3. Determine Clinical Care Priorities
  1. Care Management: Leverage health information technology (HIT) to risk-stratify all global payment patients by probability of admission to the hospital; develop registered nurse and nurse practitioner programs for home visits and telephonic intervention.
  2. Disease Management: Create registries and outreach programs especially for Medicare patients in the high-value areas of: heart failure, diabetes, chronic kidney disease, emphysema, behavioral health, and end-of-life care/palliative care to prevent Emergency Room visits and hospital admissions.