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

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

Hybrid Embedded RN Care Managers Target High-Cost, High-Utilization ‘VIPs’

When Sentara Medical Group determined its embedded RN care managers spent only 25 percent of their time on care management, it revamped its embedded model, explains Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara. In the new hybrid model, RN care managers support two to three practices and also visit high-cost, high-utilization patients at home, in the hospital and virtually.

At first, Sentara management balked at a perceived duplication of service between the RNs and home health nurses—until they saw the fruits of these patient encounters, which Ms. Morin describes in this audio interview. Home visits in particular allow RN care managers to assess the patient’s environment and meet the individual on their level, which lifts engagement in self-care, she notes.

Mary Morin will explain the motivation behind Sentara’s hybrid embedded case management model and the model’s impact on its highest risk population during a July 31, 2014 webinar, “A Hybrid Embedded Case Management Model: Sentara Medical Group’s Approach,” a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 8:28 minutes

Navigating Patients Pre-Discharge on Care Transitions

With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital’s Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF’s and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over.

Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers, a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.


Length: 12:55 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

Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community

There’s education, there’s experience, and then there’s the ‘right stuff’ — the indefinable personality traits that earmark an individual as a change agent, collaborator and ambassador of case management, says Annette Watson, senior vice president of community transformation for Taconic IPA (TIPA), of TIPA’s requirements for the RN case managers it hires for its advanced patient-centered medical homes.

Then there are the not insignificant contributions of the RN case manager to accountable and patient-centered care, which Ms. Watson describes in this interview.

While staff-buy-in and communication continue to challenge the embedded case manager model, the participant in CMS Innovation Center’s Comprehensive Primary Care (CPC) initiative says reimbursement for embedded case management is less of an obstacle today than in the past, due to funding-friendly care models and pilots descending from healthcare reform.

Ms. Watson shared how TIPA has successfully embedded case managers in an open, multi-payor community during an October 9, 2013 webinar, Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community.


Length: 8:36 minutes

Medicare Pioneer ACO Year One: Lessons from a Top-Performer

Lauded for its care coordination service, Monarch had to overcome a few challenges when retrofitting the Naylor Transition of Care (TOC) model for the ACO — among them insufficient patient access, patient skepticism and resource limitations. By focusing on readmissions reductions and four disease management conditions — ESRD, COPD, CHF and diabetes — and creating a care coordination team that included the newly created care navigator, case managers, and pharmacist, the organization has improved patient compliance, reduced negative drug interactions and hospital days and improved patients access to community services.

During Medicare Pioneer ACO Year One: Lessons from a Top-Performer, a September 18th webinar at 1:30 pm Eastern, Colin LeClair, executive director of ACO for Monarch HealthCare, shared first year lessons from its Medicare Pioneer ACO experience, how it evolved in year two and the impact on its organization’s participation in other accountable care organizations.


Length: 14:03 minutes

The Role of Case Managers in Emerging Care Delivery Models

With ACA reforms underway, the case manager is fast becoming a major player in the patient-centric, quality over volume healthcare mindset, taking on more standardized, collaborative approaches to care coordination and its changing delivery systems. But as crucial as case managers are to the evolving healthcare landscape, they also need to realize that they are, in many ways, the new kids on the block. Embedded case managers in particular need to understand that how they relate to their professional partners is one of the most important keys to their success, explains Teresa Treiger, president of Ascent Care Management. Here she shares her views on this and other aspects of the industry, including the opportunities for home-based care and how case managers can maximize the use of technology to manage patient care plans.

Teresa Treiger provided perspectives on the changing healthcare landscape for case management and care coordination during The Role of Case Managers in Emerging Care Delivery Models, a February 21, 2013 webinar, now available for replay.


Length: 13:06 minutes

Advanced Illness Care Coordination: A Case Study on Aetna’s Compassionate Care Program

Aetna’s Compassionate Care Program is a case management initiative that specifically targets health plan members with advanced illness, focusing on improving the quality of care they receive. As a result, explains Dr. Joseph Agostini, senior medical director of Aetna Medicare, these patients get more of the type of care that they want and spend less time in the hospital. Patient satisfaction with the program is high, he says, which reflects the strong bond between Aetna members and nurse case managers. In this interview, Dr. Agostini explains the key elements of the Compassionate Care program as well as some of the challenges the case managers may face in the management of advanced illness.

Dr. Joseph Agostini presented during Advanced Illness Care Coordination: A Case Study on Aetna’s Compassionate Care Program, a 45-minute webinar on June 13, 2012, now available for replay, during which he shared the key features of the Compassionate Care Program at Aetna, along with the impact the program has had on healthcare utilization and quality outcomes.


Length: 3:53 minutes