Osteoporosis Best Practices Learning Collaborative

Developed an osteoporosis-related fracture screening algorithm and disseminate it to PCPs, gynecology, and endocrine departments with provider education at departmental meetings

Achieve additional referrals to the osteoporosis clinic for appropriate patients as determined by inpatient clinical criteria

Weekly review of all DXA and X-rays for an abnormal bone DXA (T score < -1.0) or presence of fragility fractures. Developed a new osteoporosis process for abnormal bone DXA

Developed Best Practice Alerts that will re-display every time a patient qualifies for the screening and no DXA was done or a referral in the last 365 days

Develop Smart Sets in Epic for patients diagnosed with osteoporosis including medication interventions, laboratory tests, and imaging. Developed Best Practice Alert in EPIC for screening patients post-fracture

Joseph Baglio, MBA, Senior Vice President, Eastern Region Ambulatory Services; Armando Castro-Tié, MD, Senior Vice President, Eastern Region Ambulatory Physician Executive; Cindy Maher, Associate Executive Director, Site HR Officer, Eastern Region Ambulatory Services; and 
Jeffrey Musmacher, Assistant Vice President, Operations, Eastern Region Ambulatory Services, Northwell Health

Brief Summary:

In this session, leaders from Northwell Health’s Eastern Market detailed their transition from a fragmented service line model to a regionally integrated operating structure. The transformation aligned ambulatory and hospital operations across three geographic regions—Eastern, Central, and Western—improving coordination, efficiency, and responsiveness. Emphasis was placed on engaging staff, fostering collaboration, and leveraging technology to improve access and outcomes. They highlighted cultural change, data-driven decision-making, and frontline empowerment as essential components of success.

Key Takeaways:

1. Regionalization Replaced Fragmentation with Agility and Accountability
   By shifting from a service line model to a regionally governed structure, Northwell decentralized decision-making, enabling more locally tailored strategies and stronger collaboration between hospitals and ambulatory services. This change empowered sub-markets to operate with greater autonomy while aligning operational goals with hospital priorities. The regional shift enabled faster execution and cost efficiencies. Localized control over budgets and access planning led to a 50% reduction in average specialty appointment wait times, directly improving patient satisfaction and throughput without adding infrastructure.

2. Automated Outreach Closed Gaps in Care—Without Overburdening Staff
   To tackle the issue of “lost to follow-up” patients, Northwell automated patient reminders and scheduling prompts using a multi-step outreach flow involving email, text, and postcards. Over 129,000 patients were contacted, resulting in more than 52,000 appointments, of which 90% were fully automated without staff intervention. The automated system reduced administrative workload and boosted practice volume. With a 40% conversion rate, the automation effort helped reclaim revenue from dormant patients while reducing manual labor and burnout in frontline staff.

3. Referral Navigation Strengthened Network Integrity
   Northwell deployed a structured referral tracking system to ensure that patients leaving one touchpoint (e.g., urgent care or ED) were promptly scheduled for follow-up appointments. A centralized navigator team ensured referrals were actioned quickly, often within four hours. In one example, 10,000 follow-up appointments were scheduled from 18,000 urgent care referrals, yielding a 61% conversion rate. This not only retained patients in-network but preserved revenue that would have otherwise leaked to competitors—critical in Long Island’s competitive healthcare environment.

4. Physician and Employee Engagement Programs Reversed Retention Challenges
   The region introduced initiatives like “Java with Joe” and “My MADE for This Journey”, personalizing engagement for new hires and physicians alike. These touchpoints included early orientation, stay interviews, and career development conversations, fostering connection and loyalty across geographically dispersed teams. First-year employee retention improved from 71.6% in 2021 to over 77% in 2024, closing a 9-point gap with system benchmarks and outperforming other Northwell regions. This improvement reduced hiring and onboarding costs, while increasing workforce stability in high-turnover roles like front desk staff and MAs.

5. Clinical Innovation and Concierge Partnerships Expanded Market Share
   Northwell launched “full-thickness” programs like its 24/7 kidney stone care pathway, integrating ED, urgent care, imaging, and specialist navigation to provide coordinated, same-day services. Additionally, partnerships with residential communities introduced dedicated lines, navigators, and onsite services. The kidney stone program saw 98.5% patient retention in-network with some patients seen by a specialist within an hour of referral. These programs not only improved health outcomes but increased volume in profitable specialty areas and helped Northwell maintain a 38.6% market share in a population of 2 million.

Dan Liljenquist, Chief Strategy Officer, Intermountain Health

Brief Summary:

In this deeply candid and forward-thinking presentation, Chief Strategy Officer Dan Liljenquist discussed how Intermountain Health navigates the structural challenges facing health care—particularly workforce shortages, aging populations, and shifting expectations from patients and providers. The focus was on how sustaining organizational culture through trust, communication, and adaptability is essential for survival and growth. The discussion emphasized the importance of transparent engagement with physicians and staff, shifting care delivery models to expand access, and embracing systemic change as a strategic imperative—not a burden. Through anecdotes and specific actions, Liljenquist illustrated how culture, when deliberately supported, drives not only internal cohesion but operational ROI and improved patient outcomes.

5 Key Takeaways:

1. Trust-Building Through Transparent, Iterative Communication Prevents Costly Disengagement
   Intermountain’s “Speak → Listen → Act → Report Back” model is more than a philosophy; it’s a structured feedback loop used to identify issues early, course-correct, and close communication gaps. For instance, after physician concerns surfaced over new productivity expectations, leadership proactively engaged those individuals, clarified assumptions, and adjusted messaging. This prevented a potential wave of provider dissatisfaction and attrition, which would have led to costly recruiting and onboarding expenses—especially during a time of nationwide clinical shortages.

2. Redesigning Primary Care to Expand Panel Sizes While Reducing Clinician Burden
   Rather than simply asking physicians to “do more,” Intermountain offered specific workload relief solutions. such as removing routine refill requests and centralizing medication titration. When one provider was asked if he would double his panel size, he initially said no. But after hearing about support from pharmacists and preauthorization teams, he reconsidered. These changes helped unlock additional patient slots without increasing hours, effectively boosting access capacity without increasing headcount, a cost-saving solution to the provider supply-demand imbalance.

3. Shifting to a ‘System-Patient’ Relationship Model Increases Preventive Care Access
   Recognizing that a huge segment of patients in their 30s–50s weren’t engaging with care until it was too late, Intermountain began shifting away from the traditional “one doctor, one patient” model. The goal: to engage earlier and more often via digital, virtual, and team-based care. By catching chronic conditions like diabetes earlier and reducing complications, the system avoids millions in long-term treatment costs—a move from reactive to proactive, value-based care.

4. Virtual Hospital Model Preserves Access and Generates High-Value Encounters
   In rural areas where hospitals risk closure, Intermountain’s virtual hospital enables high-acuity care via telemedicine. One success story involved a stroke patient in a remote hospital who, through virtual coaching, received thrombolytic treatment faster than many urban centers. The rural hospital not only saved a life but also billed at a higher acuity level—preserving critical revenue, demonstrating how telehealth investment leads to clinical and financial sustainability in underserved regions.

5. Operational Efficiency Through Standardization Unlocks Thousands of Appointments
   When Intermountain questioned the need for in-person visits for simple contraceptive refills, it uncovered outdated assumptions. By creating a virtual workflow, they freed up 7,000 appointment slots in their maternal-fetal medicine clinics. This single redesign significantly expanded access for high-demand services (e.g., deliveries), generating revenue from additional visits while improving patient convenience and reducing care delays.

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Steven Kalkanis, MD, EVP, Henry Ford Health, CEO, Henry Ford Medical Group, and CEO, Henry Ford Hospital 

Brief Summary:

In this dynamic session, Dr. Steven Kalkanis shared how Henry Ford Health has approached artificial intelligence (AI) not as a tech trend but as a transformational force requiring structured oversight, clinical alignment, and ethical grounding. Facing a deluge of vendors, ethical questions, and dizzying advancements in generative AI, Henry Ford established a comprehensive AI governance model composed of three committees to vet and prioritize AI use cases. The session highlighted how this structured model led to measurable results in physician efficiency, early cancer detection, and patient access—all while protecting data integrity, minimizing risk, and enhancing workforce wellness. The talk underscored the need for collaborative industry-wide frameworks to manage bias, interoperability, and cybersecurity threats.

5 Key Takeaways:

1. Structured AI Governance Enables Scalable Innovation Without Chaos
   Henry Ford implemented a three-tier governance structure: an executive AI Steering Committee, a Workgroup for due diligence, and a “Care of the Future” committee to vet new ideas and align them with strategic priorities. This model balances innovation with institutional oversight. This governance allowed Henry Ford to greenlight high-impact projects quickly—like ambient listening for clinical documentation—while avoiding wasted investment in poorly aligned vendor tools. The model ensured that AI pilots could scale without disrupting clinical workflows, accelerating time-to-value.

2. Ambient Listening Technology Reduced Physician Documentation Time and Burnout
   A pilot of Nuance DAX ambient listening across 250 primary care providers led to a reduction in note-writing time per visit from 9 minutes to just under 5 minutes. Importantly, this initiative was born not from financial aims, but from an urgent need to address physician burnout and reduce after-hours “pajama time.” The efficiency gains translated into $2 million in annual savings at just one clinic site, plus freed up hundreds of hours for additional patient visits or personal recovery time. Over 86% of providers said they’d be disappointed if the tool was taken away—showing not only cost savings, but also major improvements in morale and retention.

3. AI-Driven Early Detection Projects Dramatically Improved Screening Outcomes
   By using AI to analyze environmental and clinical data, Henry Ford increased the effectiveness of lung cancer screenings—moving from 1 positive result per 250 scans to 1 in 50. Similarly, AI identified patterns in “negative” mammograms that later developed into breast cancer, highlighting pre-disease signals missed by humans. These projects led to 5x the early detection rates, saving lives and reducing costly late-stage interventions. The improved diagnostic accuracy enhances reimbursement rates tied to value-based care and strengthens population health metrics.

4. AI Use in Clinical Documentation Improved Risk Adjustment Scores
   The use of ambient listening and smart documentation tools helped improve HCC (Hierarchical Condition Category) scores, critical for risk-adjusted reimbursements. Providers using AI tools had 62% completion of required documentation, compared to 32% for those without the tools. More complete documentation led to better capture of clinical complexity, directly improving Medicare Advantage payments and quality metrics tied to shared savings arrangements.

5. Centralized Vetting Helps Avoid Overinvestment in Redundant Vendor Tools
   With over 150 AI vendors vying for health system attention, Henry Ford's “Care of the Future” committee vets which projects align with system-wide priorities and workflows. This process prevents AI hype from draining resources and enables thoughtful deployment. Rather than investing millions in unproven AI tools, Henry Ford channels its funding into projects with demonstrated ROI and operational alignment—protecting capital, maximizing returns, and preserving staff trust in the value of innovation.

Changed fall risk screening tool requirements from annual to biannual to identify those patients who are at high risk for falls to include the post-fracture patient.

Primary care WebEx on osteoporosis treatment guidelines & osteoporosis screening recommendations added to the internal website.

Questionnaire developed and distributed to patients to assess their knowledge of osteoporosis. Patient education material developed from survey responses

Create multi-media (brochures/EMMi video/web links), multi-channel (My Chart messages, AVS updates, patient brochures) patient education campaign

Collaboration between Clinical pharmacist and virtual engagement provider to provide outreach to virtual high-risk patients with prior hip fractures for medication and treatment management to prevent secondary fractures.

Survey to understand healthcare providers’ understanding of osteoporosis and provide education.