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Enhancing Depression Identification and Stratification with a Claims-Based Analytical Framework

Abstract Depression, a prevalent health condition, substantially impacts both socioeconomic outcomes and individual wellbeing. Despite the availability of diagnostic tools, existing approaches for identifying depression […]

Association of frailty with outcomes of patients undergoing transvenous lead removal for cardiac implantable electronic device infections in the United States

Abstract Background Frailty, marked by reduced physiological resilience, is associated with adverse outcomes in patients undergoing various cardiovascular procedures. The rising incidence of cardiac implantable […]

Long-term healthcare resource use and cost associated with COVID-19 disease from a health system perspective. An equity-focused population-based cohort study

Abstract SARS-CoV-2 strained Ontario’s health system, with social determinants of health (SDH) underexplored in cost analyses. We examined COVID-19 attributable healthcare resource use and costs […]

The need for long-term support: Five-year outcomes after severe injury in older adults

Abstract Background While the short-term risks of severe injury among older adults (age≥65) are well studied, little is known about long-term functional outcomes in this […]

Primary care unattachment: impact on mortality, hospitalizations and costs

Abstract Introduction Primary care attachment is the formal or informal affiliation with a regular primary care clinician. In countries with near-universal primary care, a physician’s […]

Evaluating an insurer-based health coaching program: Impact of program engagement on healthcare utilization and weight loss

Abstract Insurers and employers are increasingly offering lifestyle and weight-loss coaching programs; however, few evaluations have examined their effectiveness. Our objectives were to determine whether […]

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Population Health Profiling

This webinar will explore how the ACG System can – and is – being used to support commissioners and those responsible for the management of […]

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Risk adjusted resource allocation in Sweden

Presented by:Andreas Johansson, M.Sc., Founder of Ensolution

Comparison of health care needs of child family members of adults with alcohol or drug dependence versus adults with asthma or diabetes

J Dev Behav Pediatr 35:282-291. Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA OBJECTIVE: To compare the health problems, preventive care utilization, and […]

Prevalence of depression in adults with type 2 diabetes in the Basque Country: relationship with glycaemic control and health care costs

BMC Public Health 14:769. Basque Institute for Healthcare Innovation, Barakaldo, Spain BACKGROUND: The aim of the study was to estimate the prevalence of depression in […]

Data resource profile: Pathways to Health and Social Equity for Children (PATHS Equity for Children)

Int J Epidemiol 43:1438-1449. Manitoba Centre for Health Policy, Winnipeg, MB, Canada The PATHS Data Resource is a unique database comprising data that follow individuals […]

Incidence of severe hypoglycaemic episodes in patients with type 2 diabetes in the Basque country: impact on healthcare costs

BMC Health Serv Res 15:207. Basque Institute for Healthcare Innovation, Barakaldo, Spain; Osakidetza, Basque Health Service, Erandio, Spain; University of Deusto, Bilbao, Spain BACKGROUND: Hypoglycaemia […]

Variability in potentially preventable hospitalisations: an observational study of clinical practice patterns of general practitioners and care outcomes in the Basque Country (Spain)

BMJ Open 5:e007360. Osakidetza Basque Health Service, Erandio, Bizkaia, Spain; University of Deusto, Bilbao, Spain OBJECTIVES: To explain the variability in the frequency of potentially […]

Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo

Ann Neurol 79:32-41. University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronot, ON, Canada; Institute of Health Policy, Management and Evaluation at the […]

Evaluation of an innovative program to improve outcomes among military beneficiaries with diabetes

Nurs Econ 33:271-280. University of Texas at Tyler, Tyler, TX, USA; Texas A&M University Health Science Center, Bryan, TX, USA Patients with Type 2 Diabetes […]

Health administrative data can be used to define a shared care typology for people with HIV

J Clin Epidemiol 68:1301-1311. Bruyère Research Institute, Ottawa, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada; Ottawa […]

Trends in relative survival in patients with a diagnosis of hepatocellular carcinoma in Ontario: a population-based retrospective cohort study

CMAJ Open 3:E208-E216. University of Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research/Cancer Care Ontario, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, […]

Prevalence and costs of chronicity and multimorbidity in the population covered by the Basque public telecare service

An Sist Sanit Navar 36:429-339, Published in Spanish. Centro de Salud Astrabudua, Erandio, Spain BACKGROUND: The public telecare service in the Basque Autonomous Community (betiON) […]

Medication, diagnostic, and cost information as predictors of high-risk patients in need of care management

Am J Manag Care 15:41-48. Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA OBJECTIVE: To contrast the advantages and limitations of using medication, […]

Preventive screening of women who use complementary and alternative medicine providers

J Womens Health 18:1133-1143. Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA BACKGROUND: Many women use […]

Conference Welcome – Amy Salls

ACG Training Conference WelcomeAmy Salls Director, Population Health Strategy DST Health Solutions 

01 Welcome & Introduction – Alan Thompson

Alan Thompson Director of User Support Johns Hopkins HealthCare Solutions

02 Population Health Management – Ming Tang

Ming Tang Director of Data & Analytics Data, Analysis and Insights Service (DAIS) NHS England and NHS Improvement

Welcome & Introduction – Jonathan Weiner & Mark Cochran

Welcome and IntroductionJonathan Weiner Professor and Director, Center for Population Health IT  Mark Cochran Executive Director, Johns Hopkins HealthCare Solutions

03 Complex Case Management Programme – Jim O’Donnell

Dr. Jim O’Donnell Slough Locality Lead, NHS East Berkshire CCG Frimley ICS Clinical Commissioning Lead EBCCG Reducing Variation Workstream Clinical Lead Deputy Chair Slough Wellbeing […]

04 Advances in Population Health Sharing Insights – GE Healthcare & Sollis

Pat Nichols, GE Sarah Ouanhnon, GE Graham Head, Sollis

05 From Cake-mix to Case-mix – David Shepherd

Dr. David Shepherd GP & HNN Lead Leicester City CCG

06 Working Together to Deliver Population Health – Chris Roche

Chris Roche Information Manager Gloucestershire STPPlease note: There are three buttons below. One will link to the presentation slides. One will link to a separate […]

07 Using Predictive Models to Support Case Finding – David Brown & Peter Glover

Dr. David Brown Peter Glover Farnham Integrated Care Services

08 Risk-Adjusted Resource Allocation in Leicester – Mark Pierce

Mark Pierce Senior Strategy & Implementation Manager Leicester City CCG

01 David Shephard – Casemix Adjustment in Primary Care

Dr. David Shephard GP and Health Need Neighbourhood Chair, Leicester South

Session 1: Brad Myers – Version 12 Supplementary Data

Version 12 Supplementary Medical ServicesBrad Myers DST Health Solutions 

01 Karen Kinder Welcome Presentation

ACG System Dr. Karen Kinder Executive Director

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New Medicaid Enrollees with Highest Care Needs

The ACG System can help identify new Medicaid enrollees with high care needs.

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COVID-19: Marathon Health Outreach

By leveraging the Johns Hopkins ACG System, Marathon Health was able to offer outreach and options to individuals identified as a higher risk of contracting or experiencing complications as a result of COVID-19.

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Recalibration of Predictive Models

This short report provides details of the third recalibration of the predictive models within the ACG System for the UK.

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Reducing Disparities in the Delivery of Primary Care

This report details the work of 2020 Starfield award winner Discovery Health to demonstrate, using the Johns Hopkins ACG System, the impact of improving primary care utilization.

Session 2: Don McGaw – Version 12 JHU ED Visit Classification

Version 12 JHU ED Visit ClassificationDon McGaw DST Health Solutions 

Session 1: Mitchell – Assessing Patient Morbidity: Risk Factors

DST Health Solutions Assessing Patient Morbidity: Risk Factors Anna-Marie Mitchell Senior Product Consultant

02 David Colin Thome – Primary Care Home

The Primary Care Home (PCH) David Colin-Thomé Independent Healthcare consultant Visiting Professor Manchester Business School Former General Medical Practitioner and National Clinical Director for Primary […]

Keynote I – Jonathan Weiner – Analytics & Big Data in Support of the Social and Medical Health of Populations

Analytics & Big Data in Support of the Social and Medical Health of Populations: The ACG System Today and TomorrowJonathan P. Weiner, DrPH Professor and […]

Session 3: Anna-Marie Mitchell – Version 12 Laboratory Measures

Version 12 Laboratory MeasuresAnna-Marie Mitchell Senior Analytic Product Consultant DST Health Solutions 

Session 2: Myers – Hospitalization Risk

DST Health Solutions Hospitalization Models Brad Myers Predictive Modeling Product Consultant

03 Nick Harding – Challenges Faced By Primary Care

NHS Sandwell and West Birmingham Clinical Commissioning Group The challenges faced by primary care and the need for good quality information Professor Nick Harding OBE FRCGP […]

Session 4: Amy Salls – Assessing Candidates for Care Coordination

Assessing Candidates for Care CoordinationAmy Salls Director, Population Health Strategy DST Health Solutions 

Session 3: McGaw – Care Coordination

DST Health Solutions Care Coordination and Care Density Donald D. McGaw Jr. Client Relations Consultant

Session 4: Salls – Assessing Candidates for Care Management

DST Health Solutions Assessing Candidates for Care Management Programs Amy Salls Director, Population Health Strategy

Hospitalization Risk Scores: Amy Salls, DST Health Solutions

ACG System DST Health Solutions Hospitalization Models Amy Salls

Session 5: Sokchay Chiv & Kate Hollidge – Catching a Breath Program for COPD

Catching a Breath Program: Implementing and Expanding Clinical ProgramsSokchay Chiv Director, Population Health Strategies Meridian Health PlanKate Hollidge Senior Manager, Population Health Programs Meridian Health […]

05 Lizelle Steenkamp – Segmentation and the Impact of Vitality

Discovery Health Vitality Segmentation and impact of Vitality (Population Health Management) Lizelle Steenkamp

Session 5: DiLorenzo – An Analysis of Risk Scores of Patients with Less Than Twelve Months of Claims History

MVP Health Care Analysis of Risk Scores of Patients with Incomplete Claims History Tyson DiLorenzo, PhD. Manager, Finance & Actuarial Analytics at MVP

Session 6: Brad Myers – Version 12 Opioid Markers

High Risk Opioid Use MarkersBrad Myers DST Health Solutions 

06 James Barrett – The Benefits of an Integrated Dataset When Predicting Future Risk

James Barrett Johns Hopkins HealthCare Solutions Johns Hopkins ACG System

Data Validation: Lisa Kabasakalian, DST Health Solutions

ACG System DST Health Solutions The Johns Hopkins ACG® System Data Validation Lisa Kabasakalian

Session 5: Khomenko – Health Questionnaires and Population Risk Indexing

DataSmart Solutions Health Questionnaires and Population Risk Indexing Bernard Khomenko, CEBS Vice President of Client Services

Session 7: Sokchay Chiv & Kate Hollidge – Opioids Among the Masses

Opioids Among the Masses: Using Advanced Analytics to Drive Clinical ProgramsSokchay Chiv Director, Population Health Strategies Meridian Health PlanKate Hollidge Senior Manager, Population Health Programs […]

07 Alan Thompson – Segmentation: Exploring the Relationship Between Frailty and Other High-Risk Groups

Alan Thompson Johns Hopkins HealthCare Solutions Johns Hopkins ACG System

Assessing the Impact of Incomplete Date: Kelsey Rauch, DST Health Solutions

ACG System DST Health Solutions Patient Identification with Incomplete Data Kelsey Rauch

07a Mark Pierce – Applying the ACG System in Whole Population Management

Leicester, Leicestershire and Rutland Integrated Teams Mark Pierce

07b David Cochrane – Applying the ACG System in Whole Population Management

Conrane International Health Solutions (IHS) Whole Population Management- What to do about it David Cochrane

Session 8: Philip Bruns – Population Health Management for Non-Clinical Analysts

Population Health Management for Non-Clinical AnalystsPhilip Bruns BenefitFocus 

09 Population Segmentation and Risk Stratification – Kelechi Nnoaham

Kelechi Nnoaham Director of Public Health Cwm Taf Morgannwg University Health Board, Wales

Program Evaluation: Amy Salls, DST Health Solutions

ACG System DST Health Solutions Using The Johns Hopkins ACG® System for Program Evaluation Amy Salls

Session 6: Terrell-Hoxter – The Challenge of Visualizing Diagnostic Conditions in the Population

Lightbeam Health Solutions The Challenge of Visualizing Diagnostic Conditions in the Population Mike Hoxter, Tim Terrell

08 J Pall S Adams – Working Together to Gain Insight

Sollis Working together to gain insight Supporting and enhancing the lives of people in Brighton Jaivir Pall

Session 9: Nathan Cohen – Leveraging Data to Improve Outcomes and Delivery of Care

Leveraging Data to Improve Outcomes and Delivery of CareNathan Cohen Philips Population Health Management 

Session 1 – Ines Vigil & Martha Sylvia – Achieving Population Health Surveillance with ACG System Outputs

Achieving Population Health Surveillance with ACG System OutputsInes Vigil MD, MPH, MBA VP, Advanced Analytics Priority Health   Martha Sylvia PhD, MBA, RN President ForestVue Healthcare […]

10 Features in the Next Version of the ACG System – Steve Sutch

Dr. Steve Sutch Product Management Director Johns Hopkins HealthCare Solutions

Session 6: Sylvia – A Pilot of Using the ACG System with Electronic Medical Record Data to Identify Children with Medical Complexities at the Medical University of South Carolina

Medical University of South Carolina (MUSC) Health Using ACGs in the Electronic Medical Record to Identify Children with Medical Complexities Martha Sylvia, Seray Gardner, Corey […]

09 C Morris S Scobie – Population Health Analytics

NHS – South, Central and West Commissioning Support Unit SCW | CSU Population Health Analytics – from supporting clinical commissioning to shaping New Models of […]

Session 10A: Anna-Marie Mitchell – Assessing Mortality: Ontario Mortality Score

Assessing Mortality: Ontario Mortality ScoreAnna-Marie Mitchell Senior Analytic Product Consultant DST Health Solutions 

Session 7: Prada – Using the ACG System in Colombia: What Have We Learned About Our Health System?

Universidad Icesi – Proesa Using the ACG System in Colombia: What have we learned about our health system? Sergio I. Prada, PhD Melissa Perez, M.A.

Session 7: Lieberman – Integrating The Johns Hopkins ACG System with Other Proprietary and Non-Proprietary Tools

Mile High Healthcare Analytics Integrating The Johns Hopkins ACG System with Other Proprietary and Non-Proprietary Tools Richard Lieberman

10 David Shepherd – Pin the Tail on the Donkey

Pin the tail on the donkey and other party games David Shepherd

Session 10B: Tyler Boese – Assessing Mortality: Ontario Mortality Risk Score

Assessing Mortality: Ontario Mortality Risk ScoreTyler Boese Medica

11 Alan Gwynne – The Magic of Venn Diagrams

Some practical examples of using population profiling and risk stratification within The South Cotswold’s locality Alan Gwynne

Session 8: Hall – Creating Reporting Benchmarks for Provider ACOs

Minnesota Department of Human Services Creating Reporting Benchmarks for Provider ACOs Jackie Sias, Data Analyst Kristofer Hall, Provider Informatics Lead

Session 11: DST Health Solutions Team – Ask the Experts

Ask the ExpertsDST Health Solutions Team

Session 8: McGaw – Customizing ACG System Output Using Filters and Calculations

DST Health Solutions Customizing ACG Output Using Filters and Calculations Donald D. McGaw Jr. Client Relations Consultant

12 Alan Thompson – Closing Remarks

ACG Johns Hopkins Healthcare Solutions (JHHCS) Reflections on the Day Alan Thompson  

Session 12: Adele Allison – Value-Based Payment

Anatomy of Value-Based PaymentAdele Allison Director, Provider Innovation Strategies SS&C Health

Session 9: Khomenko – Confidence in Predictions to Meet Organizational Needs

DataSmart Solutions Confidence in Predictions to Meet Organizational Needs Analytics Driven Solutions Bernard Khomenko, CEBS Vice President of Client Services

Session 1 – Pepa Soriano – ACG System as a key factor for a PHM program

ACG System as a key factor for a PHM programPepa Soriano Leader of the Population Management Program at Ribera Salud

Session 13: Amy Salls – Total Cost of Care

Total Cost of Care AnalyticsAmy Salls Senior Director, Analytics SS&C Health

Session 14: Arielle Trzcinski – Advanced Analytics Required to Win, Serve, and Retain Customers

Advanced Analytics Required to Win, Serve, and Retain CustomersArielle Trzcinski Senior Analyst Forrester Research

Session 9: Singal – Pharmacy Value-Based Programs

DST Pharmacy Value Based Programs Rahul Singal, MD Chief Medical Officer

Session 15: Tim Terrell – Storytelling with Exploratory Data

Storytelling with Exploratory DataTim Terrell Director of Analytics Lightbeam Health Solutions

Session 16: Dustin Burt – Turning Health Risk Assessments into ACG System Inputs

Turning Health Risk Assessments into ACG System InputsDustin Burt Data Scientist Buckeye Health Plan 

Session 17: Don McGaw – ACG Panel Size and Risk

Panel Sizing using ACG outputsDon McGaw DST Health Solutions 

Session 1 – Sokchay Chiv – Implementation and Continuation of a Care Coordination Program

Meridian Member Clinical ProfileSokchay Chiv Director Population Health Strategies and Analytics