PinnacleHealth’s Patient Engagement Coach for Clinicians: Supportive Peer at Provider’s Elbow

Kathryn ShradleyHow receptive are clinicians to being coached in patient engagement techniques? At PinnacleHealth, provider reaction to rollout of patient engagement coaching has followed a standard bell curve, notes Kathryn Shradley, PinnacleHealth’s director of population health.

In this HealthSounds episode, Ms. Shradley outlines the framework underscoring the engagement coach’s supportive and educational role while at providers’ elbows as well as ways the health system earned clinicians’ support for the initiative.

During A Two-Pronged Patient Engagement Strategy: Closing Gaps in Care and Coaching Clinicians, an August 2017 webinar now available for replay, Ms. Shradley describes her organization’s two-pronged approach to increase engagement rates across the health system, including details on the key patient survey data that helped to shape this program, three ways PinnacleHealth works to engage its more resistant patients, and more details on the essential role of the engagement coach for clinicians.


Length: 3:49 minutes

Integrated Case Management: The Surprise Question That Can Improve Timeliness of Hospice Referrals

Laura OstrowskyFor patients with cancer, palliative care should begin at diagnosis to help them shoulder the disease’s emotional, physical and financial burdens, explains Laura Ostrowsky, director of case management at Memorial Sloan Kettering Cancer Center (MSKCC). However, for multiple reasons, referrals to hospice frequently happen too late for MSKCC patients to derive full benefit from that service.

In this episode of HealthSounds, Ms. Ostrowsky shares some key questions for integrated case managers to ask providers to improve timeliness of hospice referrals, patient and family satisfaction with hospice service, and awareness of end-of-life care. The strategy is one way MSKCC uses integrated case management to validate its worth in a value-based system: providing the best care in a quality-effective manner.

During Integrated Case Management: A New Approach to Transition Planning, an August 2017 webinar now available for replay, Ms. Ostrowsky outlines MSKCC’s use of a team-based case management model that follows patients as they transition across the health system.


Length: 3:06 minutes

4 Foundational Behaviors Forge Framework for UnityPoint Health Patient Experience Improvement Plan

Paige MooreTo engage staff in its patient experience improvement action plan, UnityPoint Health defined four foundational behaviors expected of every team member (not just providers) across the organization.

In this podcast, Paige Moore, director of patient experience at UnityPoint Health, describes the rationale and rollout for the four behaviors, which are based on patient and visitor feedback and comments.

During Improving the Patient Experience: Engaging Front-line Staff for a System-Wide Action Plan, a July 2017 webinar now available for replay, Ms. Moore shares how the deployment of department-specific service action teams facilitated the switch from a top-down, leadership-driven patient experience improvement approach to one that engages front-line staff to own the process.


Length: 3:56 minutes

Social Determinants of Health: Adapting Screenings for Different Populations

Amanda ParsonsAfter choosing two validated tools to assess social determinants of health (SDOH) in its largely Medicaid and otherwise government-insured patients, Montefiore Health System allowed each physician practice to determine its target population for screening.

In this podcast, Dr. Amanda Parsons, MBA, vice president of community and population health at Montefiore Health System, explains the various screening approaches taken by the physicians, and how that multi-site strategy figures into the health system’s overall plans for SDOH interventions.

During Assessing Social Determinants of Health: Collecting and Responding to Data in the Primary Care Setting, a June 2017 webinar now available for replay, Dr. Parsons provides insight into her organization’s evolution of SDOH screening into an EPIC®-supported process.


Length: 3:17 minutes

Michigan SNF Collaborative Sets Competition Aside to Improve Quality and Readmission Rates

Susan CraftTo hold the line on hospital readmissions, a tri-county, skilled nursing facility (SNF) collaborative in Michigan evaluates 130 participating SNFs by a host of quality metrics the SNFs enter into a common data portal.

In this podcast, Susan Craft of the Henry Ford Health System (HFHS), one of four collaborative founders, outlines a few SNF participation and reporting mandates that run the gamut from meeting attendance to LACE readmission risk scores.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvement, a May 2017 webinar now available for replay, Ms. Craft, director, care coordination, family caregiver program, HFHS Office of Clinical Quality & Safety, shared the key details behind this SNF collaborative, the program’s impact on readmission rates, and new readmission reduction targets derived from the program’s data analysis.


Length: 4:15 minutes

The Science Behind Care Transition Management: More Than Case Managers and Discharge Calls

Jennifer DragoAmong the myths surrounding care transitions management is the belief the intervention can be effectively executed pre-discharge or by phone only, explains Jennifer Drago, executive vice president of population health for Sun Health.

In this audio interview, Ms. Drago dispels this myth, outlining requirements for a professionally designed, evidence-based transitions of care program, and why inclusion of dedicated staff and home visits will enhance clinical outcomes and possibly save lives.

During A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay, Ms. Drago shared the key features of Sun Health’s care transitions program, which achieved the lowest readmissions rates in CMS’s recently concluded Community-Based Care Transitions Program.


Length: 2:34 minutes

CMS’ Physician QRUR Tables Highlight High-Value Referral Patterns for Medicare Population

William HoldingAmong other data, detail tables in a physician practice’s Quality Use and Resource Reports (QRURs) pinpoint specialist referral networks for Medicare beneficiaries, explains William Holding, consultant, PDA, Inc., which can help physician practices determine their highest value referral pathways.

In this audio interview, Holding explains the benefits of tapping CMS-generated QRUR reports to enhance performance under Merit-Based Incentive Payment Systems (MIPS), one of two payment paths for physician reimbursement under MACRA.

During Physician MACRA Preparation: Using QRUR and Other CMS Data To Maximize Your Performance, a January 2017 webinar now available for replay, Holding and colleague Nancy Lane, president of PDA, Inc., share the critical steps physician practices should take when analyzing their QRUR data, along with details on other CMS data points that can help practices improve MIPS performance.


Length: 3:07 minutes

Social Determinants of Health: Scenarios to Encourage the Sharing of Sensitive Information

Dr. Randy WilliamsIdentifying social determinants of health (SDH) requires providers to probe beyond the scope of clinical data. But how can health teams ensure that patients and health plan members provide valid data during SDH assessments? In this audio interview, Dr. Randall Williams, chief executive officer, Pharos Innovations, describes three scenarios to build trust and encourage individuals to share sensitive information during SDH interactions.

During Social Determinants and Population Health: Moving Beyond Clinical Data in a Value-Based Healthcare System, a December 2016 webinar now available for replay, Dr. Williams shares his insight on the opportunity available to providers to impact population health beyond traditional clinical factors.


Length: 3:16 minutes

Trends Shaping Healthcare in 2017: Employ Technology for Patient Engagement

Steven ValentineThe engagement of patients, particularly those with multiple chronic conditions, continues to challenge healthcare providers.

However, as Steven Valentine, vice president of advisory consulting services for Premier Inc., explains in this podcast, clinicians actually have a host of tools at their fingertips to engage patients—tools they must employ in order to succeed in value-based healthcare.

During Trends Shaping the Healthcare Industry in 2017: A Strategic Planning Session, a November 2016 webinar now available for replay, Steven Valentine provides a roadmap to the key issues, challenges and opportunities for healthcare organizations in 2017.


Length: 2:52 minutes