Population Health
Population health describes the management of health and illness. At MUSC Health, the health we manage includes not only the absence of illness but the concept of health.
Vision
A healthy South Carolina.
Mission
Transforming healthcare delivery to achieve better outcomes for the lives we touch.
Growth
Process
We offer health care that is consistent, sustainable, equitable, scalable, patient-centered, and value-based to better serve our population. We leverage technology, evidence-based practice, community partnerships, and engagement.
What We Do
Value Institute
The Value Institute was established in 2012 to support MUSC's efforts to advance evidence-based practice at the bedside through innovative solutions and the education of future leaders.
Evidence-based practice (EBP) is the integration of research evidence with clinical expertise and a patient's values and preferences. The motivation for EBP integration comes from payor and healthcare facility pressures for cost containment, greater availability of information and greater consumer savvy about treatment and care options. The EBP process encourages patient-centered care by more clearly defining the benefits and harms of interventions as part of shared decision-making between providers and patients.
Vision
To optimize healthcare delivery and value based on evidence.
Mission
Transforming healthcare delivery by leveraging evidence to create tools that improve value.
What is evidence-based practice (EBP)?
For more information visit Overview of EBP - Evidence-Based Practice - Guides at Medical University of South Carolina
How do we support evidence-based patient care?
- EBP staff education through our project-based courses to support continuous improvement of clinical care and quality.
- MUSC Health guideline development (Ideal Care Plans) which establishes the “MUSC Health standard of care” for patients treated in our facilities across the state of South Carolina.
- Population-based Pathway development for providers and nurses to promote evidence-based care in our electronic medical record (EMR) for patients in our clinics, emergency departments, and hospitals.
Value Intelligence
The South Carolina Quality Achievement Program (SC QAP)
- Gathered, performed quality assurance checks, and submitted data to meet program requirements
- 18,894 diabetes encounters, 98,720 ED visit encounters, 33,487 hypertension encounters, 2,196 maternal care patients, 236 ED navigation patients
- Supported ED Navigator workflows and development of Compass Rose tools
- Improved performance visibility with dashboard summary view for Diabetes and Hypertension
BCBS Cooper
The Value Intelligence Pharmacoeconomics team identified an opportunity to confirm from Humira® to biosimilars which we anticipate will result in over $200,000 in shared cost savings in the coming year.
Compass Rose – 35% of Care Management Programs using Compass Rose tools, with goals of 65% by FY 25
Social Determinants of Health – Performed Slicer Dicer and SDOH training sessions including Black River Emergency Food Box Slicer Dicer Assistance
Primary Care – Developed Slicer Dicer Dashboard focused on key Health Maintenance elements
Healthy Planet – 100,000+ value-based contract lives tracked in Epic in collaboration project with Information Solutions.
Care Management
- New and optimized Compass Rose care management program tools for Community Health Workers, Chronic Care Management, Transitional Care Management, Chronic Kidney Disease and Pharmacy Concierge services
- Healthy Planet link provides communication and care coordination pilot programs
Regulatory
Hierarchical Condition Category (HCC)
- The Value Intelligence team has played a significant role in the development of new tools and programs to support clinicians in HCC coding
- New analytics data models, suspected diagnosis suggestion based on clinical criteria, and pre-visit CDO activity are under implementation
- New program to develop an Outpatient CDI team is underway
Engagement Management
Communicated provider feedback to IS resulting in several provider satisfaction improvements:
- Defaulting program data elements to save provider clicks
- Redesigned EOM SmartForm to improve workflow
- Created EOM Checklist SmartPhrase to streamline documentation
Risk Adjustment
Developed risk adjustment tactics including increasing opportunities for outpatient visits where diagnosis can occur and capitalizing on opportunities to improve Outpatient Clinical documentation.
Community Development
Created dashboard for SDOH grants to demonstrate impact, streamline data submissions and identify opportunities for our Population Health Sickle Cell and Community Health Worker programs.
Diabetes Prevention Program
The Diabetes Prevention Program is an evidence-based lifestyle change program to help patients eat well, move more & prevent or delay the onset of Type 2 Diabetes. This group-based program includes a full year of sessions & support to help you achieve your goals!
Tobacco Treatment Program at MUSC (Tobacco-Free)
We’ll show you how to conquer your urges, use nicotine-management gums and lozenges, control your environment and get the emotional support you need.
CMS Innovation Models
MUSC Health participates in Centers for Medicare & Medicaid Services (CMS) innovation modules in select health care facilities. Ask your care provider to see if these models are applicable to your care.
Overview of the CMS GUIDE Model
The Guiding an Improved Dementia Experience (GUIDE) Model is an 8-year initiative launched by the Centers for Medicare & Medicaid Services (CMS) on July 1, 2024. This nationwide, voluntary program is designed to transform dementia care by offering comprehensive support systems for patients and their caregivers.
Core Objectives
- Coordinated Support: It bridges the gaps in fragmented healthcare by offering dedicated care navigation and 24/7 access to a helpline.
- Caregiver Assistance: Recognizing the immense physical and financial toll on families, the model provides essential training, education, and up to $2,625 in annual financial support for respite care.
- Aging in Place: The ultimate goal is to help individuals with dementia live safely in their own homes for longer, delaying the need for nursing home placement.
- System Efficiency: By introducing early, structured interventions, the model aims to enhance the quality of life for families while reducing overall Medicare and Medicaid spending.
Overview of the CMS TEAM Initiative
The Transforming Episode Accountability Model (TEAM) is a mandatory, five-year project introduced by the Centers for Medicare & Medicaid Services (CMS). Running from January 1, 2026, through December 31, 2030, the model holds selected acute care hospitals across various U.S. regions accountable for ensuring that Traditional Medicare beneficiaries receive coordinated, high-quality care during and after major surgeries.
The program focuses specifically on coordinating healthcare from the initial operation through 30 days post-discharge for five specific surgical procedures:
- Lower extremity joint replacements
- Surgical treatments for hip femur fractures
- Spinal fusions
- Coronary artery bypass grafts (CABG)
- Major bowel procedures
Key Objectives & Strategy
- Eliminating Fragmented Care: Surgical patients often face disjointed transitions between surgeons, hospitals, and post-acute care facilities, which can stall recovery. TEAM incentivizes hospitals to bridge these gaps, ensuring a seamless handoff between different healthcare providers.
- Prioritizing Primary Care: To encourage long-term health recovery and continuous wellness, participating hospitals are required to connect patients with primary care services following their surgeries.
- Reducing Avoidable Complications: By closely tracking patient recovery for a month post-hospitalization, the model aims to significantly decrease unnecessary emergency room visits and preventable hospital readmissions.
- Protecting Healthcare Resources: In alignment with broader federal innovation goals, TEAM looks to optimize taxpayer dollars by cutting out redundant care, improving overall system efficiency, and elevating the patient recovery experience.
