For hospitals and provider networks to successfully navigate the transition to value-based care, they must develop new care models that emphasize education and outreach to patients, experts say.

This is particularly important in the case of patients with chronic conditions, many of whom ineffectively manage their health and medications, resulting in expensive emergency room treatment, readmissions, and unfavorable outcomes.

Winona Health has been practicing outreach on a number of fronts and, in fact, was among the Office of the National Coordinator’s Beacon programs, winning a grant as a participant of the Southeast Minnesota beacon Community Project.

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The Minnesota-based health network with more than 60 physicians and associate providers, 1,100 employees and 400 volunteers, a hospital, nursing home and two assisted-living communities, also launched an initiative called the Community Care Network.

"Many of the reasons people come into the ER and have these re-hospitalizations aren’t necessarily medical," said Rachelle Schultz, president and CEO of Winona Health. "It’s often a home situation: Do they have enough food to eat? Do they have social support?"

In a talk at HIMSS16 titled, "Building a Community Care Network for High-Needs Patients," Schultz will describe how Winona enlisted volunteers from a local university to act as its eyes and ears in the community, thus providing the hospital with ground-level information, an essential ingredient of effective population health management.

"When we see the same patient coming back for readmission, for ED visits on some level of frequency, something’s happening that we don’t know about," Schultz said. "This initiative allows us to see what’s broken outside of our walls."

Hospitalized patients are asked if they would like to take part in the program, which sends volunteers into their homes and communities. Participants range in age from 19 to 91, with an average age of 62. Most typically have multiple chronic conditions such as diabetes and COPD, while 25 percent to 30 percent have a primary diagnosis of a mental health condition.

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The volunteers don’t provide clinical care; rather, they act as a partner and resource for patients, meeting them for coffee, walking them around the block, making sure they’re eating the right foods, listening to them, and suggesting small changes that will improve the patient’s health. Volunteers also use positive messaging to encourage healthy patient behavior.

Winona’s population health initiative also relies on smart registries to learn where else patients may be seeking care in the area or region.

In the first year of the program, Winona Health achieved an 85 percent to 95 percent decrease in readmissions and preventable visits, saving more than $250,000. But Schultz said the initiative isn’t about money.

"We talk about patient-centered care in healthcare, but we don’t really do it," she said. "This is the most patient-centered care we could possibly provide. Based on what we’ve seen, I know we’re making a big impact in people’s lives. We’re transforming how we deliver care."

Schultz said C-suite healthcare professionals attending HIMSS16 would benefit from attending her session because "if they don’t buy off on this kind of initiative, it won’t go anywhere."

The session, "Building a Community Care Network for High-Needs Patients," is slated to take place Tuesday, March 1, from 11:30 a.m. to 12:30 p.m. in Center Palazzo I at the Sands Expo Convention Center.

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This story is part of our ongoing coverage of the HIMSS16 conference. Follow our live blog for real-time updates, and visit Destination HIMSS16 for a full rundown of our reporting from the show. For a selection of some of the best social media posts of the show, visit our Trending at #HIMSS16 hub.