Home Visits 101: Empower the Patient, and Don’t Forget the Gloves

September 2nd, 2014 by Patricia Donovan

It's hard to plan a home visit for a recently discharged patient if you don't know they've been in the hospital. Obtaining data on hospitalized patients is one of the challenges of administering a home visits program, notes Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care (SCC), a part of Stanford Hospital and Clinics.

Some of the challenges I’ve experienced with our home visits program is first of all, knowing when our patients are actually in the hospital. It’s easy to know when they’re at SCC; I get an electronic communications or an EMR. However, if patients go outside our system, I may not know. Sometimes that discharge summary is not available when I’m ready to go see the patient the day after. Holidays and weekends always increase that 48- to 72-hour window and I really do try to get in there the following day if possible.

For patients that don’t see primary care doctors within our clinic, it can sometimes be a challenge getting hold of their primary care doctor outside of SCC, and then explaining my role and why I need them.

On the back of our patient ID card, we emphasize to our patients to please contact us if they’re even considering going to the emergency department so that perhaps we can avoid a hospital admission or a readmission. If they are being seen in the hospital, we want them to call us as soon as they’re there, as soon as they’re able to, or to have their family member call so we can make sure that we’re involved in that transition.

Another lesson learned is definitely to empower the patient. Again, as a nurse I try to do as much for the patient as I can. But I have to keep in mind that when I’m in the home, my goal is to make sure will be able to identify the red flags and symptoms that indicate things are not going well, and that they’ll be able to contact the doctor’s office with their needs. I make sure that both handoffs are very clear; I never want to leave a patient wondering, ‘Oh I had this nurse and she came into my home and then she called me every few days and then all of a sudden she was gone.’

I need to make sure that I have good communication with that next transition.

And then last, I always carry a set of gloves, because you never know what you’ll walk into. I was not a home health nurse before I did these types of home visits, so I was ill prepared on one of my first visits to a patient with a dialysis catheter that was oozing blood. My nursing instinct caused me to run in there and try to clean things up.

Now I carry a good stock of gloves and supplies, because you just never know.

value-based reimbursement
Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care (SCC), a part of Stanford Hospital and Clinics.

Source: Home Visits for High-Risk Patients: Tools, Timing and Outcomes

Infographic: Patient Leakage

September 1st, 2014 by Melanie Matthews

Inefficiencies in patient access programs, including poor customer service within a call center and appointment scheduling problems, can not only impact the patient experience, but can also cause patients to seek care elsewhere.

An infographic by Kyruus looks at which points in the patient care-seeking process can pose concerns and the impact lost patients can have on an organization.

Patient Leakage

The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture, and Patient ExperienceLearn the steps your practice can take to reap the many payoffs of achieving high patient-centered standards without having to make a big financial investment. In The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture, and Patient Experience, authors Cheryl Bisera and Judy Capko, explain how healthcare professionals and organizations can thrive in the new patient-centered environment.

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Infographic: Trends in Employer-based Healthcare Benefits Strategy

August 29th, 2014 by Melanie Matthews

Nearly all employers are changing their healthcare benefit strategy in light of the Affordable Care Act and rising healthcare costs, according to a new report by Towers Watson depicted in this infographic.

The infographic examines the changes that employers are making to their benefit plans and the top five focus areas for best practices in employer-sponsored coverage.

Employers Act to Control Health Care Costs

Narrow Network Strategies and Trends for Health Plans and PBMsNarrow networks — for both medical and pharmacy providers — are gradually becoming more accepted by carriers, plan sponsors and patients. Smaller provider networks allow payers to manage overall healthcare costs while still maintaining access to benefits — an important consideration as plan designs become more commoditized in the age of public and private health insurance exchanges. Narrow Network Strategies and Trends for Health Plans and PBMs outlines the tactics health plans are using to restrict medical and pharmacy networks while still maintaining adequate access to care and positive relationships with providers. It also summarizes case studies of health plans and PBMs that have formed narrow networks and the results they’ve seen.

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4 Goals for Furthering Care Coordination in the Medical Neighborhood

August 28th, 2014 by Cheryl Miller

With the advent of the medical neighborhood, care coordination is no longer the sole domain of the primary care practice (PCP), but a responsibility shared among all providers that touch the patient. But how to formalize co-management of patients by PCPs and specialists — in a way that both assures efficient delivery of high-quality healthcare and addresses the ‘pain points’ of each provider group? Here, Robert Krebbs, director of payment innovation at WellPoint, Inc., discusses the four goals for furthering care coordination in the medical neighborhood.

The care compact isn’t intended to solve all the world’s problems. We know it’s not going to make care coordination perfect, but it’s a starting point. Just like the PCMH provides a foundation for the medical neighborhood, the care compacts provide a foundation for care coordination between practices. It’s an essential starting point to further care coordination expectations across the medical neighborhood.

First, with the care compact, we’re helping the pilot practices by identifying the PCPs they can collaborate with to put care compacts in place. We’re playing connector for these two practices.

Second, we’re assessing the current care coordination capabilities of the specialist practices in the pilot and looking at where they’re starting from in terms of care coordination.

Third, we’re watching them customize the care compact and monitoring how they adapt it to their practice needs so we can come up with a stronger template at the end of this pilot than we started with that guides this last point.

Finally, we’re going to disseminate best practices throughout the process to all participants in the pilot. Everyone will benefit from the hard work of each participating practice.

Excerpted from Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination.

Infographic: Physician Practice Patterns

August 27th, 2014 by Melanie Matthews

Physicians are key to improving hospital quality and lowering costs, according to a new infographic by Dimensional Insight.

The infographic looks at how physicians influence healthcare spending, the growing trend toward physician data transparency and the potential impact if all states improved to best-performing state levels.

Physician Practice Patterns

Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for PerformanceIn healthcare's post-reform volume-to-value world, payor reimbursement strategies are tipping in favor of providers who can deliver the clinical and financial goods. In the mix are bundled payments, shared savings, pay for performance and bonuses — with some going so far as to restructure organizations for maximum gain. The Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance goes beyond theory explores emerging models of episode-based payments, physician-hospital organizations and physician bonus structures.

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Trained Military Medics Ease Transitions for John C. Lincoln’s Newly Discharged Patients

August 26th, 2014 by Patricia Donovan

A large part of the success of the John C. Lincoln Network accountable care organization (ACO) can be attributed to its Transition Coach Program, which uses trained military medics as care transition coaches, explains Heather Jelonek, the organization's CEO for ACOs.

We applied for a CMS Innovation grant in spring 2012. Our hypothesis was that we could take military healthcare professionals, medics and army corpsmen; these individuals are incredibly well trained. Army medics can do appendectomies in the field; they’re providing basic primary care services. However, when they’re discharged from the military, they have no equivalent licensure.

We decided to begin a program where we hired individuals we referred to as having ‘blood on their boots.’ Tom Jargon was our first transition coach; he started with us about 90 days after his last tour in Afghanistan ended. But what the program really does is bring these young men and women into our health system. They get six weeks of training, they meet with a cardiologist, they are introduced around the hospital staff, and they get to know how to use the EPIC® electronic health record to its most effective benefit.

These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients and develop a rapport, but they also start preparing the patients for discharge. They are doing basic things like making sure the patient has a social support system in place and transportation to their primary care or specialists’ visits. They also try to determine the patients' financial resources.

Once that patient is discharged from the hospital, our transition coaches follow them for a minimum of 30 days. They’re going into the patient’s home looking for fall risks. They’re helping the patient set up their home so that they’re a little bit safer. They’re doing a general review of cabinets: does the patient in fact have food in the refrigerator? Do they have pet food available if they have pets? Sometimes we find patients are feeding their pets rather than feeding themselves. So through our relationship with PetSmart®, we’ve been able to collect donations of animal food; we deliver those to our patients’ homes so they can afford food for themselves.

If on the other hand they’re finding evidence that the patient has pet food in the home but no food for themselves, we connect those patients with our Desert Mission Food Bank.

Transition coaches help patients learn to monitor their blood pressure. They explain their medication. They go through basic nutrition and education services. We bring in a registered dietician to work with patients who have dietary issues.

Source: Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care

Beyond the EMR Population Health Analytics


Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care
Reviews the concentrated data dig undertaken by John C. Lincoln to prepare for participation in the CMS Medicare Shared Savings Program (MSSP).

Infographic: Value-Based Insurance Design

August 25th, 2014 by Melanie Matthews

Value-Based Insurance Design

The healthcare cost discussion is shifting from "how much" to "how well," when designing health insurance benefits, according to a new infographic by the University of Michigan's Center for Value-Based Insurance Design.

The infographic describes this new approach, the benefits to stakeholders and the implementation and impact of this model.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and ProfitabilityIn today's value-based healthcare sphere, providers must not only shoulder more responsibility for healthcare outcomes, cost and quality but also align with emerging compensation models rewarding these efforts—models that often seem confusing or contradictory. 6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability examines a set of provider compensation models across the collaboration continuum, advising adopters on potential pitfalls and suggesting strategies to survive implementation bumps.

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Infographic: High-Performing Medical Groups

August 22nd, 2014 by Melanie Matthews

For physician practices to succeed in emerging healthcare delivery and financing models they have to forgo traditional practice management models, according to a new infographic by The Advisory Group.

The Advisory Group identifies the 16 steps to becoming a "high-performance medical group."

16 Steps to a<br />
High-Performance Medical Group

Improving Healthcare Team Performance: The 7 Requirements for Excellence in Patient CareTeams and collaboration have become an expectation in most healthcare facilities and environments. It is accepted that high performance, patient-focused teams are critical to quality patient care. However, there is often a wide gap between traditional practices and the new behaviors and practices required for teamwork and collaboration. Improving Healthcare Team Performance: The 7 Requirements for Excellence in Patient Care goes beyond theory to provide the knowledge, tools, and techniques required to develop a single team, or to develop an organization-wide team-based culture, from which exceptional patient care emerges.

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8 Challenges to Medical Home Success

August 21st, 2014 by Cheryl Miller

"The reality of today is that the healthcare world as we know it is changing more than any time since the advent of Medicare," says Dr. Terry McGeeney, director of BDC Advisors. System coordination, patient-centeredness and patient engagement are some of the new industry goals, he says, which bring new challenges, chief among them being physician reluctance to change.

  • First, there are some real challenges to making the changes to patient-centered medical homes (PCMHs). A lot of physicians are reluctant to change. Physicians have been trained to be change-averse and variable-averse to avoid making mistakes at two o’clock in the morning, etc.
  • Second, physician leadership and physician champions are critical, and again, sometimes this has to be trained and taught.
  • Third, there’s a culture that is very traditional in healthcare; we need to think and talk about that. There is also a culture within individual practices and health systems that creates barriers to successful transformation.
  • Fourth, some providers are not able to function effectively in a team environment and this needs to be supported and transformed with the appropriate training provided.
  • Fifth, communication is critical at multiple levels. Successful medical neighborhoods and clinically integrated neighborhoods (CINs) are built around communication, care plans, care that’s delivered, data, quality metrics, lab data, etc.
  • Sixth, there has to be trust between all of the entities as systems are transforming and payor data becomes more critical. Partnerships with payors around shared savings or shared risk are becoming more common. Trust is critical, and again, that hasn’t always existed.
  • Seventh, we need to make sure there are aligned incentives; you can’t ask people to do more work for the same compensation. You can’t ask them to assume more risk for the same compensation. Incentives need to be aligned around what is now called ‘value-proposition’ or ‘pay-for-value,’ or to where there is an expectation to improve quality and lower cost.
  • And finally, there needs to be full recognition that PCMH transformation is not easy. It’s very difficult, it’s time consuming, but at the end it’s highly rewarding.

value-based reimbursement
Terry McGeeney, MD, MBA, is a director at BDC Advisors. He was recently appointed a visiting scholar in Economic Studies for the Brookings Institute in Washington, D.C.

Source: Driving Value-Based Reimbursement with Integrated Care Models

Infographic: Healthcare Consumer Evolution

August 20th, 2014 by Melanie Matthews

As healthcare technology and patient accountability continue to grow, healthcare consumers are taking on a much more active role in their healthcare.

This new infographic by Vitals looks at how healthcare consumers are evolving and five habits of highly-evolved patients.

Evolution of the Healthcare Consumer

The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture, and Patient ExperienceLearn the steps your practice can take to reap the many payoffs of achieving high patient-centered standards without having to make a big financial investment. In The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture and Patient Experience, authors Cheryl Bisera and Judy Capko, explain how healthcare professionals and organizations can thrive in the new patient-centered environment.

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