Situated in Mississippi, a state with high rates of chronic disease, Hattiesburg Clinic has faced steep challenges in providing quality health care to its patients. But through its smart use of technology and implementation of value-based care, Hattiesburg Clinic has saved millions of dollars and cut hospital readmission rates by helping high-risk patients with chronic care management.

Spanning 17 counties and 70 locations in South Mississippi, Hattiesburg Clinic is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine. 

Hattiesburg Clinic operates with multiple aims: high-quality, low-cost care, combined with patient satisfaction, value-based care and physician well-being, Bryan N. Batson, MD, CEO of Hattiesburg Clinic, said during an AMA webinar on value-based care and technology. Hattiesburg Clinic’s journey to value-based care through adoption of multiple technology platforms is also outlined in an AMA case study (PDF).

“For physicians and other members of the care team to provide the highest quality care in the lowest-cost environment with patient satisfaction, those care team members need to be satisfied in their work environment,” he said. “And we believe that technology plays a big role in that.”

Bryan Batson, MD

Physician-owned and -governed Hattiesburg Clinic adopted a value-based payment format, which bases payments on health care outcomes and performance metrics such as cost and quality. In 2012, Hattiesburg Clinic joined the Centers for Medicare & Medicaid Services’ Physician Quality Reporting System through the Group Practice Reporting Option to see how it performed in comparison to other group practices. 

Falling short of performance goals, Hattiesburg Clinic invested in technology solutions, engaging its EHR data to address three critical areas to prevent unnecessary hospitalizations: chronic care management, transitional care management and health inequities.

In other quality initiatives, Hattiesburg Clinic launched an advanced model for clinical episodes, an accountable care organization (ACO) and bundled payments model. Since 2016, Hattiesburg Clinic has accrued value-based payments of more than $53 million across all plans. Medicare savings alone amounted to more than $66 million. Technology solutions were critical to achieving these results, says the case study.

During the webinar, Dr. Batson discussed the IT tools Hattiesburg Clinic uses to drive its success in value-based care, specifically within its care-management programs. 

Hattiesburg Clinic has employed risk calculators as part of its workflows in the clinical, operations and quality management space. 

“We use a significant amount of risk-adjustment support and risk-adjustment coding tools to help us make sure we're doing appropriate risk capture of our value-based care patients,” said Dr. Batson, who holds the small/medium group seat on the AMA Integrated Physician Practice Section Governing Council.

Specific tools include disease registries, an analytics catalog and dashboards that help physicians, managers and care coordinators identify gaps in quality performance. Clinical decision-support tools for physicians and care teams and patient-facing tools are also part of this strategy. 

A pilot study using ambient scribe technology reported saving 60% of time working outside clinic hours in its first month. The pilot now has 68 physicians and seven nonphysician providers, according to the case study. Physicians and other health professionals can opt in to use the service, which continues to lessen the burden of clinic notes from patient visits.

“It’s a lot of technology, but really crucial to our view of how to make the best use of technology…[by] marrying those tools to the operational and clinical workflows and incorporating the technology team into the operations and clinical teams very early in the process,” Dr. Batson explained. 

From AI implementation to EHR adoption and usability, the AMA is fighting to make technology work for physicians, ensuring that it is an asset to doctors—not a burden.

Through the EHR, Hattiesburg Clinic uses predictive analytics to calculate a hospitalization and emergency department risk score for patients with multiple comorbidities who might benefit from its chronic care management program. About 5,000 patients are enrolled in this program, which has improved chronic care outcomes. 

“We can very easily see at a dashboard or schedule level how many diseases any given patient may have,” explained Dr. Batson, noting orange banners identify any patient enrolled in chronic care management across the organization. It lets everyone know that this patient has a care manager. 

The case study highlights that hypertension-control rates rose from an average of 54% to 70% over three years, resulting in a 12% drop in hospitalization for chronic care management-enrolled patients. Hattiesburg Clinic has also reported improved clinical quality measures for patients with chronic kidney disease, cardiovascular disease and diabetes.

From a value-based care standpoint, chronic care management has reduced Medicare costs “per member per month” by $74 for each patient, and reduced hospital readmission rates by 25%, Dr. Batson shared. 

Another component of chronic care management is collecting data on social drivers of health during annual wellness visits. Nurses gather data to identify social needs in five domains: food insecurity, housing instability, transportation needs, utility difficulties—such as paying for electricity, water and other utilities—and interpersonal safety. The EHR prominently displays any social drivers of health needs at the point of care, alerting the physician and care team to address them during patient visits. 

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The transitional care-management program at Hattiesburg Clinic uses a predictive analytic model to seamlessly transition patients from hospital to home care, identifying patients at highest risk for readmission, then ensuring they get a transitional care visit post discharge. 

Hattiesburg Clinic tracks patients approaching discharge who are most likely to be readmitted, putting clinical workflows in place for those patients, said Dr. Batson. Transitional case managers can track the admission diagnosis as well as the patient's risk for readmission on the dashboards. 

“After the patient is discharged, we incorporate GEO [Gene Expression Omnibus] data into that discharge data and identify those patients who are highest risk,” coordinating their care if they’re unable to return to the office for a follow-up visit, he explained. 

Nurse practitioners are also on hand to do any home visits with high-risk patients who can’t see the physician in person. 

In 2023, Hattiesburg Clinic conducted more than 130 telehealth visits to transitional care management patients. Meanwhile, 30-day Medicare ACO readmission rates have also been reduced by 50% for patients who complete the program while one in 12 visits prevent avoidable readmission, said Dr. Batson. 

Hattiesburg Clinic also relies on analytics to optimize travel time for nurse practitioners participating in the transitional care-management program.

Many of the health system’s patients live in rural areas and face challenges traveling to the clinic for post-discharge visits, so nurse practitioners were sent to patient homes. While it benefited patients, the home visits posed some challenges for the nurses who were spending long hours on the road.

The solution: using real-time geographic data and predictive analytics to identify patients at the highest risk for readmissions. This allows teams to group patients within a similar geographic area and streamlining route planning. It helps to reduce driving times while increasing the number of patients cared for. 

To promote continuity of care, Hattiesburg Clinic links externally to other health information exchanges. Internally, physicians can view each other’s notes on a specific patient and track patient trends through the EHR. 

EHR tools are also important. But validating them with your data sets and making sure that they make sense in workflows is crucial before implementing new programs, said Dr. Batson. It’s also important to use those technology tools in a way that makes sense for your operations and clinical teams. 

“We can build a lot of cool fancy things in a technology silo, but if we're not incorporating the operations and clinical teams in that decision-making process, those tools won't get their full value,” he said, emphasizing that success lies not in the tools themselves but in the hands of the people who use them.

Discover more—and register now—for other free webinars from the AMA on value-based care in 2025 such as aligning payment, integrating behavioral health and successful data sharing.

Learn more with the AMA about value-based care, including ways to improve data sharing and best practices for payment methods.