Behind the Scenes of Value-Based Care Performance

Lori Cox: Hi, everybody, and welcome back to another one of our wonderful AAPC podcasts, The Pulse. Thank you all for continuing to listen, we appreciate… we've got so many listeners now, it's wonderful, so thank you all for following us and to listening. I have with me today Ava Johnson. So, Ava is gonna give you a little bit of a background. Now, here's what I know about Ava. I did meet her for the first time at HealthCon last month. She has a great sense of humor, and her fashion sense is off the wall. So, Ava… Tell the listeners something else about you.

Ava Johnson: Oh, thank you so much, Lori. Hi, everybody, I'm Ava. I'm the Director of the Ambulatory CDQI Department, Mount Sinai Hospital, New York. Cdqi stands for Clinical Documentation Quality Improvement. So, I oversee a department that sends queries to clinicians at the point of care when their patient visits regarding open HCC gaps that the patients have, basically conditions that haven't been addressed in the current calendar year. And then we follow up, ensure the documentation is… and coding is complete, and Yes, that's what we do, very, very important work, and… Just so everyone's aware, ambulatory CDI, like. CDI was really big on the inpatient side for decades, and when value-based care really started kicking off in the early 2000s, for example, we at Mount Sinai really started in 2012. A few years later, we decided that it was imperative that we open an ambulatory CDI department. So basically doing the same kind of things that the inpatient CDIs do, except for our focus is on HCC conditions.

Lori Cox: Interesting. Okay, so that was going to be, like, one of my first questions, your role, and how you connect to value-based care, because value-based care is… I will be honest with you, it's not one of… it's not in my real realm. I'm more of a surgical CPT coder, but we have so many coders out there that do so many things, and I know value-based care is very important. So, awesome. How is this shift, though? So, from your perspective, you know, being inside of this healthcare system, because Mount Sinai's pretty large, how has this shift to value-based care kind of changed the way your teams operate?

Ava Johnson: Well, the shift to value-based care. So, we had to really start an entirely new department. So, there's a population health department that runs at multiple, healthcare systems, including You know, private practices or smaller practices, but basically population health oversees the value-based care sectors of our patient population. which runs alongside the fee-for-service side, which everyone is more familiar with, but value-based care really required an entirely different set of management and leadership roles. You know, like, on-site, at practices, you'll have a practice manager, and they will work with the clinicians, they'll see, like, you know, the finances of the practices, you know, the workflows, the day-to-days. But we also have population health managers, and they oversee the quality, the risk scores, provider engagement sort of things that we do at the practices, so it's an entirely different site of the healthcare system that runs alongside the fee-for-service side. So, yeah, we have a quality department, we have the risk adjustment coding and documentation department, which is mine, we have utilization management, which is also a really big deal. They deal a lot, and I kind of double in that as well. But utilization management, they deal a lot with overseeing the readmissions, like keeping the readmissions down to a minimum. Of course, you don't want a patient to be readmitted. And then you look into the cause of the readmission. Was it something related to the initial inpatient admission? Was it completely unrelated, something we couldn't have helped? The other part is ensuring that our ED utilization is down to a minimum. Like, only necessary ED visits. Like, you'll have cancer patients, right, and they, you know, will, have, like, severe anemia or shortness of breath in the middle of the night, sort of nothing you can do about that. They'll go to the ED. But then, what if it's a patient that, you know, has, a URI or a UTI or something, but they also haven't seen their physician during the year? And so it's like, was that something that could have been caught during a visit, or maybe they could have just visited the urgent care clinic, or actually followed up with their PCP, so… There's one thing, you know, keeping ED and readmissions down to a minimum, and then also making sure that patients are getting sent to the right place after the release from the hospital. Was there follow-up care provided? Did we follow up with the patients afterwards to ensure they had a follow-up visit with their PCP? Should they have been discharged to a SNF versus discharged to, in-home care? You know, in-home hospital care? Did they have gone to rehab? Did we keep them too long in the SNF? So there's, like, this whole thing. But, basically value-based care is just performing quality care at, you know, efficient costs, keeping everything down to a minimum and just necessary.

Lori Cox: Right, so, I mean, just thinking about all of that, you guys have got to have some really good communication and collaboration between all your teams, like, even your coding, your CDI, your quality, your utilization that you talked about. How do you guys Do you email? Do you Teams? Do you have weekly meetings? Like, how do you get that collaboration going?

Ava Johnson: That's a great question. So, we have monthly cult meetings, which are clinical operation leadership team meetings.

Lori Cox: Oh, nice, I like that acronym. Right.

Ava Johnson: So we have, just these big meetings monthly. They're usually on-site, in New York City, but I'm currently remote. I visit quarterly, so I'm able to make those visits quarterly, sometimes every two months. But we have those. If you're not there in person, you attend via Zoom. Other than that, we have smaller, more informal meetings, which are still pretty formal, because we have to have deliverables and PowerPoints ready and everything, but they're KPI meetings. And, there we go over the same type of things, at a, at a, with more context, like, we'll go over the specific data, like, I'll show how we're doing with, graph scoring and recapture and suspecting, how our clinicians are responding to the alerts we're sending them at the point of care, because that's a whole thing in itself we work with.

Lori Cox: Yeah.

Ava Johnson: the Epic team to do that, but yeah, we have those, and then you just have nosy people like me who are just reaching out to different people, like, hey, can I see what you're working on? How to calculate commits on this? But, so that's really it. We have to absolutely work together, otherwise it's, like, impossible. You know, you think… you think, like. people are like, oh, your RAF score should be here, your recapture rate should be at this level, but it's like, well, I can do as much as I can do, but if the patients aren't coming in for visits, like, if there's a wedding happening, but the bride doesn't show up, trust me, there's no wedding. Like, the patients have to come to the visit, so there's outreach there. Quality and provider engagement work on that a lot, and I'll help out too, but, like, how do we follow up with the patients? Are these patients active on my chart? Should we send them a message about visiting their PCP via their MyChart message, or should we email them, or is this an elderly folk that responds mostly to, snail mail? Then we do that, or a phone call, or text message. So, there are many, many different, parts of the machine that keep things moving.

Lori Cox: Would you say that's probably one of your biggest challenges, is trying to get patients to… and I get it, any patient, and me being a patient myself, sometimes the doctor could tell me, hey, you need to do this, you need to exercise more. Yep, I'm gonna do that, and then I sit at my desk all day, right?

Ava Johnson: Like, don't tell me to stop eating cheese.

Lori Cox: Oh my gosh! That would be awful!

Ava Johnson: But, yeah, no, totally, and that is the hard part. It's like, so we track those kinds of things as well. We have dashboards, and we'll be like, how often does this patient cancel visits? So, if they're coming in for a visit, then, you know, like, my… we work with… my team, we work with a vendor as well to help supply suspect and recapture opportunities to us, and then we will review things manually too, but then we have to prioritize which patients should get a manual review. So patients like that, that barely come in, we're like, hey, they come in once a year, if anything, so we better work on this chart manually and make sure that we're checking everything, all the signs and symptoms, and sending a good query to the clinician, because our vendor will help with that part, but they just send pretty generic stuff through the system. So, we're working on improving that, like, something new with them, but right now, if it's a recapture opportunity, for the group here, if you're not familiar with recapture, it's basically conditions that were coded within the past 2 years that should still be active, or could still be active, so you're hoping that they'll get readdressed this year, basically, recoded, so that, you know, the calendar, the CMS calendar resets every January 1st. So, all chronic conditions that patients have should be assessed and documented in CODL down… coded downstream, every year. So, we send these alerts, and, whenever the vendor supplies those things, it'll literally just say in the system, you know, this condition coded X amount of times by X amount of providers. And then, that could be erroneous. Sometimes those conditions have no more basis, or they're irrelevant. Sometimes they're miscoded to begin with, but when someone manually reviews it, like my team member, we can go in there and see that suspect that came through from a vendor and be like, you know what, I'm not seeing any active labs from this, or yeah, I do see one clinician coded that a patient has CKD3A, but there are no labs to support this at all, so I'm just gonna make the call to not send this forward to the clinicians. So, when we look at our response rates to our alerts, the clinicians favor and respond to and accept, like, 15-20% more of whatever our team sends versus what's auto-sent by the vendor. So, when we talk about AI and, you know, all this stuff, I'm like, trust me, we very much still need manual review and people.

Lori Cox: Agree. That was gonna be one of my next questions to you. How big is AI a factor in your organization right now?

Ava Johnson: You know, well, so, that vendor I'm talking about, like, does help a lot, and our upper leadership really loves AI, and believe it or not, clinicians also love AI. They love everything to be automated as much as possible, but there are just so many things that can be missed, so one thing that we're working on is, like, the, agentic AI kind of stuff, like Ambient. A certain vendor that we're gonna begin working with. But… My issue with that is that, you know, this, this, AI scribe will document this whole note, but the clinicians who are so short on time will just be like, hey, okay, sign it, I'm good, let's sign off on this, but then they won't review the small details, and it'll say completely random stuff. Oh my gosh, one time I had this, this, interview, or whatever, this review with a vendor, and they're like, oh, this is our tool, it's so great, and I was looking at it with my boss, and they're like, here, test it out. So we tested it out, and, like, my boss said this whole, like, you know, fictitious story. He's like, yeah, I live on, you know, the top floor of my building, but when I was walking up the stairs, I… I fell, and I kind of sprained my ankle, so I had to go to urgent care, this and that. And, you know, that's why I'm here for a follow-up visit. That note picked up that my boss had fallen from the top story of the building and sprained his ankle. And so… and then the vendor's just like, oops, little glitch. I'm like, little glitch! You know, so…

Lori Cox: Dang!

Ava Johnson: Yeah.

Lori Cox: pretty lucky. Maybe she bought a water ticket, right?

Ava Johnson: Incredible. Walking careful.

Lori Cox: That might be a good podcast for the future. Funny things in AI.

Ava Johnson: I know.

Lori Cox: Good. Well, yeah, and I'm glad to hear you say that your physicians are kind of leaning towards it. I've seen it both ways, too, here at AAPC with the clients that we work with, and at my own practice, I've seen some of them embrace it, and some of them are kind of iffy, so it's… I always like to get everybody's… opinion on… on how they feel, but good, I'm glad you guys are embracing it somewhat.

Ava Johnson: One thing that's funny, just to, like, close the loop on that, you know how, like, the big topic right now for coders is, like, is AI gonna take over?

Lori Cox: Yes, you know.

Ava Johnson: The thing is, there are clinic… like, every industry, my response to that is, like, every industry is having that fear, like, even clinicians, look at chat… I'm sorry, lawyers, chat GPT, right? You can ask it for things, and, like, lawyers are like, are we gonna… but I just went to the APG conference in San Diego, American Physician Group. And there was a whole session on AI, and I was surprised at the number of clinicians that were like, we're actually scared that, like, AI's gonna take some of our job away. And I'm like, even clinicians are feeling that way, yeah. And so, you know, and my argument to that is, like, well, still, it's clinicians who have to perform the physical assessment on the patient, perform the procedures and surgeries. It's attorneys who have to face the judge. you know, like, it's not gonna be AI, so just, just like that, like, coders and CDIs are very much needed to audit, continue auditing records and… you know, like I said about my example, about the AI, you know, vendor that's helping us supply our suspects, the clinicians, like, ignore a lot of what the vendor sends, but will even give more mind to whatever we send when they see, like, a human draft of this, I'm seeing the signs and symptoms, it's a concise query, this makes sense to me, it's sound, and someone reviewed this, and I feel better about it.

Lori Cox: I agree. Completely. Good point, too. I like that. I'll have to… tuck that away for future reference, because you're right, it's gonna… it's here, AI's here, and we're gonna evolve with it, just like… remember how I always like this analogy that, you know, back in the 1800s, farmers were plowing fields, and when tractors came, they all thought they were gonna be out of a job, but guess what?

Ava Johnson: You still need food.

Lori Cox: farmers to drive the tractors, even today, even though some of them can probably drive themselves, I would be a little worried.

Ava Johnson: I'm gonna take that one, Lori, thanks. That's a good one.

Lori Cox: Well, we're about halfway through, let's take a little break, and we'll be right back.

Ava Johnson: Alright, see you!

[BREAK]

Lori Cox: All right, everybody, welcome back to The Pulse. We are sitting here chatting today with Ava Johnson from Mount Sinai, talking about… well, we've talked about a whole bunch of different things today. In fact, during the break, we were talking about the Kentucky Derby. That's just how clear off-topic we can get on some of these podcasts. Okay, let's try to stay on subject. Tell me, okay, tell me a little bit, like, what kind of knowledge does someone need to truly understand value-based care?

Ava Johnson: Alright, so what type of knowledge? If you're moving from the fee-for-service side, you're gonna have to really learn about, contracting. Because when you have the payers, like, let's just talk about, like, Medicare Advantage contracts for a moment. But basically, those are private insurance companies, commercial insurance companies that bid for contracts with CMS, And they receive a capitated rate from CMS, for their, you know, patient demographics that are associated with certain organizations that they're working with. So, they might choose to, you know, partner with, like, let's say my company, Mount Sinai. So, we have a bunch of MA payers, and we'll get a capitated rate, work together on, like, risk, and we'll, you know, sometimes have more risk, full risk, upside risk only, depending on how confident a health system may be and how well they can perform in certain areas. So, like, for quality, for example, you'll have, you'll have to meet bonuses like HEDIS metrics and. MIPS and STARS ratings, and make sure, like, basically that you're performing depression screenings. Make sure that all diabetic patients' A1C's levels are, below a 9% for a certain age range. Make sure that women who are 40 and above are getting their breast screenings done. Breast cancer screenings done, every year. So there are quality metrics, and you just send this data back to your payer, and they'll be like, okay, you, you met the, you met the bonuses, or met the percentages here. And then there… there's, like, the risk adjustment side, which is one of the biggest ones, where you can… make the most funds. In some areas of contracting, it's about, like, using less, like utilization. It's, like, keeping everything down to a minimum, but with risk adjustment, if you're doing it accurately, then you can actually, you know, gain more income, which is necessary to treat your population. Like, I don't know who's familiar with, like, the V24 to V28, transition, but, you know, CMS releases these, HCC mappings annually, and they contain thousands and thousands of codes of risk adjustment HCC codes, basically conditions that have a RAF score value, like a coefficient, a risk adjustment factor, value, and those equate to a monetary value, and it basically is how much it costs to treat that condition each year. So let's say, like, putting contracting aside, and you multiply, like, by 10 percents and hundreds and everything, but let's just say, like, in a perfect world. You know, diabetes, for example, has a score of 1.160, which could essentially be, like, $1,500 a year. So you'll get that capitated rate, and that rate will include the cost of medication, you know, maybe a patient getting admitted if they have to, but really shouldn't, but basically it's the cost of medication for the year. Let's say heart failure, end-stage heart failure, that has a really large score of 2.5, which is, like, essentially maybe 24,000 bucks a year, which includes The cost of home oxygen, which is expensive, the medication, and that one includes the cost of a patient potentially having shortness of breath in the middle of the night and visiting the ED, or being hospitalized. So they're really… or, also, like, a heart assist device that the patient might have. So, the more complex the condition, the higher the RAF score, and if you have a really sick population, your RAF score would naturally be higher, because you are, spending more to treat that population. So, like, we'll have these… Monthly meetings with our payers, and then they'll say, like. This was your overall expenditure for utilization, this quarter. Or, you know, we have a few patients that are outliers, which are driving up your costs of utilization. But then we'll look at those, and we'll be like, well, this is an end-stage heart failure patient, and there's nothing we could have done to avoid this visit. Or, you know, they did have to stay in the hospital for 3, 4 days. So, you really want your coding to be accurate for cases like that, because, you know, end-stage heart failure is, you know, a shorter life expectancy than just unspecified heart failure. But unspecified heart failure patients wouldn't cost as much as end-stage heart failure patients, and sometimes the patients are already in the end-stage phase, but the coding's just inaccurate in the chart, like a less severe code is being used. So that's why it's really important that you have HCC coding knowledge, and that people are certified in their CRC, the Risk Adjustment Certification. Although, I have… taken a chance on some CPCs on my team, and just trained them in recognizing HCC codes, or everyone who comes to my department, be it a foreign clinician or a coder turned CDI, they all go through the same training program, so we'll walk them through everything about HCCs, get familiar with HCC mappings. I'm talking about, what risk adjustment is, what kind of things we're looking for, so It is possible for any coder to be trained in risk adjustment.

Lori Cox: But, yeah.

Ava Johnson: So quality and risk adjustment and, and utilization are really important. Sorry.

Lori Cox: Yeah, no, that's okay, because you're leading into what I was going into next, because there are some credentials out there. I think the CRC, most people are familiar with, or even, like, the CPMA, but there's, the CVBA? Is that… am I saying those? That's a little bit of a mouthful to try to say.

Ava Johnson: Totally.

Lori Cox: Tell me about that a little bit.

Ava Johnson: So, that's a really exciting one. The CVBA, was developed, the Certified Value-Based Care Administer, and it's really intended for people who are in risk adjustment. I was just mentioning, like, CPCs, and you mentioned CPMAs, right? They can transition into risk adjustment coding and risk adjustment auditing, but if you want to sit for the CVBA exam, you should already be in some sort of risk adjustment role. Whether that be auditing, coding, because you're gonna need to have knowledge of contracting, like I keep mentioning, and quality, risk adjustment coding, and CDI, vendor management, you know, I was mentioning our vendor earlier. All of that falls into this, so it's really intended for people who are in sort of leadership, value-based care roles, to really show your proficiency. And that you can lead an organization into the transition from fee-for-service to value-based care, or that, you know value-based care, so if you're going to go to a new organization, or a payer group, or even a vendor, wherever you're gonna… or private practice even, because everyone needs to be in some sort of value-based care contract by 2030, according to CMS. So everyone's got four… three and a half years to just get that ball moving. And, there are smaller mom-and-pop practices that are not… participating in value-based care contracts yet, but they don't know they need to. So, like, the conversation there is, you know, advising smaller practices. to get enrolled in, like, a bigger healthcare organization system somehow, and, like, affiliate with them. So, like, we have a ton of voluntary or community clinicians, which are those smaller practices that partner up with Mount Sinai, and then we'll have a Mount Sinai logo. If patients want to visit them, and it's a clinician nearby, they'll be, like, a Mount Sinai clinician, but really they were originally independent, but they're contracting with us to take part in our shared savings. So, it's for people… so you really need to have a lot of knowledge of that, and I'm getting a lot… I'm stressing that because I am getting people, who are wanting to take the workshop, the CVBA workshop, like we just had one at HealthCon that I led. But, like, a lot of people want to take the workshop or want to sit for the exam, but they have no knowledge or experience in value-based care, and that's really not advised. We have a few credentials at AAPC that require a certain level of experience, like the CPCI, The CPCM that just came out, the CBBA is one of those two, where you really should have experience before sitting for the exam, and you should be in that role, and it'll show prospective employers that you are certified, and that you know what you're doing, and that you can handle a transition, or leading all these initiatives.

Lori Cox: Oh, good. Okay, good. So I'm glad you said that. I know a lot of our, our AAPC clients that we work for, like, on the audit side of things, the larger clients are… they're getting together with the smaller practices to try to help them you know, become part of their organization, so they get all those benefits, and so then they'll have us come in and do, like, some due diligence audits to make sure that the providers are doing their documentation, and if they are participating in either HCC or value-based care programs, that they're following the guidelines for those.

Ava Johnson: Yeah. Oh, that's awesome.

Lori Cox: That's really important, and I'm glad that some of the larger… and I know it's probably hard for some of the smaller practices to be like, well, I guess I gotta join this large organization, or I'm gonna get beat up, but it does have its benefits in the long run, I think.

Ava Johnson: It totally does, and you're under their blanket and their covering. And, you know, the only challenge… well, the main challenge we have is, you know, I was talking about our team sending queries at the point of care, so those are sent via our major EHR, which is Epic. The voluntary, smaller mom-and-pop clinics don't have Epic. They have.

Lori Cox: Yes.

Ava Johnson: 150 different EHRs. I agree. our team can't query them. You know, what we do is, we'll look for a vendor that can integrate with as many HRs as possible, so, like, have our whole host list, and we'll be like, which HRs do you integrate with? And I say, do you, not can you, because every vendor will be like, oh, we can do that.

Lori Cox: We can do that.

Ava Johnson: So, it's like, no, which ones do you integrate with? And it's really just, like, 5 major ones, you know, often it's ECW, Athena, you know, but… it really is important that you are able to query them if you can, but for us, like, we're not able to right now, so we will do certain things with some of them. Like, some of them are struggling with risk recapture, so… we will just email them a list of open gaps, but it's not, like, a robust query process like we do with our Epic employee clinicians. This one is just, like, it's gonna be pretty basic, and I'll just have one of my managers do it instead of, like, the CDI teams do it, so it'll be high level, just here's an email of your open gaps, and they won't have detailed queries around them, but it's just a… Serves as a form of a reminder, and then those on-site managers or admins will help and give, like, paper to the clinician or whatever they do on-site, but… It is a bit of a challenge, but there are workarounds through vendors. EHRs also have things to do, but if you don't have a team sending them, then it's good to do something like I kind of said, where you're, you know, sending, like, a… maybe get their, patient visit scheduling data for the next two weeks, and then look through the open gaps for those patients, and just send, like. 20 open gaps, whatever the patients have, and then the practice, it's up to them to really do it well. They also need to do well in risk recapture, because it's part of their contract, too, so they are sort of incentivized and have a motive to want to do well and perform well, so you find ways.

Lori Cox: Hmm. How big of a team does it usually take? Like, say for… and I know we're kind of comparing apples to oranges here, but Mount Sinai is pretty big. A smaller practice may just need one person, but how many… do you have, like, a big team that just does… I know you said you're kind of a head over a team that does that.

Ava Johnson: Right, you know what? I used to have 14 CDQIs, and that was my dream state. My dream state would be 30, but… Really? Yeah. We used to have… 14. Right now, we… we have about 8, and that's because I've promoted some people, you know, and, like, some people became managers, and then we didn't quite get a backfill, or we didn't get a backfill, or it's like, hey, we can actually handle the load with this many, which, you know, is not my fave, but, like…

Lori Cox: Yes, I know.

Ava Johnson: Like, you know. But, so right now we have about 8, and let's say we get… the thing about risk adjustment is, like, you will get a lot of work, and the busiest season is the first 6 months of the year, and then things kind of slow down. So that's why you have, like, retro vendors who will have seasonal workers, or you have seasonal coders. So, for us, it is okay right now, but, like, let's say for the first 4 months, we'll have, like, 3,000 patients that come into our work queue. We can review about 600 of them. So, each CDQI can review about 70 to 75 patients in general a week. So, I'm not… you know, for me, I'm just like, you might do 20 today, you might do 10 tomorrow, you might be doing 25, just have your work done by the end of the week, and make sure your follow-ups are done in time. So, that's the kind of, trust I have. with my team, but let's say we can review about 600, so about 75% of our things get auto-sent, so I'm always hounding our vendor to make sure, like, everything they're sending is as accurate as possible. But the thing is. sometimes it's our clinicians that are doing the wrong thing to begin with, like I was mentioning, you know, that CKD3, reference earlier. CKD3 was legitly coded in the patient record, there's just no evidence of it, and then you do some digging, and you find that it was an external clinic that coded it, or a clinician miscoded it, which we see a lot of. And then, in the outpatient setting, these conditions, these… anything you drop on an outpatient claim is permanent in a patient's record. So, of course, if you're looking at recapture. These codes are going to be following the patient, so they're not always right to begin with, and that's something to consider too, but But yeah, so I work with our vendor to make sure it's accurate, because they are sending, like, the bulk of what the patients have open, so that's where we are, but yeah, so it's okay, but it would be great to have more, and I'm trying to get more actively more CDIs.

Lori Cox: Well, and I think probably a lot of the people listening, and even across, like, even with my own team at the University of Missouri, we need coders, and a lot of the coders these days, they're in their positions, they're happy where they are, so they're… not leaving, or, like, I need a highly specialized certain area, like, say, vascular, for instance. You know, and those highly trained vascular coders, they're not going anywhere. So, yeah, it's… I think it's across the board, it's just staffing is just an issue everywhere.

Ava Johnson: It is, it is, and it's, it's… It's unfortunate sometimes, just because, like, I feel like a lot of people are jumping on the AI bandwagon, and I'm not… I'm totally not anti-AI.

Lori Cox: I love chatting with you.

Ava Johnson: you trust me, and, like, I know I need it. But, like, we very much still need manual review, like. you know, especially with NLP, this is something big in risk adjustment.

Lori Cox: And…

Ava Johnson: natural language processors, so a lot of vendors now are supplying prospective NLP, basically. You might send them PDFs of your patient records, or ideally, they should have some sort of really limited access to your EHR. So they gain access, user access, and then they can run through your EHR and find evidence of conditions that were documented And not coded, or conditions that are found on imaging reports that haven't been coded in a visit note, or they're getting advanced and they're able to look at labs and decipher that a patient might have a condition based on those labs. So they're essentially trying to do the work of a CDI, But there are a million and one errors still happening, so my big thing is if you're a vendor, make sure that you have those clinical people and coders working on your tool actively. Don't just be like…

Lori Cox: I agree.

Ava Johnson: hey, it works! It goes on.

Lori Cox: Yeah.

Ava Johnson: And the data's totally erroneous, like, that's the biggest headache, you know, and I'm… sometimes I'm really frank with them, and I'll be like, I'm sorry, but your tool, I know you have, like, all these clients, but your tool should have never been launched as is. Like, it's not ready for the public, and sometimes I'm, like, not everyone's best friend, but I'm like, hey.

Lori Cox: you're telling them the truth, because other people are going to if you don't, too, you know, so…

Ava Johnson: Big thing.

Lori Cox: Well, we're almost done. I have one more question for you. What advice would you give to teams trying to improve performance in value-based care?

Ava Johnson: Well, that is a really, really good and big question. If you're trying to improve, with risk adjustment, you should definitely invest in a CDI team. Cdis can front-end the process. While it's important to have coders. Coders can only back-end the process, CDIs can front-end the process, and what's even better is if you have certified coding CDIs, which is, like, what we have. We have… every… every CDI on our team is a certified coder, so they can look at the coding and documentation after, apart from querying a clinician, prior to the patient visit. And just make sure that you utilize your EHR as much as possible with quality. You know, there are alerts you can send, like, with med adherence. You know, one of the big things is… one of the metrics is, like, refills not being filled. and then the patients aren't adhering to their medication, but then you find that the clinician forgot to add a refill to that initial prescription. Oh. So things like that, like creating alerts in Epic if ever you see, like, a clinician, put an order in for a prescription, and it's like you add a flag where if they didn't, add a refill to alert them to. You know, little things like that. You have to have people who are not scared to. get into the details. And, one big thing is that we're dealing with a lot of different generations working, and Don't be afraid to do work that doesn't necessarily fall under your scope. Like, the people who will say, like, well, that's not my job, are not the best people to be working in this field, because you're going to be doing a lot of stuff that's not necessarily your job, but if you care about doing good work. then you'll get it done, and, you know, trust me, leadership pays attention. That's why a ton of my people on my team, I've promoted without them even needing to ask me for anything. Like, I just pay attention to those things, and I'm like, this person… I once had someone who, like, just started a week in, and I'm just like, you can be a manager one day. And they're like, I just started as a CDI when I had the opportunity a year and a half later. almost two years later, they were… they were manager. Like, you'll see potential in people, so, just don't be afraid to do the small details, and just make sure that you are paying attention to those things, because sometimes big problems come from little things that could have been fixed right on the offset.

Lori Cox: Oh, agree, and in every aspect of our… Yes. For sure.

Ava Johnson: Totally.

Lori Cox: Well, thank you so much. This has been a really great conversation. You have top knowledge on value-based care, so I know where I'm going if I have any questions.

Ava Johnson: So awesome chatting with you, thanks for having me on.

Lori Cox: Yep, thanks everybody, thanks for listening, and we'll see you next time on The Pulse.

Ava Johnson: Bye!