Yale-New Haven Embedded High-Risk Care Coordinators Monitor Geriatric Homebound

Dr. Vivian ArgentoFollowing weekly huddles with nurse practitioners, Yale New Haven Health System (YNHHS) geriatric care coordinators use a red-yellow-green system to prioritize care for its Medicare homebound patients, explains Dr. Vivian Argento, the executive director of geriatric and palliative services at Bridgeport Hospital, in this audio interview.

While the bulk of care provided by YNHHS’s geriatric care coordination model is delivered during house calls to seniors deemed homebound by Medicare criteria, the program also provides care to patients in assisted living facilities.

The YNHHS geriatric care coordination model was one of three embedded models of care presented during a June 2015 webinar, Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, now available for replay. During the program, Dr. Argento was joined by Amanda Skinner, YNHHS executive director for clinical integration and population health, who described livingwellCARES, embedded on-site care coordination for YNHHS employees; and its patient-centered medical home’s hybrid model of centralized and embedded care coordination resources.


Length: 3:11 minutes

7 Metrics to Build a Business Case for a Multidisciplinary Care Coordination Team

Shameka ColesBecause care management and coordination often defy traditional return on investment formulas, come budget time, AltaMed Health Services Corporation had to take a hard look at contributions of its multidisciplinary care team to the organizational bottom line.

Shameka Coles, AltaMed’s associate vice president of medical management, outlines seven key metrics presented to AltaMed’s CFO tying the coordinated care team to Altamed’s financial goals—data that ultimately secured funding for phase four of the coordinated care management initiative.

During a May 2015 webinar, A Comprehensive Care Management Model: Care Coordination for Complex Patients, now available for replay, Ms. Coles shared the key steps in development, rollout and evaluation of this care management model for AltaMed’s highest risk patients, a population that includes dual eligibles.


Length: 3:48 minutes

CHRISTUS Remote Monitoring for Chronic Condition Management: Coaching Patients to Wellness at Home

Shannon CliftonThe daily monitoring phase of CHRISTUS Health’s remote care management workflow involves the patient, a care transition nurse coach, and the patient’s primary care physician if needed. During a February 24, 2015 webinar, Remote Patient Monitoring for Chronic Condition Management, Shannon Clifton, director of connected care for CHRISTUS Health, described this critical stage of the 60-day program that strives to keep high-risk patients within wellness parameters.

During the 45-minute webinar, now available as on on-demand replay, Ms. Clifton and Dr. Luke Webster, chief medical information officer, CHRISTUS Health, shared the key features of the remote monitoring effort, including program design and impact, ROI, and how the program fits into Christus’ long-term strategy as a risk-bearing organization.


Length: 3:46 minutes

Billable Chronic Care Management Services: What Counts as Care Coordination, and What Doesn’t?

Paul RudolfWhat constitutes care coordination under the new Chronic Care Management (CCM) codes?

While CMS has identified a long list of CCM activities that can be counted toward the 20-minutes-per-month requirement, physician practices must also keep in mind certain services that cannot be billed when CCM is billed.

During a February 12, 2015 webinar, Chronic Care Management Reimbursement Compliance: Overcoming Obstacles and Meeting Requirements, Paul Rudolf, MD, a partner with Arnold & Porter LLC, outlined exceptions to and examples of billable CCM tasks.

During the 45-minute program, now available as on on-demand replay, Dr. Rudolfe and Nicole Liffrig Molife, counsel, Arnold & Porter, delve into CMS requirements and discuss approaches and challenges to meeting the CCM requirements. The program was sponsored by the Healthcare Intelligence Network.


Length: 3:43 minutes

Chronic Care Management Medicare Reimbursement Could Boost Patient Portal Use

Rick HindmandProvisions for separate payments for chronic care management (CCM) services included in the 2015 Medicare Physician Fee schedule support more flexibility in communications between healthcare provider and patient, notes Rick Hindmand, attorney with McDonald Hopkins, including the use of patient portals.

Hindmand, whose law firm advises a nationwide client base extensively on healthcare reimbursement, outlines communication scenarios expected to qualify for CCM service payments as well as suggestions for segmenting care transition management services provided under CCM and a second CMS initiative.

Rick Hindmand advised physician practices on how to best structure their organizations to optimize CCM reimbursement during a November 19, 2014 webinar, Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 5:16 minutes

PCMH-Neighbor Concept Builds on Patient-Centered Medical Home Momentum

Specialists working day to day with primary care medical homes will move more easily into the role of patient-centered medical home neighbor (PCMH-N) than those who have not, notes Robert Krebbs, WellPoint’s director of payment innovation. WellPoint recently launched a medical neighborhood pilot for three specialties with clear care coordination alignment opportunities with primary care medical homes.

The neighborhood model requires education on the part of specialists and patients who have not been part of integrated delivery systems so they can better benefit from the new patient-centered medical world, Krebbs explains in this audio interview.

Robert Krebbs shared the key components of WellPoint’s Enhanced Personal Health Care for specialty care program during a May 15, 2014 webinar, Care Compacts: Forming the Foundation of Care Teams with PCPs and Specialists, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 4:31 minutes

BCBSM Specialists Warm to Outcomes from Care Coordination Collaborations

Although initally challenging, the engagement of specialists in Blue Cross Blue Shield of Michigan’s medical home program generated several outstanding primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend related to difficult-to-manage patients, notes Donna Saxton, field team manager for BCBSM’s value partnerships program.

A pioneer since 2005 in the development of outcomes-based measures to evaluate patient care, BCBSM based its standards on the Chronic Care Model. Today, the payor acts as a resource for other medical home recognition and accreditation efforts.

Donna Saxton share details from its PCMH designation requirements and the system of rewards and incentives that has produced results for the plan, the PCMH practices and its members during an April 30, 2014 webinar, Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures, a 45-minute program sponsored by The Healthcare Intelligence Network, now available for replay.


Length: 4:31 minutes

Humana Remote Monitoring Pilots Engage Member’s Circle of Care

Humana’s remote monitoring pilots go beyond traditional targets of heart failure, diabetes and COPD to observe functionally challenged members, explains Gail Miller. This novel approach uses a Personal Emergency Response System (PERS) with a built-in accelerometer to monitor members challenged by activities of daily living (ADL), says the VP of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. Another pilot, a collaboration with HealthSense, places sensors around the member’s home to study algorithms of normal movement so Humana can detect changes and intervene before a member’s crisis.

All Humana remote monitoring pilots engage the circle of care surrounding the member — be it home health, a family member, or a spouse.

Gail Miller shared more details of Humana’s telephonic care management and how remote monitoring pilots will enhance care coordination during a March 19, 2014 webinar, Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 4:26 minutes

HCSC’s Community Behavioral Health Links Essential to Duals Care Coordination

Relationships with community organizations that support mental health as well as recovery from addiction are essential to care coordination of Medicare-Medicaid beneficiaries, notes Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation (HCSC). These collaborations enable HCSC to address the needs of duals as “a whole sick person, and not just as a diagnosis,” she explains, noting that duals often suffer from depression along with some physical disability. HCSC also has its own integrated team with behavioral health expertise.

Julie Faulhaber shared her organization’s approach to designing a care coordination model for dual eligibles and initial findings from these new programs during a March 12, 2014 webinar Moving Beyond the Medical Care Coordination Model for Dual Eligibles, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 4:06 minutes

Assessing Readmission Risk to Prioritize Home Visits for Complex Patients

Modifying a popular hospital admissions risk assessment tool for its own use helps Stanford Coordinated Care to prioritize home visits for its roster of high-risk patients, all of whom have complex chronic conditions, explains Samantha Valcourt, MS, RN, CNS, Stanford’s clinical nurse specialist. Stanford’s HARMS-11, based on Iowa Healthcare Collaborative’s HARMS-8 hospital risk screening tool, looks at individuals’ utilization, social support and medication issues, among other factors, to measure a patient’s risk of readmission.

The resulting home visits, a critical component of Stanford’s care transitions management program, help to uncover health challenges the complex chronic patient may still face, including four common medication adherence barriers Ms. Valcourt describes in this interview.

Samantha Valcourt shared how Stanford’s Coordinated Care uses a home visit assessment to improve care transitions post-discharge during a December 19, 2013 webinar, Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions.


Length: 6:28 minutes