Leveraging an Enterprise Data Warehouse To Identify Care Gaps and Clinical Quality Improvement Opportunities

=With an increasing percentage of at-risk healthcare payments, Allina Health System’s Minneapolis Heart Institute (MHI) began to examine clinical variations among its cardiovascular patients.

In this HealthSounds episode, Pam Rush,
cardiovascular clinical service line program director at Allina Health, shares how MHI leveraged over 80 different data sources fed into its Enterprise Data Warehouse to identify gaps in care, clinical variations and quality improvement opportunities.

During Predictive Healthcare Analytics: Four Pillars for Success, a March 2018 webcast now available for rebroadcast, Ms. Rush, along with Dr. Steven Bradley, cardiologist, MHI and associate director, MHI Healthcare Delivery Innovation Center, share their organization’s four pillars of predictive analytics success…addressing population health issues, reducing clinical variation, testing new processes and leveraging this enterprise data warehouse.

The webinar provided details on creating a culture of quality and innovation, building dashboards, as well as several case examples of quality improvement initiatives contributing to these savings and much more.


Length: 3:44 minutes

Remote Patient Monitoring Scalability and Sustainability: UPMC’s Nine-Point Vision for Future Success

=With a successful history in reducing readmissions and improving patient outcomes for congestive heart failure through its remote patient monitoring program, the University of Pittsburgh Medical Center (UPMC) is expanding its program to additional disease states and developing systems to ensure continued success.

In this HealthSounds episode, Dr. Ravi Ramani, director, UPMC Integrated Heart Failure shares UPMC’s nine-point vision for a sustainable, scalable remote patient monitoring program.

During Remote Patient Monitoring at UPMC: Creating Early Warning Systems To Reduce Unplanned Healthcare Utilization, a March 2018 webcast now available for rebroadcast, Dr. Ramani provided a detailed case study of UPMC’s remote patient monitoring.

The webinar provided UPMC’s key factors for future success in remote patient monitoring, the impact the program has had on UPMC’s clinical outcomes as well as details on the remote patient monitoring clinical development process, clinical pathways and graduation protocols and much more.


Length: 4:33 minutes

Focus Group Findings Shape Bronx Community Health Improvement Action Plan

Charmaine RuddockHow do you engage community residents in their health when many are distrustful of and feel disrespected by the healthcare system?

Encourage them to both direct and participate in the initiative, advises Charmaine Ruddock, project director of Bronx Health REACH.

In this HealthSounds episode, Ms. Ruddock shares what Bronx Health REACH learned early on in its coalition-building from community focus groups, and how this local feedback informed program development for a community traditionally ranked last in New York in terms of health outcomes and health factors.

During Innovative Community-Clinical Partnerships: Reducing Racial and Ethnic Health Disparities through Community Transformation, a November 2017 webinar now available for replay, Ms. Ruddock shares the unique partnerships forged by Bronx Health REACH with area faith-based programs, bodegas, restaurants, schools, clinics and art groups and how these partnerships promote the health and well-being of area residents. Program highlights include partnering with the American Bodega Association and bodega suppliers to increase healthy purchase options; engaging clinics and patients in a Vegetable and Fruit Rx program to encourage healthy eating in obese patients; encouraging teachers to add nutrition education to their curriculum; promoting healthy eating options at Bronx restaurants via ‘The Bronx Salad;’ facilitating discounts for SNAP beneficiaries for healthy items.


Length: 4:59 minutes

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

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