Archive for July, 2009

Care Pathways, Telemonitoring Foster Self-Management

July 30th, 2009 by Melanie Matthews

As part of its successful medical home pilot, Geisinger Health Plan (GHP) has crafted patient education tools that support nurse case managers in their care coordination efforts, whether conveyed to the patient telephonically or face to face, explains Janet Tomcavage, R.N., M.S.N., GHP's vice president of health services.

"For example, there’s no better way to teach foot care to diabetics than to have them take off their shoes and socks when they come into the office and show them the parts of the feet that they need to look at. Then, get a bottle of lotion and teach them where the feet tend to get dry and how to protect their feet. Teach them how to look at the inside of their shoe and the types of socks that leave ridges in their toes and cause areas of friction that can then cause open areas or pressure sores."

Geisinger reinforces these patient education efforts with telemonitoring, such as in the case of heart failure patients whose homes are equipped with Bluetooth® scales. "We teach them to step on that scale. They get up and go to the bathroom in the morning and before they do anything else, they step on that scale."

That scale automatically transmits their weight to a Web portal that monitors daily weight. "If we notice a two- to three-pound weight gain overnight or a five-pound weight gain over five to seven days, the nurse is then alerted so she can reach out to that patient," Tomcavage explains.

Similarly, diabetic patients are taught to check their blood sugars at home and look for patterns identifying the extremes of when they should be calling in to the clinic. "Symptom monitoring is very critical in chronic disease. For example, asthma patients learn how to do peak flows and know their normal peak flow. "If their peak flow is dropping, which usually means they’re getting a little more restrictive in their breathing, they have an action plan to respond."

Tomcavage said that even though the medical home pilot population is largely rural, with few patients having Internet access, GHP is starting to see more seniors surfing the Internet or using EHRs. Also, she notes, family members of the Medicare patients love the patient portals.

"We have many nurses who communicate with the patient’s families, who are often the caregivers, who work during the day. The portal is an easy way for them to communicate with us."

ER Visit Reduction Efforts Best Focused on Non-Emergent Cases

July 23rd, 2009 by Melanie Matthews

Dr. James Glauber, medical director for Neighborhood Health Plan of Massachusetts, explains why his organization no longer targets "frequent flyers" in programs to reduce ER use.

When intervening to reduce ER visits, one of the decision points a plan needs to make is whether they’re going to focus on frequent ER utilizers — who make up only a small percentage of total ER use — or whether they’re going to adopt a broad-based strategy to target ER use among the 90 percent of the population that is visiting the ER occasionally.

We’ve made some observations in regard to using case managers to target frequent ER utilizers. It’s difficult to find and engage these individuals regarding their ER use patterns. We outreach them sometimes weeks or months after their last ER visit. Often they report that the reason they went to the ER was because they were directed to go by their primary care site, either because of the nature of their condition or the fact that there weren’t any available appointments. Often, they do not appreciate being contacted regarding their ER use. In addition, it’s unlikely that they will remain high ER utilizers the following year.

The Massachusetts Division of Healthcare Finance and Policy conducted an analysis of ER use, based on a database of all the ER visits that occurred in 75 ERs across the state over a two-year period. They defined frequent use as greater than or equal to five ER visits per year, in the baseline year of 2002. They identified the group of frequent ER utilizers and determined the likelihood that they would remain a frequent utilizer in the following year. They found that only 28.4 percent of frequent utilizers remained frequent utilizers in the following year, and 25.1 percent had no ER visits the next year. The remaining group — slightly less than 50 percent — was just occasional users in the following year. They did, however, identify a subgroup of frequent users who also visited four or more different ERs in the following year. This group of "frequent ER travelers" tended to visit the ER for pain-related diagnoses such as lumbago, headache, migraine and tooth pain. These frequent ER travelers were much more likely to remain high utilizers in subsequent years.

Based on this information, we are no longer investing resources in targeting high ER utilizers. We've focused the majority of our efforts on interventions to reduce ER use for non-emergent conditions among the occasional ER utilizers in our population. Our strategy is to provide resources and information to enhance members' self-care decision-making. The strategies we’re using are low-touch but broadly based — at the very least they will not do any harm. Also, they have the potential for collateral benefit in terms of giving members access to information that may more broadly benefit their health and healthcare. To be effective, these strategies require ongoing marketing to reach the targeted audience.

New Successes in Smoking Cessation

July 23rd, 2009 by Melanie Matthews

In 2008, the CDC put the amount of U.S. adults age 18 years and over who smoke cigarettes at 22 percent, making tobacco use the most common preventable cause of death. This week's DM Update brings you a new cessation technique that shows promising results for tobacco quitters and improvements in stage classification methods for lung cancer patients.

Telehealth Engages Rural Iowa Medicaid Population

July 16th, 2009 by Melanie Matthews

"The biggest lesson that we learned was that a Medicaid population can be engaged," says Dr. Thomas Kline, medical director at the Iowa Medicaid Enterprise, which used telephonic self-reporting to engage Medicaid patients in rural areas of the state in disease and care management programs. "Had you asked me this question before we launched, I would have said, 'They can’t be reached. You can’t get them involved, and they don’t want to participate.' But we learned through the development of this program and with the aid and assistance of Pharos [telehealth vendor] that we’re able to identify and engage a much greater percentage of the patient population.

As a result of this increased engagement, the Iowa Medicaid Enterprise is much more effective overall, says Dr. Kline, noting that specific results depended upon participant need.

"Participant “pools” are not always equal. We stratify them into three different areas. The first area is made up of those with more immediate needs and those that were more critical, more beneficial of the intervention care that we provided. The second group is less so and the third group, where we didn’t recruit that many people from that area, is certainly different. Our effectiveness and management was different in all three pools."

Most importantly, the technology and intervention must be simple, convenient and familiar, stresses Dr. Kline. "This is probably more true in the Medicaid population than it would be for a commercial population. The need is there, but the need for something simplistic, something that can be done and participated in regularly — that if they had access to a telephone, they’re able to push the numbers one, two, three or four — they were simple questions that were kept to a minimum. As a result of the simplicity, more effectiveness occurred."

Because depression is very prevalent in this population, the program had to address this issue, Dr. Kline concluded. "Because of our success and our experience with this program, we have now incorporated it into all of our programs. To date, we have probably screened in excess of 2,000 Medicaid members, referred approximately 200 of them and we’re engaged with our behavioral health provider. Iowa’s Medicaid experience was successful and beneficial; we plan on pursuing it and keeping it going forward."

Read more about using health IT in care management to improve health and effect behavior change.

Three Ways to Evaluate Health Coaching Performance

July 15th, 2009 by Melanie Matthews

Three health coaching experts share their organization’s methods for evaluating a health coach’s performance to ensure client satisfaction.

Hummingbird Coaching Services provides a monthly report card to every coach, which includes customer review. "Much of it is quality reviews of their interactions with clients, and whether they followed the coaching model versus perhaps dipping into the prescriptive side," explains Sean Slovenski, Hummingbird’s president and CEO.

"Training is important, but the ongoing support of the coaches through the quality assurance (QA) is critical. Since it isn’t an exact science, you must ensure that you’re doing the assessments on a constant basis, because continual learning needs to occur to constantly improve the quality of the coaching."

To determine satisfaction, behavior change and goal achievement levels of its participants, Mayo Clinic Health Management Resources does phone-based outcomes and satisfaction calls. "One call is at the end of the program, when we have an engagement specialist — someone other than the coach — reach out to the participant," notes Michael Casey, senior director of population health products and services at Mayo Clinic Health Management Resources. "That’s important, because the participant is more likely to be honest if a third party on the phone is saying, 'I know you just participated in a coaching program, what did you think?'" "From a validity perspective, we have someone other than the coach do those satisfaction and outcomes calls," Casey continues. "About 50 percent of our participants participate in those calls, which is pretty good. We have to chase them down a little bit to get there." In addition to phone calls, Mayo is also testing the collection of satisfaction outcomes data via e-mail and the Web.

Ceridian LifeWorks conducts annual competency tests in five core areas to make sure that its coaches have the knowledge to do their job effectively and that they haven’t forgotten anything. It also helps the company identify areas for continued training and education, says Darcy Hurlbert, M.P.H., health and wellness product specialist at Ceridian.

Online health coaching presents its own evaluation challenges. Hummingbird Coaching Services has its own proprietary system that the coaches do their work through. "All interaction, established goals, communications, e-mails, educational materials picked by the coach for the individual — are automatically catalogued and date and time-stamped and are conserved. This gives us a real transactional record of what’s happening all the time, and because you have that, there’s no room for misinterpretation," notes Slovenski.

New Hospital Readmissions Data Boon to Patients, Payors

July 13th, 2009 by Melanie Matthews

With a reduction in hospital readmissions high on the healthcare reform agenda, the CMS Hospital Compare site is now providing data on 30-day readmissions rates for patients with heart attack, heart failure and pneumonia. On average, about a fifth of patients with these conditions are rehospitalized within 30 days of discharge, a statistic CMS is hoping to influence with the publication of this data. The new Hospital Compare measures, described in a featured Healthcare Business Weekly Update story this week, are endorsed by the NQF and supported by the Hospital Quality Alliance. One way to avoid these readmissions is to pay close attention to care transitions to avoid medical errors or misunderstandings that often send the elderly back to the hospital.

Also last week, a study published in Circulation: Cardiovascular Quality and Outcomes found that hospitals in New Jersey, Vermont, New Hampshire, Washington and Oregon had the least deaths and fewest hospital readmissions following a heart attack or heart failure. The worst performing states were Oklahoma, Arkansas, Tennessee, Missouri and Louisiana.

The availability of this data is good news for consumers who want to maximize their chances of a successful recovery from these conditions and for healthcare organizations hoping to reduce the cost of avoidable readmissions, especially for the Medicare population. The CMS readmission measures — as well as improved data on previously reported mortality rates — are risk-adjusted and take into account previous health problems to "level the playing field" among hospitals and to help ensure accuracy in performance reporting.

Caffeine Reverses Memory Impairment

July 9th, 2009 by Melanie Matthews

According to the National Coffee Association, in 2000 an estimated 54 percent of U.S. adults drank coffee daily. This week's Disease Management Update brings good news to these java junkies, as a new study published this month by the University of South Florida suggests caffeine can have positive effects on some forms of dementia.

Watchful, Prepared Waiting Can Equip Healthcare Companies for Reform

July 8th, 2009 by Melanie Matthews

Not sure how healthcare reform will impact your organization? Understanding the 'moving parts' of reform and walking through what-if scenarios can help healthcare organizations prepare for major changes in the industry that will likely hit this fall, advises Dr. Paul Keckley, executive director of the Deloitte Center for Health Solutions. "One, I think you have to be knowledgeable about the various moving parts of this. We can’t be caught by surprise," he states. "I appreciate questions about episode-based payments and comparative effectiveness because I find that most people really don’t understand the concepts."

Second, Keckley continues, "We have to begin doing scenario plans in our organizations, creating a set of “what ifs” and actually plugging in real numbers. An example would be in my prior role at Vanderbilt [as executive director of the Vanderbilt Center for Evidence-based Medicine]. If we were looking out five years in our capital expenditure budgets, I would be revisiting those. I would be revisiting how I deploy my capital for facilities versus infrastructure, inpatient versus my network of community-based providers.

"We are going to know what [reform] looks like in the early fall," Keckley stated during a recent mid-year analysis of healthcare trends. "At that point everyone has to be in a position to act. Between now and then it is, it is beyond watchful waiting. I think it is watchful, prepared waiting."

Funding and Establishing Medical Home Care Coordination

July 8th, 2009 by Melanie Matthews

Experts on medical home models of care share their experiences in funding medical home transitions and care coordination fees.

Funding the Medical Home Transition

Question: How can a health plan fund the transition to a more chronic care medical home model?

Response: (Dr. George Rust, family practice physician for Physicians in Practice, head of the National Center for Primary Care at Morehouse School of Medicine) There are lots of different options. Capitate payments can sometimes offer the opportunity to have a more multidisciplinary team involved in care. If you’re in a purely fee-for-service (FFS) environment, broaden your teams so that nurse practitioners (NP), mental health professionals and behavioral healthcare specialists are all part of the team. In our state, we found that many of our community health centers believed that they could not have two visits by different providers billed on the same day out of the same facility. For example, they could not co-locate psychologists and primary care clinicians in the building on the same day. That turned out to not be true. Those types of visits would indeed be paid for.

Therefore, the first step would be determining how to broaden the team so that it isn’t just a doctor-centered model, but it includes individuals who currently may not be in the practice like NPs, psychologists and behaviorists. This is especially important in the high disparity or multi-cultural communities. Community health workers — people who are of the culture that you’re trying to serve — are important. They’re even more important if your own providers do not match that culture, since they can act as a cultural bridge or ambassador to the community to champion certain outcomes.

(Elizabeth Reardon, president of Reardon Consulting, National Council for Community Behavioral Healthcare Integrated Care Consulting Team) There are some current procedural terminology (CPT) evaluation and management codes that address care coordination and treatment planning. They even have some that involve telephone contact. Not all payors want to pay for that. However, it gives you some background. Also, the CPT behavioral management codes that Medicare pays can help. Some of them relate to care planning and some to practice teams getting together to address what they need to work on.

Establishing Care Management Fees

Question: Dartmouth-Hitchcock recommended a $4 per member per month (PMPM) care management fee, but could not operationalize that. What are you doing instead?

Response: (Barbara Walters, senior medical director of Dartmouth-Hitchcock Medical Center) There are some potential options on the table. There are G-codes that have been published. Medicare has chosen not to adopt them this year, but they are available for use by the commercial plans. If the commercial plans can program a care coordination CPT code into their systems, then we will negotiate a monthly or quarterly care coordination fee. That will allow us to get reimbursed for care coordination for the complex patient.

With CIGNA(R), we negotiated an increased regular FFS reimbursement rate on the E&M codes that are billed by our primary care departments. We hope this will cover the cost of care coordination, but because this pilot just started, we have to do a reconciliation at the end of the year to see if the amount of money we received trues up for the number of patients for whom we coordinated care.

Bucket List for Healthcare Reform

July 7th, 2009 by Melanie Matthews

There are four major buckets of health reform activity, including a foundation in information technology, a platform of comparative effectiveness in evidence-based medicine, a refocus toward primary care and the coordination of care through that primary care provider, and a mechanism to increase the consumers' share of financial responsibility for their healthcare decisions, according to Paul Keckley, Ph.D., executive director of the Deloitte Center for Health Solutions, who outlined reform for us during last month's HIN webinar, Healthcare Trends in 2009: A Mid-Year Financial and Legislative Update.

In this week's Healthcare Weekly Business Update, you'll see the federal government and the industry moving toward these initiatives even as Congress begins to shape health reform bills. The federal Coordinating Council for Comparative Effectiveness Research last week released recommendations on how HHS should spend the allotted $400 million for comparative effectiveness research. Recommendations were also released by the Certification Commission for Healthcare Information Technology on the development of certifications for long-term and post-acute care EHRs. Lastly, you'll also read about provider reimbursement options that exist for care coordination under the medical home model of care.