20 Modern Healthcare | August 19, 2019
Population health
Jennifer Velez
Dr. Jen Brull
Medical director
Aledade’s Kansas accountable care organization
Brull leads Aledade’s accountable care
organization in Kansas and helped implement
the “Roadmap to Awesomeness,” an
improvement tool for practices to assess data
and follow best practices. The ACO taps into
real-time data to address gaps in care. The
road map helped Brull’s solo medical practice
in Plainville, Kan., reduce ED utilization for
diabetic patients. Overall, the ACO cut hospital
admissions by 23% for congestive heart failure
patients and reduced ED visits by 11% in 2017
for Medicare patients (the most recent year for
which data is available). The ACO also saw a
17% increase in breast cancer screenings and a
31% increase in well-child visits.Jennifer Velez
Executive vice president, community and
behavioral health | RWJBarnabas Health
Velez co-chairs an opioid task force that’s
working to both improve care for the patient
population and destigmatize drug addiction.
She’s put together a multidisciplinary team
and uses real-time data to take action. In
its fi rst seven months, the task force helped
reduce emergency department opioid
prescriptions by 42%; 25,380 ED patients
and 21,116 inpatient discharges who could
have received an opioid prescription did
not. Across the system, 46,496 patients
were provided alternative treatments in lieu
of opioids. More than 6,000 patients with
substance use disorder were connected with
a peer recovery specialist and 80% of them
used those services.RWJBARNABAS HEALTHDr. Bechara Choucair
Senior vice president and
chief community health offi cer
Kaiser Permanente
Choucair’s innovations have reached
multiple populations in Kaiser’s
membership and beyond. Among
other things, he leads Kaiser’s
$200 million effort to increase access
to affordable housing. Through
the system’s Thrive initiatives,
he’s helping connect patients with
other services to address social
determinants of health. He also
oversees the organization’s research
into preventing gun violence, an effort
launched in 2018.Drew Crenshaw
Chief population health offi cer
Oak Street Health
With an eye toward reducing
readmissions, Crenshaw developed
Transitions-in-Care, a new module within
Oak Street Health’s IT platform. It gives
clinicians a more detailed view of patient
data, pulling from nearly 1,300 datasets,
allowing them to take proactive steps
to reduce the risk of readmission. As a
result, Oak Street has seen a 15% drop in
year-over-year 30-day readmissions since- And Oak Street’s readmission rate
is 40% better than the average reported
by the CMS.