In this episode of Enabling Health Value, we sit down with Patrick R. Young, President of Population Health at Hackensack Meridian Health (HMH), to explore his leadership in transforming population health and advancing value-based care. Young has spearheaded numerous initiatives that have significantly enhanced patient outcomes and driven savings across the system, including the growth of HMH’s clinically integrated network from 800 to over 4,100 providers. Under his leadership, HMH’s Accountable Care Organization has been one of the top performers in the country, generating $247 million in combined savings since 2012.
By integrating community health workers into care teams and addressing social determinants of health, Hackensack is setting new standards in patient engagement and culturally competent care. In this episode, you will learn strategic approaches that balance innovation with practicality, emphasizing care coordination, managed care contracting, and technology integration. We explore Hackensack’s use of advanced analytics, predictive modeling, and AI to improve care for high-risk populations, reduce costs, and enhance outcomes—particularly through their “Hospital From Home” and SDOH programs. We also discuss the importance of building trust in patient communities and how asset-light care models and system integration can drive sustainable impacts in population health.
Podcast Bookmarks
01:15 Introduction to Patrick Young, President of Population Health for Hackensack Meridian Health
02:30 The Lumeris and Hackensack Meridian Health partnership in value-based care.
04:15 HMH ACO (recently combined from 3 other legacy ACOs) has earned $247 million in combined total savings from 2012 to 2021.
06:00 The visionary leadership of HMH CEO, Bob Garrett to empower the development of HMH’s population health division.
06:30 The opportunity to synergize operations within a CIN to create greater value.
07:00 An overview of population health at Hackensack Meridian Health with recent earnings exceeding $50M.
07:30 How Lumeris’ data aggregation and technology solutions drive performance in HMH practices.
08:15 New Jersey ODS licensure and the creation of Braven Health MA Plan (a JV with Horizon BCBS and Robert Wood Johnson).
08:30 Hackensack Meridian Healthy Connections (HMH’s social determinants of health program that uses community-based CHWs).
10:45 Performance of SDOH program using predictive analytics (i.e. $2.9M in Medicare savings, $8PMPM reduction in spend for ED visits, $40PMPM reduction in inpatient spend, 25% increase in PCP utilization).
11:30 Referencing Bob Garrett’s Keynote Address at HIMSS24 (“Hackensack Meridian CEO says AI could improve health of billions”)
12:45 The importance of choosing the right technology and analytics partner to make data actionable.
13:00 HMH population health team has issued about 4 million referrals to community-based resources.
13:00 The power of using non-clinical information in risk stratification models.
14:00 The composition of an effective care team to deliver patient-centered care.
15:00 Making data useful for care managers and community health workers.
16:00 Performance success will ultimately come down to the trust that health systems are able to build within communities.
18:15 Building trust between interdisciplinary care team and the individual patient.
19:15 Leveraging AI/data analytics and team-based care for an individual’s care optimization.
22:00 The prioritization of health equity at HMH and at the national level.
23:15 HMH had the first hospital in the nation to achieve The Joint Commission’s Health Care Equity (HCE) Certification.
24:30 Key SDOH interventions: food security, housing, transportation, caregiver support, behavioral health/SUD support.
26:00 >85% of underserved patients are screened through HMH’s SDOH program.
26:30 Medically Tailored Meals (healthy medically-compatible meals for chronically ill patients)
27:45 Fresh Match Program (nutritional incentive program to increase accessibility of fruits and vegetables)
29:00 Trends in asset-light care delivery and hospital-at-home models.
31:00 Expansion of HMH’s ambulatory footprint and their strategy to move care into communities.
32:00 Hospital from Home Program at HMH (development of care infrastructure, high satisfaction)
35:45 Outcomes from home-based hospital care include lower readmissions and SNF cost avoidance.
36:45 Achieving true “systemness” that goes beyond the traditional CIN model.
38:30 The integration impact of HMH’s population health team.
43:00 Improving the health of our communities with AI and actionable data intelligence.
44:00 The imperative to improve health equity.
44:30 Creating synergies with SDOH, hospital from home, VBC, and technology stack.
45:00 Gratitude for the team. Pride in the work. Building a culture around population health.