accomplish was to bring the ACOs to financial success with capturing shared savings dollars while succeeding in clinical outcomes for Colorado's rural population. Western Health Alliance's Board of Directors needed ongoing and concise performance reporting from CCA's leadership.

Situation
To accomplish a collaborative and effective ACO performance tracking, CCA needed a platform tool capable of aggregating, unifying, and modeling data to create dashboards. eClinical Works was chosen as CCA's population health tool and was pushed out across the network. It resulted in failing to deliver the needs of CCA with no support to their specific needs and ongoing issues with the dashboards. Tyler's first task was to create an RFP for a population health platform that could deliver the quality of data aggregation and effective dashboarding, while maintaining CCA's needed level of customer service engagement.

Solution
The Garage was selected with the opportunity to allow CCA to meet their objectives and goals. The release was focused on Bridge's Insights tool. Insights is a snapshot of an organizations population health metrics based on payer data with KPI, utilization, and membership management reporting. At a high level, a user is able to view summary analytics, get down to the practice and physician level, compare performance between entities, and isolate patient lists with claim level details tied to the metric being reviewed. Ability to view and study cost drivers and trends allows CCA to review opportunities for improvement. The Insights dashboard can be adjusted to view data sets across selected timeframes and payers, allowing Tyler to dynamically respond to WHA's Board requests. Tyler used the KPI report as his #1 choice to put together practice comparison-based performance reviews.

Outcome
The ease of KPI report design and ability to be exported, combined with a little pivot and visualizations allowed Tyler to successfully build executive dashboards. Insights became Tyler's primary and only way of informing the board in ACO performance, saving time from manual data normalization, aggregation, and construction.

Tyler would like to add:

The second major problem was GPRO reporting for the ACO. Marguerite was doing all preparation work manually on spreadsheets: taking CMS requirements and ranking lists, building individual spreadsheets per location, writing out instructions and plan for competition. It was a "nightmare" for time and resourcing. Garage's easy to use attestation tool, configured and guided by CMS requirements, has greatly supported CCA's effort to complete GPRO in peace.

Addendum/Update: Tyler Downing is no longer with CCA at the time of this publication.

Background
SOMOS is a physician-led network of 2,500 health care providers who serve more than 500,000 Medicaid beneficiaries in immigrant communities in New York. At the onset of the COVID-19 Pandemic, SOMOS was awarded by the Governor of New York State a delegate responsibility to implement and oversee COVID-19 Testing, and later when became available COVID-19 Vaccination Sites. SOMOS spread across boroughs on the front lines of churches, community centers, New York City Housing Authority (NYCHA) low-income housing centers, the MTA, and pop-up sites. The responsibility to mass manage and distribute the vaccines came in the most immediate sense as New York was the epicenter for highest COVID rates and hospitalizations.

Situation
Thus, came the need to communicate with the New York population in a quick, compliant, and effective manner. Since SOMOS was serving the general public, the population under management was in the hundreds of thousands. Due to the array of sites, uncontrollable circumstances such as winter blizzards, and a large population that needs administrative oversight, SOMOS had reached a barrier in effective mass communication. Turning to EMRs for support in COVID vaccine and testing appointment related reminders and cancellations was a barrier as EMRs required the patient record to exist, the communication be tied to an encounter, had limited templates, and sometimes a cost associated with the texting functions. Other communication platforms failed to meet SOMOS' needs as all refused to sign a BAA with SOMOS to protect SOMOS's data as a partner. Any other solution found was to not be cost effective for implementation. The SOMOS Call Center was unable to use telephonic methods to reach its population for COVID-19 related matters based on sheer volume. A need for a tool that is compliant, scalable, can outreach mass populations, and uses a popularly accepted by general population method of communication – texting - gave opportunity for Garage to support this population health initiative.

Solution
BlazeCare Communicator was stood up in under a week to meet these urgent needs. The Communicator has allowed the SOMOS Call Center representatives and leadership to reach out to thousands of patients at the same time via text. The ability to provide immediate information, without the dependency of e-mail, phone calls/voicemail, at the hands of a simple text message, has guaranteed a higher chance of patient response and awareness. The tool allows for any patient lists to be loaded, customizable text, and tracking of campaign success metrics.

Outcome
Due to severity of Winter Storm Orlena in January 2021, SOMOS was able to last-minute cancel more than 1500 vaccine appointments in a matter of minutes using the Communicator tool. This has prevented confusion for the public whether someone should stay at home during the storm or make the trip for something as critical as this vaccine. In another instance, a set of appointments were cancelled at a NYCHA site due to logistical issues with vaccines. As vaccine efforts continue, the demands from government partners of tracking vaccine appointments have become greater. The NY Governor and his staff are always looking at SOMOS to provide more information to understand if appointments are being honored and tracking systems are in place. The Communicator has allowed SOMOS to feel relief in this compliance requirement in a scalable way. SOMOS continues to use it to today with engaging non-users and follow-ups post COVID.

Background
Tampa Bay Health Alliance (TBHA) is a Clinically Integrated Network of five leading and independent medical groups spread across Florida. With more than 1,300 primary and specialty care physicians and health care practitioners, TBHA is in the advantage and position of meeting the challenges of a health care industry transitioning from today's expensive fee-for-service system to a value-based model of care, emphasizing better health outcomes at lower overall costs.

Situation
In 2017, TBHA entrusted The Garage with managing a significant part of their lives under Cigna and Aetna contracts. The obstacle Bridge set out to solve was to unify the care coordination teams that belonged to different subgroups with unique and different workflows. Additionally, the care coordination teams expressed the need to have a one-stop centralized application where they could perform all their care coordination activities instead of toggling between multiple applications and siloed patient information.

Solution
Bridge's multiple applications tied to Care Management activities was deployed bringing in multiple data sources across various health plans and practices into a collaborative singular care management system. The primary solution was focused on a custom design through the BlazeBoard application that aggregated ADT, care gap, and care management data for care coordination teams. Actions can be taken to close care gaps, manage ADT/ENS discharges, create care plans and a whole realm of other care coordination activities.

Outcome
Bridge was able to meet TBHA's requirements around care management and reporting on quality metrics. Deborah, Dorothy, and the rest of the case management team utilized BlazeBoard to streamline their daily workflows and interactions. This application allowed every user to daily access and see open care gap opportunities, ADT alerts to conduct Transitional Care Management, create care plans and progress notes - all from the same interface. Any action chosen in BlazeBoard opens a pop-up within the same interface with TBHA's custom workflow, allowing the user to perform the desired function with the "minimum clicks possible". The collaborative approach allowed for clear productivity and impact of outreach reporting.

Background
The Community Care Collaborative of Pennsylvania and New Jersey LLC is an Accountable Care Organization (ACO) formed by Doylestown Health, Holy Redeemer Health System, and their associated clinically integrated networks: Doylestown Healthcare Partnership (DHP) and Innovative Wellness Alliance (IWA) which is contracted with eight unique value-based-care contracts across commercial and Medicare Advantage lines of business. DHP and IWA is brought together by a common mission to be a collaborative group of clinically integrated healthcare providers focused on quality and efficiency in partnership with their communities, to collectively improve the health of individuals and populations by ensuring quality, access, and efficiency, using data-driven & patient-centered models of care.

Situation
Joe Taylor, Executive Director of Community Care Collaborative of PA & NJ & Senior Vice President of Redeemer Health is held responsible to achieve various North Star goals such as ongoing revenue/financial performance improvement year over year, maximize quality score to as close to 100% as possible, and hit coding revalidation at 90% or more. To achieve such high metrics, DHP & IWA must be unified in this common goal and understand everyone's roles and responsibilities. There are various engaging techniques DHP & IWA uses to succeed in this collaboration.

1. Leadership of IWA hosts quarterly meetings with the clinically integrated network where they spotlight physicians and practices that are succeeding in expected benchmarks. This breeds a sense of competitive eagerness that energetically forces poor performers to engage, ask questions, and work towards hitting those goals.
2. IWA really focuses on a "Success Breeds Success" mentality. Instead of using an indictment approach to poor performance, DHP/IWA focuses on what is being done right and sharing that knowledge with the network, allowing it to foster progress.
3. IWA maintains the importance of having a core internal team of population health specialists as a conduit between the organization and practices. Currently two staff members are responsible for monthly check-ins at all practices, lead engagement, provider education, and support the adoption of Bridge Population Health tools.
4. Garage leads bi-monthly workshops and office hours that allows for an open forum to address operational stories or best practices, lessons learned, ask hard data or policy questions. This forces peer to peer conversations that perpetuate growth.

Solution
All the above breeds a culture of responsibility on the servicing providers and their practices and aligns the network to truly agree with the Mission Philosophy of DHP/IWA. That culture and knowledge allows them to accept and adopt tools necessary for growth such as the Bridge Platform positively, with enthusiasm and interest to perform. DHP/ IWA's mission culture wants to allow doctors and servicing providers to be the best they can be, knowing there does exist the repercussion of getting kicked out if one does not participate in the holistic mission, while in parallel carefully vetting who is added into the organization.

From a Bridge impact standpoint, DHP/IWA takes a methodological and slower approach for successful adoption by training one module and initiative at a time with continued reinforcement over a few months. This allows everyone a chance to truly have the time and support to get into a tool. Often, this has been "eye opening", such as the TCM application which allows practices to know about hospitalizations they did not know about otherwise, or DeRisk which has allowed suspect conditions transparency to practices.

Outcome
In closing, Joe Taylor explains that because there is a financial reward and bonuses tied to good performance, it perpetuates desire for participation and inquiring on "how can I get better". When DHP/IWA can show comparisons between practice performance and the financial impact in a transparent way, it forces a practice to care. DHP/IWA does not hide away complex issues or situations knowing the reward is greater opportunities to learn and improve. Physicians can argue all they can, but at the end of the day, they do not get the bonus and "if you are last you are last".

Background
Middletown Medical is a multi-specialty physicians' group serving over 12,000 lives in Orange County, NY. As Middletown takes on more risk contracts across Medicare and Medicaid lives, there is a need to optimize diagnostics to clinically capture appropriate population data and achieve shared savings dollars in risk arrangements. Darcy Shephard, CEO of Middletown, was responsible for guiding Middletown physicians to achieve this performance requirement and consistently monitor, document, and present physician performance to executive leadership.

Situation
Middletown required a way to easily identify coding opportunities, especially those that are captured and billed for outside of Middletown. That lack of transparency, driven by patient behavior identified by claims data, is a key element. Middletown's EMR does not incorporate payer data across multiple contracts and has a dashboard that is cumbersome to work with. Layering in a very busy provider schedule where up to 60 patients are seen by a provider per day, there is no room for any obstruction to a physician's workflow and schedule to find, read, evaluate, and aggregate these coding opportunities. This existing need has created gaps in potential revenue, and overall improving the quality of healthcare provided to their patients.

Solution
The Bridge platform incorporated the Coding Opportunities section into a custom Container. It identifies all outstanding opportunities that have been found in the previous years that are not recorded this year, and all suspect opportunities driven by claims data where patients are getting diagnosed weighted conditions outside of their primary care providers office. The container is connected to Middletown's scheduler and runs a full day's schedule through these opportunities. The providers busy schedules of up 60 patients a day are supported by scribes and MA's daily who use the container to conduct chart prep, or real time during the encounter reconcile the missing coding changes.

Outcome
The rollout and consistent push for adoption with provider education on the criticality of this has allowed Middletown Leadership to work alongside physicians to increase performance ratings as well as deliver increasingly better healthcare for patients. With every year, there has been ongoing performance improvement, with the strongest growth in Performance Year 2021.

Background
Select Physician Associates (SPA) is a Basic Level E track managing about 8000 lives as of 2020. In addition, SPAs governing body - Physician Partners - founded a new ACO named 5 Star ACO in 2020 with a shift in patient lives from SPA to 5 Star as well as recruitment of new practices into this ACO.

Hierarchical Condition Categories (HCCs) became a pathway to success in the transition to value-based care components of ACO's in 2019. One of the things that changed for ACO businesses is HCCs took a whole level of additional importance in performance, as ACO's now had a chance and ability to gain up to a 3% margin on the benchmark.

Situation
The challenge SPA encountered, happened to be one of the biggest challenges all ACO's were facing to succeed in this new trajectory. There is no centralized system in U.S. for patient claims, therefore primary care providers have no visibility into who, when, and where these HCCs are being coded as many are coming from what other specialists, hospitalist and nursing homes are coding. It became pertinent to give physicians access to transparent data at point-of-care on what has been done for a patient in the past and by whom, in order to empower the physicians to access, reconcile, and if appropriate revalidate the diagnosis. In addition, this information must be provided in an effective and easy to access way as physicians are already burdened with heavy workloads and administrative responsibilities. SPA was looking for an application that helps them understand their risk coding from a managerial as well as a provider's perspective to make accurate clinical and business decisions based on the HCC coding data that CMS provides them with.

Solution
Bridge's DeRisk application was stood up for SPA using 3 years of CMS claims history and reconciled against the CMS-HCCs crosswalk. All claims were consolidated in a clear and concise fashion in an easy-to-use interface. In the application as it sits, SPA users are enabled to have a view of all their patients' currently and outstanding codes to give them a complete picture of where as a physician or practice stands as regards to re-documentation for a patient. At the patient detail level, the tool was outlined in a way to separate out what was originally coded by the primary care provider and has not been revalidated, versus, what was initially coded outside of the primary care's awareness by specialists. Providers then use this data to improvise on patient documentation while the patient is in the encounter simultaneously while working in the EMR. At an administrative level, Arvind Chikile - VP of Quality and Risk Management - can get a picture of the interventions needed at provider offices to seek potential areas of improvements in documenting risk.

Outcome
Providers were given access and trained on using DeRisk daily during patient visits. This has empowered physicians to a level of visibility that is comprehensive to the EMR with an opportunity for provider education and training centered around this app. The outcome of DeRisk adoption led to SPA's re-validation rates going up by close to 30% in 2020 performance compared to previous years. Ultimately when SPA receives the 2020 final performance review later this summer, benchmarks are expected to improve we well.

Background
Middletown Medical is a multi-specialty physicians' group serving over 12,000 lives in Orange County, NY. As Middletown takes on more risk contracts across Medicare and Medicaid lives, there is a need to optimize diagnostics to clinically capture appropriate population data and achieve shared savings dollars in risk arrangements. Darcy Shephard, CEO of Middletown, was responsible for guiding Middletown physicians to achieve this performance requirement and consistently monitor, document, and present physician performance to executive leadership.

Situation
Middletown required a way to easily identify coding opportunities, especially those that are captured and billed for outside of Middletown. That lack of transparency, driven by patient behavior identified by claims data, is a key element. Middletown's EMR does not incorporate payer data across multiple contracts and has a dashboard that is cumbersome to work with. Layering in a very busy provider schedule where up to 60 patients are seen by a provider per day, there is no room for any obstruction to a physician's workflow and schedule to find, read, evaluate, and aggregate these coding opportunities. This existing need has created gaps in potential revenue, and overall improving the quality of healthcare provided to their patients.

Solution
The Bridge platform incorporated the Coding Opportunities section into a custom Container. It identifies all outstanding opportunities that have been found in the previous years that are not recorded this year, and all suspect opportunities driven by claims data where patients are getting diagnosed weighted conditions outside of their primary care providers office. The container is connected to Middletown's scheduler and runs a full day's schedule through these opportunities. The providers busy schedules of up 60 patients a day are supported by scribes and MA's daily who use the container to conduct chart prep, or real time during the encounter reconcile the missing coding changes.

Outcome
The rollout and consistent push for adoption with provider education on the criticality of this has allowed Middletown Leadership to work alongside physicians to increase performance ratings as well as deliver increasingly better healthcare for patients. With every year, there has been ongoing performance improvement, with the strongest growth in Performance Year 2021.

Background
HealthCare Dynamics International (HCDI) is a healthcare services company headquartered in Maryland that committed to health care quality improvement and transformation. Through their work, HCDI has partnered with providers, payers, and government organizations to provide specialty services that translate policy to practice with a specific focus on Population Health, Social Determinants, Managed Care and Diabetes Center of Excellence. Since 2020, the Garage has been working with HCDI as their platform to empower work in the areas of care gaps, social determinant analytics, and even contact tracing.

Situation
Working with a large payer, HCDI was contracted to evaluate 42,000 members with potentially open care gaps. The work includes engaging the patient through an outreach program to determine if care gaps had been closed in other venues, update records accordingly, and work to close gaps where necessary. Before they began working with the Garage, HCDI had been employing a cumbersome spreadsheet system to manage their care gaps work. The process was not as efficient as it could be, requiring hours of manual tracking each week, and could not effectively report on activity and productivity of the HCDI team.

Solution
When HCDI began working with the Garage, it became clear that care gap management was a pain point. The Garage configured its care gaps application, an embedded component of the Bridge population health management platform, to track seven payer-specific measurements for the full panel of 42,000 patients. An attestation workflow specific to the project was configured to ensure a simplified process of tracking closed measures, and a suite of reports was developed to track productivity and enable reporting back to the payer.

About
SOMOS is an IPA, MSO, and ACO that was founded and is owned by more than 2500 NYC community physicians that is serving government programs population of over 1 million patients. SOMOS is comprised of multiple payer contracts in various risk models with delegated administration. With a mission to serve independent community doctors with the support necessary to drive high quality, patient center-center care in NYC's most valuable communities, comes the dependency for proactive - not reactive - population health innovations and technological solutions.

Situation
SOMOS Innovator Program was designed by the New York State Department of Health to support provider organizations committed to charting the path into the highest level of value-based payments for the Medicaid population. SOMOS has been approved by the NYSDOH as a VBP Innovator and as part of successful execution and operationalization of Innovator contracts is responsible for implementing SDOH programs for approximately 80,000 lives. As stated in the New York State VBP Roadmap, all Level 2 and 3 VBP contractors are required to show a commitment to addressing Social Determinants of Health (SDH) and working with Community Based Organizations (CBOs) and, as such, SOMOS is responsible for outlining and delivering proposed intervention(s). To accomplish this, SOMOS has partnered with Regional Aid for Interim Needs, Inc. (R.A.I.N CBO) to tackle food insecurity and housing instability interventions.

Problem
The SOMOS network is obligated to identify members' needs for social determinants of health interventions, track referral outcomes, status of interventions, success rates of closed cases, and ultimately MCO performance impact on all patient that qualified for interventions. The complexity and barrier to accomplishing this is the multiple parties involved lacking a central data aggregate tool. The trigger referral for SDOH interventions come from SOMOS via spreadsheets to R.A.I.N. and there was no effective way for R.A.I.N community healthcare workers to easily report on outcome status. In addition, an aggregate reporting tool was needed to track ED/IP utilization, cost, and patient chronic condition trend over time with clinical and payer data that is standardized and centralized.

Solution
Garage worked closely with SOMOS and R.A.I.N to develop a custom referral intake took and smart form to monitor all referrals and applications using the GRID application. Housing Security and Food Security/Access to Healthy Foods are the two interventions managed by SOMOS, with 9 and 7, respectively, program applications and closures tracked in Garage. Staff from R.A.I.N can mark attempts of outreach and status of submitted applications, to identifying what programs the patient is being enrolled in and closure date of cases. Differentiation on short- and long-term interventions can be monitored well. This allows SOMOS to access this data at any time to understand success of program, performance outcomes with R.A.I.N, and ultimately assess the impact of this SDOH program. Applications tracked through GRID includes: NYCHA Housing, SNAP Food Benefits, WIC Food Benefits, Food Pantry, and FHEPS Applications.

Outcome
Since go-live in July 2021, R.A.I.N. has received 772 referrals in Bridge. Nieve Berrido, the primary community healthcare worker at R.A.I.N overseeing the SOMOS initiatives, uses the tool in Garage as her daily reference point to receive new request, track status of all programs and call interactions, and close cases for SOMOS reporting. Below are the success points thus far:

• 379 for Food - 341 cases closed; 27 deferred; 11 in progress
• 427 for Home - 392 cases closed; 28 deferred; 7 in progress
• 102 Uncategorized Support Requests

Background
Are you having difficulty tracking and increasing AWVs across all the participating practices in your ACO? It has been proven that an effective AWV program is critical to the success of a value-based organization - here's how the Garage worked with Heartland Health ACO, located in Iowa, to implement an effective AWV program strategy that doubled their AWV completion and led to improvement in critical performance metrics across their ACO.

Situation
First, they set tangible completion goals that were achievable based on each practice's historical performance on AWV completion. In the case of Heartland Health ACO, their goal as an overall organization was to ensure each practice completed at least 50% of their patient's AWV's by the end of the calendar year for their attribution in the current reporting year. By reviewing Bridge weekly, they were able to track progress and trigger action if they noticed a practice falling behind their end of the year target goal.

Solution
Then, the Heartland Health ACO team empowered their users with real time information by using the power of the Insights application within Garage to consolidate claims data with clinical data from each practice's EMR. They reviewed the reports monthly with the practices. This has allowed their team to pinpoint what practices are on track and what practices need more assistance. Additionally, their team was able to determine if a practice need assistance with getting participants scheduled for their visits or if they need assistance in documentation or billing those visits appropriately.

Outcome
Data shows that by implementing an effective Annual Wellness Visit (AWV) program, ACOS can meaningfully impact quality metrics, cost (decreased ER/inpatient spending) and risk adjustment (improved HCC coding/RAF scores = better benchmarks)", states Jean Brodowski, President & COO of MedLink Advantage. Implementing an effective AWV program strategy is a key to becoming a successful value-based organization. We have seen the success that Heartland Health ACO experienced by leverage Bridge as a real-time communication and accountability tool for their practices. We are excited to continue this work with their team and expand on additional initiatives to further their overall ACO performance.

Background
Chronic Care Management (CCM) is an important factor in value-based payment models such as the ACO (Accountable Care Organization) MSSP model. CCM programs are designed to help providers manage select beneficiaries with two or more chronic/ongoing conditions. These programs allow providers to promote quality across the entire care continuum, prevent gaps in treatment, and maintain the health of patients with chronic conditions. CCM is crucial to improve patient outcomes, increase patient satisfaction, and ultimately help ACOs achieve shared savings.

Situation
Select Physicians Association (SPA), a multi-state ACO with close to 20K attributed Medicare lives, perfectly proves the value of CCM and care coordination. Numbers speak louder than words in this case: In 2021, looking at all-cause Inpatient Admission Per 1,000 Person Years rate, SPA consistently trended lower in each quarter than the average rate of all MSSP ACOs and National Assignable FFS Beneficiaries population. Notably, in Q2, SPA achieved an 11% lower rate than all MSSP ACOs and a 20% lower rate than the National Assignable FFS Beneficiaries population. Going back to even 2020, with the ongoing adoption of Garage's care management tools, SPA was able to generate CMS savings of $10.1 million while achieving a quality score 97.5% quality score.

Critical to SPA's successful CCM program is using an advanced population health technology that can effectively parse and aggregate immense amounts of clinical data, identify eligible patients, and offer the necessary tools for providers to close the gaps in care. Most commercial EMRs do not have the technology or sophistication required for supporting CCM at scale.

Solution
Garage's population health platform, Bridge, automatically identifies patients with chronic conditions across the population. Providers can then use the Ignite app, which is included in Bridge, to enroll eligible patients, perform telehealth services, and bill for CCM. Ignite is a one-stop-shop application that allows providers to interact with patients, document medications, create care plans specific to each patient, and generate billing reports with accurate CPT codes based on time spent with the patient for reimbursement.

Outcome
SPA ACO provides its participating practices with Garage's Bridge platform, enabling them to provide quality care at a lower cost for patients with complex needs. Mary Alfieri, Care Coordinator at SPA's participant practice, states: "I truly believe that CCM has made a difference in the health of our patients that are enrolled in the program. Regular patient interaction is beneficial on many levels. Patients have a point of contact in the office that they know is aware of their medical needs as well as their medical history. When I call, the patients go right into their updates whether they have anxiety issues, depression issues, fluctuations in their blood pressure and I can help them resolve the issue whether that is to bring them in for an appointment, speak with their provider, refill medications, whatever the need. Just today I was on a call reconciling a patient's medications when I realized that they had a new medication. Not only was I able to add that to the list, ensure that there were no interactions with their current medications, but I also found out that the specialist that prescribed the medication was not on the list of specialists in the chart. I was able to send a request for records and then send them over to the primary care provider so that they were aware of the changes in the patient's health plan." The CCM services described by Mary are crucial elements of primary care that drive better patient outcomes, increase patient satisfaction, and decrease overall health care costs.

Background
Shore Quality Partners (SQP) is an Accountable Care Organizations and a Clinically Integrated Network (CIN) made up of independent, contracted, and employed physicians together with Shore Medical Center serving a population of 45,000 in New Jersey. Shore Quality Partners allows community physicians to remain independent while forming a cooperative model that responds to local and national healthcare reform and competitive pressures. SQP is designed to help its participants improve patient care through quality and cost improvements, such as supporting its members in MSSP GPRO Quality reporting to ensures its members are successful.

Situation
As an ACO, SQP needed a data aggregation and entry tool to meet the demand of CMS Quality Reporting. In December 2021, just a month away from kick off ACO Quality Reporting season, SQP wanted to leave from their current vendor and start with The Garage but needed to make sure we could have a reporting tool up and running in time. On December 8th, 2021, SQP met with Garage to review this critical need and identify if it would be feasible to configure a platform in a timely manner with no barrier in quality and function.

Solution
With Garage's focus on SQPs situation, we were able to fully build, quality control, and release a Care Gaps application with full QPP reporting workflow questions and required outputs, alongside a loaded ranking file, within 6 weeks. This gave the SQP team a full ACO Quality Reporting attestation tool allowing them to start and finish reporting in the time needed.

Outcome
With a later start in the year than other ACO's, SQP team of just two end users were able to finish reporting within record time. SQP preliminary results register 3-4% higher in scores compared to the previous reporting year.

Western Healthcare Alliance's Community Care Alliance (CCA) is an ACO serving the rural health network of Western Colorado. Throughout the last 4 years with The Garage, CCA has transformed and evolved with different CMS ACO Models, and continues to grow in all aspects in serving their provider and patient network using data-first and digital-first driven tools. We look forward to our next chapter together!

Background
Eastern Idaho Care Partners (EICP) is an ACO serving about 9,000 lives in Eastern Idaho. EICP approaches population health management with a unique model that places care managers at each of their 16 organizations within the ACO. The care managers role is to focus on supporting practices in moving forward in organizational priority initiatives that tie to clinical outcomes, reporting success, and revenue optimization. A priority initiative for 2022, and going into 2023, has been a target of closing as many care gaps as possible.

Situation
EICPs ACO members have not previously focused on proactively monitoring care gaps aside from GRPO reporting. As EICP expanded its operational focus on quality being a year-round priority, the need became evident for an effective and efficient technological solution to support mass care gap outreach and closure throughout the year, in addition to tracking staff productivity and performance progress on those care gap closures.

Solution
Bridge's Care Gaps application allows for normalization and unification of EMR and Payer data to provide most up-to-date care gap lists, closure status, and quality scores. This empowers practices to have actionable data at their fingertips for optimized outreach. The first half of 2022 was focused on all-hands-on-deck virtual trainings with mandatory attendance from every practices' care managers, and, office hours sessions allowing Q&A and more open conversation for those that needed additional support or had questions. Since going live, two workflows have become prominent in adoption. First - care gap details are reviewed during AWV scheduling outreach and appointments are maximized to close gaps with AWVs. Second - care managers are reviewing respective practice care gap lists and scrubbing patient charts to identify opportunities to document and close a measure and conducting outreach to schedule the patient prior to end of year. The consolidated application allows EICP to target all open care gaps for the patient at one time, rather than to work on closing gaps by measure category.

Outcome
In the first half of 2022, EICP staff had an average daily care gap closure rate of 6.3 measures per day. Since adoption of Bridge's Care Gaps application and unified workflows, the average completion rate has increased to 9.6 per day. EICP is reporting a positive experience using the application, citing its ease-of-use and simple interface being easy to understand. The Care Gaps application has allowed more visibility now into how the measures are tracked and staff can see real time how they are impacting their performance in the overall build. This data driven approach to quality is opening conversations and questions about how measure rates and performance outcomes are calculated, empowering ownership and subject matter expertise at the boots on the ground level. EICP will continue to empower care managers and practices to become technology driven in achieving quality performance goals for the ACO.

Background
Middletown Medical is a multi-specialty physicians group serving over 100,000 lives in Orange, Sullivan and Ulster Counties in NY. Middletown has 9 value-based-care risk contracts within Medicaid and Medicare line of business. Due to financial responsibilities with such contracts, Middletown requires an analytics infrastructure that can cohesively and accurately present quality, utilization, and performance metrics to Middletown executives. While the goal is to achieve shared savings dollars in risk arrangements, Middletown holds its priority responsibility in guiding Middletown physicians to achieve this high-performance care through our partnership in a Data-First-Digital-First strategy.

Situation
An undisclosed payer which Middletown is contracted with notified the medical group that they would only be offered a fragment of shared savings, as a result of their quality scores captured by the payer. Knowing its physicians have a refined strategy on quality with teams and point-of-care tools to maximize quality performance, Middletown wanted to vet and validate the payers results as valid.

Solution
Darcy Shepard, CEO and her team used Bridge's Insights application and the claims search tool to generate reports by CPT code across all payers, looked at the assigned patients' data and realized the payer's numbers didn't match with Bridge. Ultimately, they found the aggregated data within Bridge showed CPT codes billed under other payers (for patients who had switched plans) that satisfied multi-year quality measures and were able to use this data to supplement what the payer had for their patient population.

Outcome
Middletown gathered evidence through Bridge exports and escalated its argument to the payer. Within a few hours, Middletown was notified that their shared savings earnings increased to $236K based on the improvement to quality scores driven by the supplemental data.

Background
While electronic claims data transmission from provider's offices to payers supports a consolidated view of the individual patient, supplemental data - such as a retinal eye exam or blood pressure - provides additional clinical information about a member for a more comprehensive picture of the care and services delivered. This supplemental data enhances the HEDIS and quality gap closure. The inclusion of mass supplemental data saves time, money and resources, mitigating the need for chasing individual charts, simplifying data attainment and improving the data available for HEDIS reporting and patient analytics. This allows health plans & providers to optimize high-value care & identify care gaps that have been closed, all in order to meet quality targets that is essential to value-based programs.

Situation
SOMOS is the largest provider led IPA in New York with more than 2500 physicians, serving 650,000+ lives across the 5 boroughs. As part of multiple risk VBC arrangements, Optimus Analytics - the data intelligence arm of SOMOS, needed an efficient way to connect to more than 250 individual EMRs, aggregate, normalize, clean, and standardize data to be packaged and sent to Healthfirst, Emblem, Anthem, and United to meet supplement reporting requirements and its' benefits.

Solution
The Garage/SOMOS Genome Data Warehouse gathers CCDAs and Reports from the individual EMRs that span the SOMOS network, automatically refreshes every weekend, and aggregates the data in a uniform way with a Master Patient Index. This empowers Optimus to pull clinical data reports for supplemental reporting to payors and any in-house analytics from the central repository. This saves substantial time and stress, while also preventing the inclusion of inaccurate patient data. Reliance upon Garage has helped ensure success, and avoid a time consuming, costly, and sometimes troubling process of manual data aggregation from hundreds of practices.

Outcome
While the plans have no effective way to vet statistical impact of supplemental reporting due to parallel claims and other supplemental data like HIEs coming in, SOMOS has continued to commit to supplemental reporting as an integral part of business success. By the Garage taking the onus of the direct integrations with each EMR, SOMOS/Optimus was able to eliminate the cost of the direct fees with eCW and repurpose personnel cost equivalent to 4-5 new FTEs to support these integration requirements.

Background
Shore Quality Partners (SQP) is a Clinically Integrated Network in New Jersey. SQP was formed with the mission of allowing area physicians and the medical center to work more closely through a collaborative model to respond to local and national health reform and competitive pressures, while allowing private practices to remain independent, yet clinically integrate to improve care and access key opportunities with payers. SQP is currently composed of a Traditional MSSP ACO (Accountable Care Organization) and two VBP Risk arrangements in Medicaid and Commercial contracts with a total population of 42,000 lives.

SQP is focused on a lean but effective way to manage their provider network and performance outcomes. SQP manages the entire patient population via a centralized support methodology to their network practices. SQPs team works on initiatives such as closing care gaps, high-risk patient oversight, and even GPRO reporting under the ACO. The team of three is composed of: a Director of Population Health and Analytics, one staff member that is a Care Expeditor whose responsibility is to help patients/practices/providers navigate the healthcare system; and second staff member works to close all care gaps while training and monitoring gap closure at a practice level with on-site care coordinators.

Situation
In previous years, SQP attempted practice level adoption with their prior population health vendor and learned that the extra work placed a burden on already short staff practices and did not align with SQPs strategic goal of how to support their constituents. With such a large, attributed patient panel, SQP required a lean, precise, data driven, and easy to use dashboards and tools that can empower them to effectively view macro-and-micro trends and gaps in clinical, financial, and quality performance.

Solution
SQP is heavily adopting Bridge's platform as a core of SQPs data analytics strategy. The Insights application and its Frequently Accessed Reports alongside the Care Gaps Application are primary tools of support to SQP. Specifically, there are a few reports that have become a priority for SQP to continue to manage successful outcomes - including the High-Cost Patients report, Lab Utilization report, and Specialist Comparison report.

• High-Cost Patients report: Since SQP has a staff of 3, it is vital for them to narrow in and focus on patients that are driving cost expenditures the most. Normally these patients need a better handle on care, more frequent PCP visits or simply to be identified as a true high-cost patient due to their illness. Having this report helps SQP focus on the bottom 20%, driving 80% of the cost.
• Lab Utilization report: Having a way to help understand lab traffic within SQPs patient base in a key focus to differentiate which labs are being done because they are not able to be done in-house versus which they cannot but are not being done. This FAR is a way SQP is looking at leakage and patient flow in and out of network. Garage was able to bring in cost details into this FAR with hover over functionality, allowing SQPs team to quickly understand everything in a snapshot right away.
• Specialist Comparison report: Because of SQP size, leakage of professional services has to be a major focal point. This report allows SQP to get a real time snapshot of how spend is happening across all specialty and types. This allows them in real-time to try and change referrals to the low-cost providers that offer equal quality service at a fraction of the cost.

As SQP continues to keep that data first approach to population management, Bridge will continue to support SQPs goal of financially understanding how patients are holistically affecting practice spend.

Outcome
The unified lines of business powered by Insights has allowed SQPs team to use the platform consistently throughout the week to work through various cost, quality and utilization lists by practice. Via this end-to-end automation, SQP is not only achieving process efficiency by eliminating manual errors, but also supporting greater clinical and operational success outcomes for their 8 practices. This has allowed cost savings from the budgeted personal cost of 2 FTEs that can be repurposed.

Situation
Mission Health Partners (MHP) is a Clinically Integrated Network (CIN) that serves approximately 120,000 attributed patients in Western North Carolina, spanning Medicare, Medicaid and commercial populations. MHP utilizes a unique and innovative combination of data-driven initiatives and a care coordination model that focuses on social determinants of health (SDOH). The Mission Health Partners Care Coordination team - available to all MHP providers - includes registered nurses (RNs), certified pharmacy technicians, licensed clinical social workers (LCSWs), clinical pharmacists, respiratory therapists, paramedics and community outreach specialists.

MHP's care model aligned well with the innovative managed Medicaid model implemented by the state of North Carolina in July of 2021. Under an 1115 waiver, four Managed Care payers were selected by the state to capitate health care services for Medicaid beneficiaries in Western North Carolina, including care management services focused on addressing barriers caused by social determinants of health. MHP contracted with each payer as a CIN care management entity, having successfully integrated care and managed cost and quality for senior populations since 2015. Another part of the state's 1115 waiver for the transition to managed Medicaid allocated $650 million in funding for a Healthy Opportunities Pilot program. This funding in part allows for payments to Human Service Organizations (HSOs) such as food banks, transportation services, housing assistance entities and legal services which provide resources to help address social determinants of health for Medicaid beneficiaries. In part because MHP had engaged in this type of work with local HSOs for many years, our region (Region I) was selected for this pilot along with two others. In addition to our usual social needs assessments, MHP must also determine patient eligibility for Pilot services and make referrals to HSOs through a state-determined platform.

Problem
The data collection and reporting requirements associated with MHP's role as a delegated care management entity and CIN for managed Medicaid and the Healthy Opportunities Pilot requires a custom software solution. Existing care management and data analysis platforms and EMR solutions were either unwilling or unable to accommodate the flexibility and customizations needed in a timely, cost-effective and sustainable manner to meet the requirements, some of which were not yet clearly defined at launch. MHP needed to be able to quickly ingest and process four new payer feeds, discharge data and weekly patient eligibility files to then risk stratify and perform transitions and social determinants assessments on a new beneficiary population of about 50,000 attributed lives.

MHP presents a one-of-a-kind in the industry comprehensive Care Management program that tackles patient care from beginning to end. The responsibility to manage and report out on Medicaid lives, as opposed to traditional Medicare CCM, requires multidisciplinary expertise and constant engagement to deliver true impact. From custom care management assessments and intricate workflows, to layering in payer data for true performance management, MHP came to Garage with an urgent need to efficiently deliver this unique care management model to change the health of their patients and provide the necessary reporting to build a sustainable and replicable model of care.

Solution
In a little under eight weeks, Garage was able to stand up the GRID application with required custom MHP elements to meet data capture and minimum reporting requirements. This included a state mandated reporting element named "Care Management Interactions" allowing for a unique way to isolate the count of outreaches to patients, both telephonic and in-person, as defined by the state. In addition, custom forms and assessments regulated by the state were integrated such as the North Carolina state's SDOH screener and Comprehensive Assessment. Due to MHP's diverse clinical care management team with wide expertise in condition management, Garage had the opportunity to develop custom assessments such as CaraMedic, Asthma New Patient, and Psycho Social Assessments, allowing all team members to effectively deliver their specialized expertise in collaborative patient management. With the urgency around MHP's onboarding to meet state deadlines and the large staff managed at MHP, a custom user configuration was set up allowing all staff to work in a collaborative way that enables MHP's multidisciplinary approach.

Outcome
From initial go-live training of 23 users in August 2021 to a current count of 40 trained users, the GRID application is used daily for all MHP care management activities related to Medicaid. As of May 2022, there are approximately 50,000 PHP lives, of which approximately 6500 have been touched through care manager interactions.

A small comparative analysis of the claims data of Medicaid members who received care coordination services is showing positive impact trends. We compared utilization rates of a group of 398 members with care plans created in GRID post go-live to the same time period the prior year. Post go-live with CM, we have seen a trend of reduction in ER utilization, avoidable encounters, and IP admissions! To highlight just one area, there appears to be a 30% reduction in both total ER encounters and IP encounters per 1,000 lives.

MHP is moving forward in their mission to provide the best care to support to their populations while helping the population transition to value based care success.

About
Healthcare has become more consumer oriented than ever before, which means methods of communication must grow with the demand and habits of current times. Texting has become a modernized method of communication as opposed to traditional mailers/cards or phone calls/voicemails across various business enterprises. A recent poll in 2020 found that "patients want more regular and immediate interactions with providers and to be more engaged in their overall healthcare and wellbeing. Nothing is more effective for that kind of communication than text." Data suppliers estimate that the U.S. has approximately 280 million smartphone users in 2020, making up 87% of the U.S. population.

There are numerous ways texting can be used in patient engagement:

• Preventive Care: 25% of providers say their practice does not proactively recommend preventive services to patients.
• Disease Management: 87% of patients wish their providers would engage between visits to support chronic disease management.
• Non-Engagement/New Patient Adoption: Payers and Value-Based-Care arrangements often reward for making sure attributed panels are seeing their PCP.

Adopting methods of texting can help engage existing patients, drive progress on care gap closure, improve your bottom line with appointment reminders and no-show follow-up, streamline communication, and ultimately keep patients healthy.

Problem
Although EMRs/EHRs offer texting solutions, they are often an expensive additional cost package. Despite the continued drop in the cost over the last few years, one major barrier that will always be limiting to texting from the EMR is the need for the text to be tied to an encounter and existing patient record. For example, if you have 30 new patients on your panel this quarter that are not picking up their phone, your EMR will not allow you to text them without the extra work and administrative stress in creating a convoluted way to make it happen. When looking at standalone solutions that are available in the market, they often do not agree to sign BAAs with healthcare organizations and offer no clear data management structure. To truly support a value-based population fully, organizations need to have a strategy outside of their email to close the gap on patient outreach.

Solution
BlazeCare Communicator was developed to take our partners into the new era of patient engagement. Communicator is an all-in-one, HIPAA compliant text messaging service that enables easy, secure, and fast SMS campaigns or 1-on-1 bi-directional conversations with patients. A seamless campaign function also allows immediate access to text delivery and subscription reports. The Communicator offers full compatibility with all mobile devices with unlimited recipients & messaging support. In this storyline we will spotlight three different organizations that have used the Communicator for different initiatives: Middletown Medical - a multi-specialty physicians' group in New York, SOMOS - an MSO and ACO of 2500 independent physicians, and Finger Lakes IPA - a behavioral health focused group of FQHC's covering Upstate New York.

Outcome

Middletown:
Over the past year, Middletown has used the Communicator for various population health engagement projects. The team has found that texting patients for scheduling AWVs and follow-ups for missed appointments has resulted in a higher rate of responses and scheduling appointments than calling. Middletown has also used the Communicator to drive focused Care Gap initiatives that get patients to participate in actionable follow-ups and referral action, as necessary. This year, Middletown is working on a pilot project for patients who have mental health and chronic disease that have not seen their PCP, and has achieved a 35% capture rate with those becoming complaint with appointments and check-ins.

SOMOS:
SOMOS provides required onsite COVID testing for approximately 700 schools located in the 5 boroughs of NYC under a Department of Education requirement for testing based on vaccination status or symptoms. Although laboratory results are provided via MiSOMOS into the hands of the patients, SOMOS came to Garage to solve the need of immediate notification to a patient when their COVID test results become available. Timing is of the essence here, as lab results have implications for school staffing, teacher availability, and families to determine of their child can go to school or not. Communicator was configured to automatically text the patient, or guardian in the case of a child, the moment new lab results available within the MiSOMOS application. As of May 2022, the Communicator has sent out almost 65,000 notifications to staff of the Department of Education and their students for their COVID results. This has removed a massive administrative burden and provided relief to SOMOS and Laboratory agencies for manually managed calls and notices.

FLIPA:
Anthony L. Jordan Health Center - an FQHC part of the FLIPA network, was tasked with engaging individuals who have not utilized any Medicaid services in over 12 months to increase provider visit engagement to achieve better health outcomes. One of FLIPA's VBP arrangements has an add-on tied to being able to drive down those rates. At the beginning of 2021, 25.35% of Anthony Jordan's patients could be considered part of this patient cohort. Actively engaging patients by traditional methods became overwhelming task for the already busy administrative staff at Jordan Health, while producing minimum results. Adoption of the Communicator has allowed Jordan Health to seamlessly deploy that outreach, schedule and remind of upcoming appointments. This simple outreach made a significant difference in connecting with those unengaged with primary care and was able to drive down Jordan Health's population who had not utilized any Medicaid services in over 12 months engagement rate to 16.01% as of December 2021.

Across the U.S., healthcare organizations have seen an explosive health data growth rate of 878% since 2016, reaching 8.41 petabytes (PB) on average in 2018. For comparison, a single petabyte is often compared to 1,000 copies of the Encyclopedia Britannica. The challenge lies in drawing useful and actionable information that informs and empowers decision-making toward value-based care. We sat down with Joe Taylor, Senior Vice President of Redeemer Health & Executive Director of Community Care Collaborative of PA & NJ, who discussed how his organization tackles big data challenges and expands on data governance and Big Data management.

The video interview covers the following topics:

• Do you believe "Big Data" offers a competitive advantage to healthcare organizations?
• How does one create confident decision-building in the context of Big Data?
• Big Data means lots of noise. Even the best data scientist can misread, leading incorrect operational decisions. How do you set confidence thresholds?
• Describe an experience where you used your data interrogation skills to solve a business goal?
• How does one identify new revenue streams in Big Data?
• Describe an experience where you erred in your analysis of company data. How did you rectify your error?
• When physicians are approached with data, there is resistance stemming from the unique patient/provider interaction which to a clinician supersedes anything that comes off a 'data point.' How do you respond to that? and how do you get your providers to trust and engage with data?

The CCC/IWA entity covers almost 30K lives in ACO MSSP, 54K lives across eight value-based arrangements from Commercial to Medicare, and its own employer group. Speaking with Joe, it became clear that confident decision-making in Big Data offers CCC/IWA a competitive advantage when a strong data governance team is established and becomes a core of the organization's knowledge. The correct people and mission-based collaboration allows everyone to discuss and agree on what metrics, definitions, criteria, and methods CCC/IWA will use to establish creativity and thresholds for success.

An example of how CCC/IWA has used big data to drive establish an advantage is in their 340b pricing program, where data is being used to optimize the discounted pricing opportunity by knowing which patients receive expensive drugs, what locations they are received at, and which physicians are driving that expenditure. This allows CCC/IWA to design and implement initiatives to drive all that utilization in-house. This does not only help CCC/IWA increase in-system business and achieve massive savings, but also gets members care closer to their homes. [To read more about CCC's 340b storyline using the Garage Data Warehouse click here.]

In data analytics, it can be easy to get lost in the "noise" of the data and one must set confidence thresholds as to what metrics will speak to a decision action point. CCC/IWA does so by benchmarking data against CMS, national or local peer rates, payer-provided regional market rates, or previous performance, depending on what metric is being evaluated. In larger data sets, Joe shares that one must remember that "it is population management, not necessarily person management. You should always look at Big Data in global comparison. How does a physician, practice, or group compare against each other?" Joe often compares CCC's MSSP performance against other ACOs. This requires a little bit less precision work and makes for a better conversation in moving the population as a whole. This allows CCC/IWA to identify not only improvements, but new streams of revenue opportunities.

When asked about making errors in decision making based of data, Joe shared an event that exemplified the need for all parties to have a clear understanding of the program requirement definitions. In example, what codes can define a closure of a measure, or the definition of such codes, and all parties must be on the page, educated, and in agreeance to the definitions. Capturing an understanding sign-off is a way to empower an organization to minimize error results.

When asked about the biggest challenge Big Data faces in adoption - physician engagement and adoption - Joe explained that to overcome push back it is important to not indict, but present and converse with clinicians. When presenting reports, analytics, scorecards, etc., CCC/IWA stays away from the accusatory and fact-based approach, and approaches conversations in an open - ended manner. Asking the 'why' and using other practices for comparison is an open-ended way to steer the conversation towards performance improvement or learning about the current reasons for success.

During the interview, Joe said something that has stood out to me as something I have observed to be truly valuable when organizations can commit to the effort of Big Data adoption: "Trust [the data], but always verify." CCC/IWA relentlessly reviews if the payer reports are as accurate as they should be, if the performance and evaluation of shared savings is correct, are the people who should be in the numerators and denominators for the quality correct, and so much more. Big Data allows and empowers organizations to vet, challenge, and review payers rating and performance calculations.

Based in Orlando, Florida, The Garage is a population health management technology company dedicated to changing healthcare for good... one community at a time. The company works with more than 140 healthcare organizations and more than 18,000 providers across 30+ states. Through its collaborative population health management platform, Bridge, The Garage touches more than 14 million patient lives, allowing providers to achieve the Quintuple AIM of lower cost, better care, improved health of communities, sustainable service models, and equitable access to care for all. For more information, visit www.TheGarage.health or give us a call at 407-739-2286.

SOMOS is a physician-led network of 2,500 health care providers that serve more than 650,000+ Medicaid beneficiaries in immigrant communities across New York. Under a select number of full risk value-based payment arrangements, SOMOS is held responsible to implement and report on Social Determinants of Health (SDOH) interventions to the State. Garage sat down with Sally Quinn Finn, Manager of Public Health Initiatives at SOMOS Innovations, and Vivian Torres Suarez, Vice President of Clinical Operations at SOMOS Innovations, to learn how this leading organization is moving the needle in SDOH program design and implementation.

The video interview covers the following topics and more:

• Why is the real-world healthcare experience still decidedly mixed despite knowledge that social determinates affect up to 80% of health outcomes?
• Can you reprise on your experience the critical success factors people need to put forth to tackle SDOH?
• How do you choose what interventions are most effective to tackle first?
• In implementing SDOH, where do you gauge between becoming an in-house expert versus external expert?
• How do you identify patients that truly need social intervention?
• What role do you see physicians taking in tackling SDOH and how has SOMOS handled this with their physicians?
• Healthcare institutions face limitations to accomplish health equity due to forces outside of control - such as housing policy, city budgeting for real estate for grocery stores, transportation barriers, etc. What role do healthcare organizations play in politics and government?
• How does SOMOS gauge the success of an SDOH intervention?

SOMOS has embraced the expression "numbers matter" in context of SDOH by looking at zip codes where the population has a direct impact in access to resources such as pharmacies or supermarkets, especially when that impacts one's ability to access the instructions that been given by their provider. Because SOMOS serves largely the Latin and Asian communities, which happens to have some of the highest rates of chronic conditions, SOMOS must wholly address the kinds of social determinants of health that impact those populations.

Despite its relevance, SOMOS believes few healthcare experts tackle SDOH due to time and lack of operational structures in these communities. Vivian states, "One cannot go into a community and say to a group of individuals, who may or may not be even remotely interested to listen to anyone that is outside of their community, 'This is the way you should do this'". SOMOS has invested the time and effort to learn more about what the communities would like to see and how to put things in place for them so that SOMOS builds off trust and respect. A caveat to this approach is resourcing. There still needs to be discussion at organizations about bringing in the right resources to be able to fund and manage programs like this, as the capacity of a physician will not be able to handle the requirements of such programs.

When designing their program, SOMOS' success stems from the fact that they honed-in and started small with a few focused interventions. Since SOMOS already had a relationship with R.A.I.N CBO (Regional Aid for Interim Needs, Inc.) from a previous Medicaid Redesign Project called DSRIP, SOMOS vetted what services already existed. In choosing what interventions to tackle, SOMOS abided by the NY State's approved VBP Interventions Guidelines. That was aligned against R.A.I.N and isolated a focused launch of the program. In SOMOS' case, the two interventions chosen were Housing Instability and Food Insecurity. Vivian expresses that having an in-house expert such as Sally Quinn dedicated to SDOH initiatives at your organization to oversee the projects and orchestrate all the outside parties has been effective for SOMOS and is pivotal to anyone's success.

SOMOS has piloted several reiterations of SDOH programs that were not as successful before the current one becoming the most promising. SOMOS isolated a patient cohort based on a population that was already engaged - making the process to achieve traction and engagement much easier. SOMOS' existing care management program added a social screening to existing workflows and depending on answers, a result triggers the referral to R.A.I.N. via Garage. [To learn more about how Garage is utilized as the referral and data collection system for this workflow, you can access the storyline here].

Of course, physician awareness and engagement are at the core of long-term success, and SOMOS accomplishes this by having SDOH as a frequent topic of discussion at physician forums and presentations. Sally explains that in an ideal state, the best place for an SDOH screening tool is to sit in some capacity in the EMR and be able to make a direct referral from the EMR over to the CBO, but that work effort cannot fall on the physician or clinical support team. This can be combated by - going back to the topic of resourcing in the healthcare workforce - creating someone more responsible for these needs at the practice level.

While the program experiences positive operational success, the core of achieving fundamental SDOH change can be limited as there are external governing institutions and policies that no physician or healthcare executive controls. SOMOS believes that healthcare leaders and representatives must work closely with the government, as elected officials have no other way of knowing what happens on the ground. There is a responsibility SOMOS choses to take with communicating that publicly and participating in the design of new plans. One cannot "just flip a switch and be able to address all these social determinants of health and equitably distribute resources at the patient level like [we] would love." Healthcare organizations cannot rely necessarily on safety-net institutions. For instance, "housing is a very big deal, and when you think of hospitals and the amount of footprint that they take over throughout [New York City], they have lots and lots of real estate that they are responsible for. So, they are key players in many ways, and they need to have a voice at the table". The found of SOMOS - Dr. Ramon Tallaj - takes on that voice and responsibility to connect with understanding the needs of the community and continues to speak up to the Office of the Governor.

Vivian states: "We say we want stay away from politics, but I don't know how we can avoid it. We need to be there. Otherwise, our communities are not going to be considered when you talk about health equity. We have got to have a voice at the table. We have got to be able to represent all our patients right from the moment they are born, all the way to the point that they need support with burial expenses."

As SOMOS enters the end of the first year in the current SDOH program, it is time to gauge success. Garage has designed a dashboard where we are trying to use the data that has been collected and generate trends to see the impact of the program. SOMOS explains that this is the part where everybody gets stuck, and not just with any SDOH programs, but any public health intervention programming. The evaluation is the most important part. SOMOS will be looking at ED and Hospital Admissions to assess performance so far, while adjusting that the population has also been under care management. SOMOS is looking forward to having a detailed data impact report later this year to take a step back and ask what has been learned from the program, and whether SOMOS made an impact.

Based in Orlando, Florida, The Garage is a population health management technology company dedicated to changing healthcare for good... one community at a time. The company works with more than 140 healthcare organizations and more than 18,000 providers across 30+ states. Through its collaborative population health management platform, Bridge, The Garage touches more than 14 million patient lives, allowing providers to achieve the Quintuple AIM of lower cost, better care, improved health of communities, sustainable service models, and equitable access to care for all. For more information on how we can support your organization in SDOH intiatives, visit www.TheGarage.health or give us a call at 407-739-2286.

May 26, 2025

What an exhilarating FUSE we had. Still reeling from its impact, I captured my reflections here - FUSE Reflections

We launched a rallying cry to Be Bold to all stakeholders at FUSE and followed it up with a Be Bold campaign whose ethos will remain with us as we embark on this very important and exciting phase ahead.

At the heart of being bold is our boldest move yet to re-imagine our core platform operations. Thrilled to announce the launch of our Garage AI Framework (GAF) - a bold, structured approach to embedding intelligence across every layer of our platform operations.

GAF isn't just a framework. It's our blueprint for speed, intelligence, security, innovation, and smarter outcomes. With GAF, we're focusing on five key impact areas (our own AI Quintuple AIM):

• 50% faster platform configuration
• 100% acceleration in time-to-market for all new innovations, including Blaze Agents
• 20% efficiency gain in data management
• 20% cost reduction in platform operations
• 50% improvement in platform SLAs

I've attached a document outlining the core structure of GAF, our AI quintuple AIM objectives, and the path ahead.

The main components of this framework are:

// Infrastructure & Monitoring

The Infrastructure & Monitoring layer in GAF provides technical scaffolding that powers blaze agents, real-time data orchestration across the multitude of sources such as EHRs, Payers, Health Gorilla (Clinical + ADT), Experian etc., and continuous platform configuration - all while ensuring enterprise-grade availability, performance, and observability. We are assembling the most secure, scalable, HIPAA compliant and HiTrust certified infrastructure lab to build and monitor our innovations, called Mozart. Just like its namesake, Mozart Lab is about orchestration - but instead of music, we'll be orchestrating intelligent care workflows, data-first interfaces, and process automation that democratizes value-based care at scale.

// Tools & Models

Designed to be the intelligence core of GAF, the tools & models layer powers Bridge's ability to understand, reason and act - turning raw data and intent into real-world impact. We are harnessing the strengths of industry-leading models and LLMs, including:

• Claude 3.5 - for language understanding and summarization
• Gemini 2.5 - for multimodal and advanced generative capabilities
• MS Copilot - for productivity enhancement within enterprise workflows
• Rasa - for fine-tuned, controlled, domain-specific conversational AI
• ACG & JSL - for clinical classification and labeling
• MCP - for structured decision logic in regulated environments
• Windsurf - for structured vibe coding and policy-driven model governance
  And our very own
• Coeus - for encapsulated logic models (synthesis, engagement, fraud & abuse etc.) that drives better decision intelligence at ALL points of care

// Governance & Change Management

The Governance & Change Management layer is the operational compass of GAF. It ensures that innovation within the platform happens responsibly, safely, and in alignment with strategic goals, while enabling agility through structured, repeatable change processes. It includes governance frameworks that aligns with regulatory requirements like HIPAA, HiTRUST and HHS / ONC interoperability rules, change management playbook integrated with DevOps, policy enforcement and guardrails, feedback loops and impact measurement across SLA, user adoption, performance and stability.

I have also included our current year portfolio of data and platform innovations that we are currently invested in to maximize our value to you all!

Thank you for your continued partnership and trust. I invite you all to reach out with any questions, comments, or ideas.

The bold future we're building - we're building it with you!

- Pranam Ben

Resources

• 2025 I&P Portfolio
• GAF 2025

March 15, 2025

We live in extraordinary times with sector wide uncertainty, regulatory turbulence, and an unpredictable near future ahead of us. It is in these times that the best of the best double down on the core, amplify their strengths, invest in initiatives that maximize value and operate with a sense of urgency. That's exactly what we @ the Garage are committed to and I wanted to share some of our key initiatives that we have mobilized for YOU that will shape the future of the Garage and bring greater value to our partnership.

My crew and I have been working relentlessly behind the scenes to scale up with a multi-dimensional approach anchored on FOUR key dimensions summarized below:

// Data

As part of our 'Data First' approach, we are investing and integrating the following to fundamentally transform our platform capabilities

• Health Gorilla Data Feeds - We are now fully integrated with Health Gorilla and their HITRUST R2 infrastructure for
  • Patient 360 clinical data feed that gives us on demand FHIR based access to deep clinical data for 220M+ adult patients, 750K+ clinicians and 147K+ care sites. We have already integrated this data for more than 200K patients across multiple customers and intend to make this available for ALL in the coming months.
  • ADT Alerts actionable ADT alerts from a nationwide network of participating hospitals and their QHIN designation serves as a national node for secure, nationwide health data exchange under the Trusted Exchange Framework and Common Agreement (TEFCA)
• In a significant move to boost the clinical capabilities within Bridge, we have signed a multi-year agreement with IMO Health, the industry's standard for clinical intelligence, used by more than 740K users with 5M+ clinical terms managed and mapped to coding standards. Their IMO precision normalize engine will be containerized on our Garage Cloud Infrastructure and will boost our clinical data standardization routines across multiple sources, including Health Gorilla.
• In our continued effort to drive a 360 degree approach to driving better community health outcomes, we have also signed a Data Services agreement with Experian Health for their syndicated SDOH bundle and their Consumer contact bundle (cell phone numbers for 95% of patients + 2B+ email ids). I have attached a flyer below on what to expect from this very strategic partnership with Experian.

#1, #2 and #3 will be made generally available to ALL our customers at NO additional costs beginning in Q2. Am very excited about its impact across the board and YOU should be too!

// Infrastructure

In deepening our commitment to building out a secure and hyper scale infrastructure to protect YOUR data assets, we engaged Security Metrics, Inc to a conduct a HITRUST i1 certification and assessment on our cloud infrastructure. We are currently in the readiness portion with Privaxi, a readiness assessor, preparing for our formal validation in early Q2. We pride ourselves in governing a fully HIPAA compliant infrastructure and the HITRUST certification elevates and prepares us for the opportunities ahead.

// AI Engineering

Our core engineering principles have always been AGILE and ITERATIVE. We formalized our DF DF (Digital First, Data First) platform architecture about two years ago and have been relentless in realizing it with every platform version upgrade. In what will unleash a new era of engineering @ the Garage, we have kicked off two major AI powered engineering initiatives

• An AI Lab, code named "Mozart", to serve as the backbone for a hosted AI model enabling us to drive powerful AI solutions for internal efficiencies - starting with AI agents in our internal bug tracker to drive much faster turnarounds for our customers. We are already good here but why not be great? The initial V1 version will be tested across the board in Q2.
• We have also kicked off a controlled adoption of Windsurf, developed by Codeium, an innovative Integrated Development Environment (IDE) designed to seamlessly integrate artificial intelligence (AI) into our software coding workflows. We chose Windsurf after months of due diligence particularly due to its privacy, security, capability to handle multi-file edits and its contextual understanding of complex codebases like Bridge.

// Rich Platform Tools

We continue to build specialized workflows within our core apps, such as GRID. In a well-choreographed and intentional strategy, we are also enabling rapid, meaningful, rich, fluid, decentralized user experiences envisioned as 'Tiny Tasty Morsels' with our vision to enable more agentic Blaze Copilots infused n Bridge. This is our vision for the NextGen Bridge[x] experience that will fuel the next 5 years of our vision to create the World's BEST healthcare platform experience.

In summary, we are massively boosting our platform capabilities by normalizing complex and comprehensive datasets while simplifying and enriching its access via Intelligent, agentic tools like Blaze Copilot - All of this operating on a hyper scale, HITRUST certified infrastructure.

None of the above would be possible without ALL your support and patience, reflected in our best-in-class overall KLAS score of 95.2%! We are super excited about these initiatives. Stay tuned for updates, and as always, your feedback is welcome. We'll be sharing more updates & our 2030 vision @ FUSE this year in May.

If you'd like to learn more or explore how these initiatives can benefit you right away, let's connect! Feel free to reply to this email or reach out to Taylor at tballard@thegaragein.com to schedule some time with me.

Thank you for being a valued part of our journey and your support over the years!

Now, more than ever, we need to be committed to changing healthcare for good...together!

- Pranam Ben

Resources

• Garage Experian Partnership Flyer

August 31, 2025

As we continue to ride the momentum from H1 and accelerate, I wanted to take a moment to reflect on key milestones since I last wrote to you. Each milestone is a testament to our relentless commitment to YOU - Our customer, partner and everybody else challenging status quo and changing healthcare for good - one community at a time!

// Mozart

Our most exciting AI initiative, Mozart, continues to make giant strides in enabling cutting-edge, AI powered solutions in record pace. To be honest, in many instances, we surprise ourselves with the power and speed of what the Mozart crew has been able to accomplish in such a short period of time - For e.g. we built an agent, Blaze Link, for Payer contract & 340B compliance in less than 6 weeks, start to finish! We intend to continue to break new ground as we march into Q4 and 2026. I have attached an overview of the spectrum of initiatives currently in motion under Mozart. They will all be integrated into your experience with us in the coming days and weeks.

Here's a link to my post on Mozart - Mozart thoughts on LinkedIn

// Platform Certifications - Built for Trust, Performance & Scale

We've fortified our platform with industry-leading certifications that reflect our commitment to security, compliance, and operational excellence:

• ONC Certified (Bridge v5.3.0) - Supports eCQMs like CMS 165v9, CMS 122v9, and CMS 2v10 with QRDA I/III export for CMS reporting.
• ONC Certified (Ignite) - Ensures secure patient access and interoperability, meeting CMS Promoting Interoperability requirements.
• SOC 2 Type II - Validated by independent audits for security, confidentiality, and availability.
• HITRUST - We are officially HITRUST i1 Certified as of July 11, 2025. This certification validates our infrastructure, privacy, and security controls across Bridge and all our operational controls. We achieved a perfect score of 100/100 across all assessment domains - no CAPs, no gaps, just excellence. This isn't just a compliance checkbox. It's a strategic investment in trust, resilience, and enterprise-readiness. From our zero-trust architecture to real-time threat monitoring, every layer of our platform is built to protect what matters most..
• eCQM Certified - Enables accurate, real-world tested quality reporting from EHR and other sources of clinical data.
• NCQA Certified (HEDIS) - Verifies our platform's ability to apply official HEDIS logic and support compliant reporting.

I have attached an overview of the certifications for your easy reference.

// PY 24 MSSP Results - $134M in Gross Savings

Our MSSP ACO customers achieved $134M in gross savings in PY 2024 - a 34% increase over last year. Congratulations to ALL! With a per capita savings of $632 and 76% of ACOs generating savings, we've proven that Bridge drives real, measurable impact. The average quality score of 83.3% was higher than the national average and the real kicker, we had 68% of our ACOs qualify to be high performance (≥3 consecutive years of savings and above-national quality). These results reflect our ability to empower ACOs with actionable data & tools, drive high-quality care, and deliver ROI in months-not years.

// Hiring Trailblazers - Building the Crew of the Future

We've continued to invest in talent that embodies our pace, mission, commitment, and culture. We are amplifying our focus to onboard more Trailblazers who aren't just employees-but are change agents & culture carriers. They bring bold ideas, relentless energy, and a deep commitment to our customers. And we're just getting started.

Here's the link to my post on recruiting Trailblazers - Trailblazers Wanted!

If any of you need more information on any of the above, you know how to get in touch with me!

Before I sign off, I want to thank ALL of you for your continued support, partnership, and trust. None of this would be possible without you!

Let's #bebold and #buildbold

- Pranam Ben

Resources

• 2025 Platform Certifications
• Mozart

August 2025

Am proud to announce the successful completion of our HITRUST I1 Certification Assessment, effective July 11, 2025. This is core to our commitment to a hyper scale, secure infrastructure that operates our Digital First, Data First platform architecture.

As a part of this rigorous evaluation, we achieved a perfect score of 100/100 across ALL assessment domains. We were found to be fully compliant, with no Corrective Action Plans (CAPs) required and no additional gaps identified. This outcome reflects the strength, maturity, and operational effectiveness of our infrastructure, security, and privacy controls. The scope of this certification included both our platform, Bridge, and our facilities including our primary offices located in Orlando, FL.

The certification assessed the implementation of controls across the following critical domains, prioritized by importance to security, data protection, and business resilience:

1. Data Protection and Privacy
2. Risk Management
3. Access Control
4. Incident Management
5. Vulnerability Management
6. Network Protection
7. Audit Logging and Monitoring
8. Password Management
9. Transmission Protection
10. Configuration Management
11. Endpoint Protection
12. Mobile Device Security
13. Wireless Security
14. Portable Media Security
15. Third Party Assurance
16. Business Continuity and Disaster Recovery
17. Physical and Environmental Security
18. Information Protection Program
19. Education, Training and Awareness

This HITRUST Certification affirms our ongoing commitment to protecting critical and sensitive health data, proactively managing cybersecurity risks, and upholding compliance with industry-recognized standards.

- Pranam Ben

Introducing Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology company founder and CEO Pranam Ben of The Garage. This podcast will feature important healthcare conversations with industry experts to help move the needle and change healthcare for good...across all communities. During these conversations, we will discuss topics such as how we can make a positive impact in healthcare, what the quintuple aim is and how we can achieve it using a digital-first, data-first approach, how organizations can achieve cost savings in value-based care without diminishing care quality, and many more. Welcome to Ben's Den.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

As the technology in the healthcare space is constantly evolving, we talk about our Top 5 Predictions in the Healthcare Industry in 2023 with Himadri Sarkar, EVP and Global Head of Consulting at Teleperformance, a global leader in solution design, business optimization strategies, front-office customer support, and back-office services. Pranam and Himadri discuss the growing emergence of remote care with telehealth visits and virtual hospitals, how to drive engagement in care coordination and patient engagement, revenue leakage and topline management in risk and performance management, personalized healthcare and why it's needed, and the addition of retail healthcare as part of the continuum.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

What is aging in place, and how can we create a sustainable care model for the senior citizens in our country? Pranam is joined by Aric Coffman, Chief Executive Officer of Honest Medical Group, to discuss the concept and how we can move the needle forward by leveraging data and re-assigning resources to bring it to life at scale in the healthcare ecosystem.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Aside from the physical factors, we need to account for all other elements in healthcare. Often, community health center patients cannot attend in-person care visits due to transportation, housing, or food security issues. Pranam Ben is joined by Finger Lakes Community Health CEO Mary Zelazny and talks about steps taken by her CHC to provide more accessible care to their patients and where they are today in their telehealth journey. Accelerated due to the COVID-19 pandemic, telemedicine is more than just a video call. Mary and Pranam discuss what's needed for successful virtual health visits, how to make virtual health more accessible to everyone, especially those in underserved communities, and what the benefits of telehealth are, including convenience for the patient and improved patient outcomes.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

The pandemic caused a seismic shift in hospitals and health systems that resulted in staff shortages and burnout, turbulence in revenue, coming to terms with the realities of a post-pandemic world, and the change in the overall constitution of hospitals and health systems. As we look into the current and future states of Hospitals and Health Systems, we discuss what Redeemer Health System has implemented to help prevent shortages and burnout, what models are currently being implemented that need to change, how they can effectively manage patient health, and how technology and data have played a role in their strategies.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

What are some of the megatrends shaping healthcare's transformation today, and what is the vision for Rubicon Founders, specifically regarding empowering value-based care? How can the public and private sectors unite to create a sustainable and inclusive healthcare system, and what are the key lessons learned in mobilizing capital to drive value-based care? Pranam Ben is joined by Founder and Managing Partner of Rubicon Founders Adam Boehler LIVE at FUSE 2023 in Nashville, TN, for this informative conversation.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

How do multi-specialty groups make sense of value-based care, what challenges have they overcome, and how do they bridge the educational gap? How has Middletown Medical's experience been with ACO Reach in the few short months it's been in effect? Has remote patient monitoring impacted patient engagement, and where can it help achieve future organizational goals? Pranam Ben is joined by the CEO of Middletown Medical, Darcy Shepard, to discuss how her multi-specialty organization has utilized value-based care.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

How can we demonstrate leadership during times of uncertainty in healthcare while upholding the highest ethical and moral standards? What valuable insights can be taken from outside of the healthcare realm that we can apply in day-to-day life? Pranam Ben is joined by Nick Kennedy, Founder, Author, and Entrepreneur, where they discuss the need for strong and accountable leadership in healthcare.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

What has been our journey in the post-pandemic era, and what are the market forces at play? How can AI help healthcare, and what should we be careful of? What is the current state of value-based care, and what should we expect on the horizon? Cliff Frank, President and founder of Healthcare Management Solutions, joins Pranam Ben for this informative conversation on the Current Dynamics of the Healthcare Ecosystem.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Is overall tech adoption in healthcare overhyped or underserved? When it comes to the AI hype, what are the risks we could run into? How do we reduce the friction between clinicians and tech? How do we maintain safety and security in a digital health world? Craig Dreher, EVP and Chief Information Officer at Community Care Physicians joins Pranam Ben for this exciting episode about Tech, Data, and AI Realities in Healthcare.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

What is the state of consumer engagement in healthcare? Is there a comprehensive framework for 360-degree patient engagement? What is the role of data and value-based care in driving patient-centric care? What is concierge medicine, and is it something that can be scaled? Alex Foxman, MD, FACP, DABOM, Founder and President at Beverly Hills Institute and Founder and Medical Director at Mobile Physician Associates and Achieve Health & Weightloss, joins Pranam Ben for this conversation about Empowering Patients in their Care Continuum.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

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Pranam is joined by Kathleen Noonan, President & CEO of Camden Coalition, a community-facing nonprofit serving South Jersey focused on enabling care management with complex health and social needs. In this episode, they dive into Camden Coalition's strategic shift from an exclusive focus on care management into symbiotic care ecosystems, the impact of SDOH and why z-codes are underutilized, what patients are the hardest to engage and how intensive care management can help engage them, and how tech & data can be leveraged as an enabler of care ecosystems.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

In this episode of Ben's Den, Pranam is joined by Scott Mancuso, Chief Medical Officer of Honest Medical Group, where they discuss a 360-degree view of aging in place, initial lessons learned in the enablement of at-home programs, and how enabling a digital-first, data-first architecture empowers success in aging in place strategies.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Pranam is joined by John Dionisio, CIO at SOMOS Community Care, and they discuss the world of Artificial Intelligence and its impact on community providers. Pranam and JD talk about the opportunities and threats that AI presents, the AI buzz and whether it's good or bad, best practices, and what can be learned from past transformative tech adoptions.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

In this special Fuse 2024 episode, Dr. Geeta Nayyar-Chief Medical Officer, technologist, and Wall Street Journal best-selling author-joins Pranam Ben live to discuss the state of the healthcare industry, the impact of misinformation, and the future of healthcare. Dr. G shares her insights on technology and data's role in this transformative era, the challenges posed by healthcare misinformation, and her vision for the future of healthcare.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Pete DiFondi, CDPHP's Chief Information Officer, joins Pranam and discusses what it means to be "Data-First" for CDPHP. They examine how this approach impacts Security and compliance, Provider Engagement, Member Experience, Business Process Transformation, Innovation, and Agility. They also discuss best practices that should be adopted when transitioning into a Data-First strategy and the common pitfalls to avoid.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Andrew Allison, Co-Founder and CEO of On Belay Health Solutions, joins Pranam for an insightful conversation about the journey of being a healthcare entrepreneur. Together, they explore the challenges and opportunities of building a healthcare startup, from securing funding and investments to identifying both articulated and unarticulated market needs. They dive into what it takes to create scalable, sustainable business models, the critical role of partnerships and ecosystem engagement, and the complexities of navigating regulatory compliance while safeguarding patient data and privacy. Andrew also shares his thoughts on fostering a culture grounded in social impact and ethics, offering valuable advice for aspiring healthcare entrepreneurs looking to make a meaningful impact in the industry.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Katherine Evans, President of the Novocardia Division of CVAUSA, joins Pranam to discuss driving more specialist accountability in population health outcomes. During their conversation, they discuss the state of outcomes-based payment models in cardiovascular care, including model adoption and organization readiness, defining KPIs in a multi-specialty setting, the role data and tech play, having patient-centered care and shared decision-making with other providers, reducing waste and overutilization in specialty care, and the key best practices and pitfalls to avoid.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

In this panel episode of Ben's Den, we dive into the transformative healthcare trends, critical insights, and the election's impact on healthcare, including value-based care and policy shifts. Gain insight on what to expect in 2025, including the tech outlook. Pranam is joined by our panel of healthcare leaders who bring unique perspectives to this conversation: Himadri Sarkar, Chief Solutions Officer at Teleperformance, Mary Zelazny, CEO of Finger Lakes Community Health, and Joe Taylor, President of Community Care Collaborative of PA & NJ.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Pranam is joined by Dr. Steven Lane, Chief Medical Officer at Health Gorilla, and together they explore the current state of interoperability and Health Gorilla's role in shaping a national interoperability standard, how to break down the current barriers and transform data into actionable insights, the increasing role of AI & machine learning in advancing data usability, and what the future holds for TEFCA and other initiatives aimed at strengthening healthcare data exchange.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Pranam is joined in person by Cibolo Health's Nate White (President/CEO), Brittany Sachdeva (Chief Clinical Officer), and Clint MacKinney (Chief Medical Officer) to discuss value-based rural healthcare. In this conversation, they dive into the key issues shaping rural healthcare in the United States, emerging trends, and what's ahead in 2025. They also unpack the critical role of Clinically Integrated Networks (CINs) in driving value-based care, having a digital-first, data-first architecture that drives accessibility and affordability for rural communities, and the role tech, data, and AI play in rural health networks.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

In this episode, Pranam takes a rare, behind-the-scenes journey through the company's history with the people who helped build it from the inside out. In this special series, he sits down with five of some of The Garage's longest-tenured visionaries - Madhu Gali (Senior Project Manager), Nadia Robeson (Director, Data Sciences), Phillip Marrett (VP, Data Analytics), Chandler Douglas (Head of Engineering), and Jessica Robinson (Chief Platform Officer). They talk about the early days, the challenges over the years, and the state of healthcare technology today. Expect a raw, real look at some of the people who have helped power healthcare's most comprehensive population health management platform.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

Broadcast LIVE from Fuse 2025, this episode brings together three of healthcare's most forward-thinking healthcare leaders: Dr. Scott Mancuso, Chief Physician Executive at Vytalize Health; Dr. Steven Lane, Chief Medical Officer at Health Gorilla; and Dr. Howard Landa, Chief Medical Informatics Officer at Adventist Health. During this dynamic conversation on bold, clinician-led transformation in value-based care, they dive into the current state of the Quintuple Aim and the pivotal role clinicians play in driving outcomes that matter. From navigating structural and policy challenges to harnessing the full potential of data, technology, and AI, this discussion provides real-world insights on how bold leadership can overcome barriers and reshape care delivery models for good. This episode is a must-listen for anyone ready to reimagine the future of healthcare led by the voices who live it every day.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

In this episode, Dr. Aric Coffman, CEO of P3 Health Partners joins us as we explore what it truly means to lead boldly in value-based care. From the evolving shift from volume to value, to the role of AI, data, and digital-first strategies, Aric and Pranam unpack the mindset and mechanics of transformation. They dive into how clinical voices are shaping the future, what it takes to rewire the frontlines, and what the next bold move in VBC might look like. Whether you're a changemaker, strategist, or just VBC-curious, this episode is for you.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!

In this episode, Brendan Keeler, Interoperability Practice Lead at HTD Health and Health API Guy, joins Pranam to unpack what it takes to make healthcare interoperable by default. From the current state of data exchange to the business model of interoperability and whether it's frictional or innovative, they explore the mechanics behind a truly connected ecosystem. Additionally, they dive into the trust and compliance layer that underpins data sharing, real-world use cases that demonstrate interoperability in action, and what a data-first future with intelligent agents looks like.

How can we make a positive impact in healthcare? What is the quintuple aim, and how can we achieve it using the digital-first, data-first approach while holding integrity to a positive physician-patient experience? How can organizations achieve cost savings in value-based care without diminishing care quality? What is health equity, and how can organizations use it to advance in healthcare? These are all topics discussed on Ben's Den, a healthcare technology podcast about innovations in healthcare hosted by Population Health Management technology Founder and CEO, Pranam Ben of The Garage.

Be sure to subscribe to our podcast, Ben's Den, on your favorite podcast app!