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.
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.