In this episode we continue our conversation with Yates Lennon, MD, President and Chief Transformation Officer of https://www.chesshealthsolutions.com/ (CHESS Health Solutions) who discusses the seven pillars of value-based care and the questions physicians and health systems should be asking themselves when transforming from fee-for-service to fee-for-value. At CHESS we often refer to the seven pillars of value-based care. What are these pillars and how does each impact fee-for-value? So, we’ve tended to use these pillars, if you will, to think about the process. Really, it follows our implementation process in many ways. So, I would start with practice transformation. So, that involves ensuring that physicians, advanced practice providers, office staff from CMA to nurses to even front desk staff, has some awareness of value-based care, understand why it is important, and then are engaged in the process of transforming that practice to a infrastructure that supports the delivery of the value-based care models and success in those models, both clinically, which is ultimately what this is really all about, and financially. From there, you can begin to layer on other services or pillars if you will. These don’t necessarily have to happen in this order, but we often start with thinking about quality. Most organizations today have some quality efforts already in place just due to primarily to the fact that CMS and other payors are pushing those. And most people have at least some pay-for-performance type of arrangements, where they’re paid for closing quality care gaps. But quality goes beyond just thinking about closing quality care gaps. For our quality team, we’re thinking about optimizing the annual wellness visit so that the template within the EMR is just capturing data points and discrete fields. That makes reporting easier back to CMS as well as to the private insurance companies, Medicare Advantage, as well as commercial. We think about Care Coordination and as we define care coordination, that includes, for our teams, nurses and CMAs. They work together to assist also in quality. So, the CMAs help close quality care gaps throughout the year. They schedule annual wellness visits, that’s a big emphasis in the first half of the year. If you can already tell, that annual wellness visit is a key component of value-based care because it touches on so many different elements of value. The other role for Care Coordination would be moving with that patient, tracking that patient, outreaching the patient between transitions of care. So, patient is admitted to the hospital, discharged to the skilled nursing facility, then discharged home. Our Care Coordination teams are monitoring that patient as they transition through those different sites of service and ensuring that each transition is as safe as possible. We all know that medication errors, in particular, are a massive problem through transitions of care. So, ensuring that patients know what medications they’re taking, or supposed to be taking, and that they can afford those medications. If they can’t, then connecting them with the resources to be able to provide those medicines for them. They also perform Chronic Care Management. So, that’s identifying. So, we can go back to population health, identifying a group of patients who are either at high risk or rising risk of a complication or with a certain disease state. Identifying those patients, and then on a regular basis, setting up telephonic or even telehealth outreach to those patients, so that between those four office visits a year, that a chronic patient might have with a provider in the office, someone is touching base with them throughout the year. As a clinician, I always think that way. That for an average chronic care patient, I might have an hour or two hours a year of face time with a chronic care patient. Whether that’s diabetes, hypertension, the combination of the two. That’s really not...