Archive for December, 2009

Top Disease Management Stories of 2009

December 31st, 2009 by Melanie Matthews

This week's DM Update is a "best of" issue, looking back on the most read stories in 2009. Interestingly enough, two of the top stories are prevention stories — one on breast cancer and the other on worksite wellness — indicating the growing emphasis on prevention in disease management. Diabetes care costs was another top story — a big topic of discussion throughout 2009 as data on rising costs of care and diagnostic trends emerged.

HBWU Top Healthcare Stories of 2009

December 28th, 2009 by Melanie Matthews

While healthcare reform continues to be the biggest story of the year, we took a look back at the most widely read stories of the last 12 months. The articles in this week's Healthcare Business Weekly Update reflect the changing face of primary care, a greater reliance on health coaching across the healthcare continuum, more interest in performance measurement (for both hospitals and coaches), and in the case of our most widely read story of 2009, a ranking by hospital executives of the best and worst insurance companies.

If you haven't already read the results of our Healthcare Trends for 2010 white paper, download it here.

May your organization begin 2010 with some healthy business indicators.

Beating Barriers to Effective Heart Failure Care

December 23rd, 2009 by Melanie Matthews

Michele Gilbert, education coordinator of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center, discusses different circumstances that lead heart failure patients to not receive proper care management.

There are many barriers to heart failure patients receiving excellent care. Patients have multiple comorbidities. They take lots of medications and experience adverse drug reactions. Dietary compliance issues are a huge problem. There are psychosocial problems, with social isolation and depression being two of the biggest challenges. There are also financial constraints. Heart failure patients are expensive. Medications are costly, and often patients can’t afford them. Patients also have physical limitations. For example, they may have trouble with their eyesight or neuromuscular problems. When I started as a heart failure nurse, I came from a clinical care background. I learned that just because I tell patients to weigh themselves daily doesn’t mean they’re able to see the numbers on the scale. This is also a component of cognitive dysfunction. The instructions we give patients don’t always translate into them being able to care for themselves.

Part of the problem with heart failure case management is the revolving door and our job is to stop it. Patients are getting discharged from the hospital earlier and earlier. Doctors’ offices are not an ideal place for them to follow up on their care or get educational support. Therefore, patients go home not able to understand their medications and manage themselves. As a result, they have an exacerbation and wind up back in the hospital time and time again.

Of all the reasons for heart failure hospital readmissions, half are related to diet non-adherence and drug non-adherence. Often patients truly do not understand, for example, how to manage a daily two-gram sodium diet. We must be specific when we talk to patients. We must ask questions such as, “Who cooks your meals? Who buys your food? How often do you eat out?” We need to explain to patients where the hidden sodium is in their diet. It’s not coming from the salt shaker. Rather, it’s in all the other things in our diet that have too much sodium for patients with heart failure to eat.

With drug plan adherence, it’s very important to explain to patients not only what their medications are and what the dosage is, but also what the pills do. For example, I visited a patient at home once and when I went through her notebooks with her, she thought that her Persantine® was her water pill. Every time she was short of breath, she’d call her doctor who would direct her to take three water pills. Instead, she’d take three Persantine and wind up in pulmonary edema the next morning in the emergency room (ER). It’s extremely important for patients to know what they’re taking and why. Two-word explanations such as “water pill, cholesterol pill, blood pressure pill or heart pill” are usually sufficient.

Beating Barriers to Effective Heart Failure Care

December 23rd, 2009 by Melanie Matthews

Michele Gilbert, education coordinator of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center, discusses different circumstances that lead heart failure patients to not receive proper care management.

There are many barriers to heart failure patients receiving excellent care. Patients have multiple comorbidities. They take lots of medications and experience adverse drug reactions. Dietary compliance issues are a huge problem. There are psychosocial problems, with social isolation and depression being two of the biggest challenges. There are also financial constraints. Heart failure patients are expensive. Medications are costly, and often patients can’t afford them. Patients also have physical limitations. For example, they may have trouble with their eyesight or neuromuscular problems. When I started as a heart failure nurse, I came from a clinical care background. I learned that just because I tell patients to weigh themselves daily doesn’t mean they’re able to see the numbers on the scale. This is also a component of cognitive dysfunction. The instructions we give patients don’t always translate into them being able to care for themselves.

Part of the problem with heart failure case management is the revolving door and our job is to stop it. Patients are getting discharged from the hospital earlier and earlier. Doctors’ offices are not an ideal place for them to follow up on their care or get educational support. Therefore, patients go home not able to understand their medications and manage themselves. As a result, they have an exacerbation and wind up back in the hospital time and time again.

Of all the reasons for heart failure hospital readmissions, half are related to diet non-adherence and drug non-adherence. Often patients truly do not understand, for example, how to manage a daily two-gram sodium diet. We must be specific when we talk to patients. We must ask questions such as, “Who cooks your meals? Who buys your food? How often do you eat out?” We need to explain to patients where the hidden sodium is in their diet. It’s not coming from the salt shaker. Rather, it’s in all the other things in our diet that have too much sodium for patients with heart failure to eat.

With drug plan adherence, it’s very important to explain to patients not only what their medications are and what the dosage is, but also what the pills do. For example, I visited a patient at home once and when I went through her notebooks with her, she thought that her Persantine® was her water pill. Every time she was short of breath, she’d call her doctor who would direct her to take three water pills. Instead, she’d take three Persantine and wind up in pulmonary edema the next morning in the emergency room (ER). It’s extremely important for patients to know what they’re taking and why. Two-word explanations such as “water pill, cholesterol pill, blood pressure pill or heart pill” are usually sufficient.

Some Good Reasons to Raise Patients’ Medication Awareness

December 21st, 2009 by Melanie Matthews

Of all the reasons for heart failure hospital readmissions, which account for the lion's share of Medicare readmissions, half are related to diet non-adherence and drug non-adherence, says the education coordinator for Hackensack University Medical Center's heart failure team in a featured story in this week's Healthcare Business Weekly Update. Even more sobering: a new University of Colorado finding that 96 percent of discharged patients were unable to recall the name of at least one medication that they had been prescribed while in the hospital. Also, almost half of study participants believed they were taking a medication when they were not.

With $27 million in Recovery Act funds just allocated to help older individuals with chronic conditions manage and improve their health, communities should dedicate a portion of these funds to programs that raise patients' medication awareness levels. Confirming that a patient clearly understands the purpose for taking each medication is part of Dr. Eric Coleman's three-question Care Transitions Measure, a patient survey endorsed by the National Quality Forum that reflects how well a hospital has prepared a patient for discharge.

A recent HIN blog post suggests a strategy for improving patient motivation for medication adherence.

Adult Obesity Trends

December 18th, 2009 by Melanie Matthews

With much of science focused on reducing childhood obesity, there is still scientific hope for reducing adult obesity. In this week's issue of the DM Update, discover how obese adolescents experience sleep apnea more than younger children and how watching less television affects calorie counts in obese adults. Also, tune in to a new NIH program to help reduce obesity rates among different populations.

Community Connections Expand the Medical Home

December 18th, 2009 by Melanie Matthews

Liz Reardon, a healthcare consultant, president of Reardon Consulting and a member of the National Council for Community Behavioral Healthcare’s Integration Consulting Team, discusses the reasons why connecting with the community would be essential in establishing a medical home.

If asked to give a single piece of advice to organizations contemplating establishing a medical home for their members, Liz Reardon advises that they “connect with community resources rather than trying to duplicate them in the practice.”

“A hospital system I worked with has a number of hospitals and practices and is initiating a major medical home initiative. We were talking about some of their challenges [regarding the medical home]. We were talking about this community piece and trying to figure out how much responsibility they had for making connections around dietary counseling or exercise programs — or not just for a Medicaid population but certainly the social services that people might need. They were spending a lot of time trying to maintain lists of who was doing what where. They were finding it incredibly frustrating, because the minute you develop a community resource guide, immediately something changes.

“Because things change so rapidly, it’s difficult for a practice to do all the care coordination and connect people with all kinds of resources. What was important for them was to develop relationships with key social service agencies. In this instance, their local health department was really helpful because they also have the connection to some of the fuel assistance, nutrition assistance and other assistance programs that low-income people needed.

“Practices can run themselves ragged sometimes trying to be everything for everybody. Spend some time and find out who the key people or key organizations are in your community, develop that relationship with them and then you’re not necessarily taking over everything.”

Sizing Incentives to Reduce Avoidable Admissions

December 18th, 2009 by Melanie Matthews

Medication reconciliation, discharge planning, communication and teamwork across settings are all activities that can help hospitals reduce the number of avoidable hospital admissions. That's why the Maryland Health Services Cost Review Commission (HSCRC) wants to help fund an infrastructure to support hospitals that do a better job at these functions, explained Dianne Feeney, the HSCRC's associate director of quality initiatives, during a recent webinar on aligning reimbursement to reduce avoidable hospital admissions.

"We’re in the planning stages of this infrastructure support phase now," said Feeney. "Other areas of infrastructure coordination across settings include shared care information, self-care management focus, joint clinical care protocols and shared single assessment templates. Nursing homes potentially need to be working with the hospitals who commonly have patients that go back and forth between the two entities. They should share certain kinds of protocols for certain patient types, for instance.
Then there may be some more broad efforts that are systemic problems like physician/patient communication. How do we improve that? Inappropriate use of 911 in the state and inappropriate use of emergency departments can also impact the readmission picture that we are seeing.

"Payment incentives for these activities are the hard nut to crack because hospitals' bread and butter is getting the patients to come in the doors," Feeney continued. "You have to size the incentive to make it attractive enough so that the hospital wants to go for it and reduce readmissions without losing their margin to be able to operate. The truth be known, there are probably just too many hospital beds, and there will be some shrinking of the inpatient hospital bed number because there is too much care being provided. At the same time, we still do have to set up the incentives and structure them such that hospitals will see reducing rate of admissions as a very positive thing to their bottom line."

Stroke Risks and Prevention

December 11th, 2009 by Melanie Matthews

According to the American Stroke Association, stroke is the number three cause of death in the United States, behind heart disease and cancer. In this week's issue of the DM Update, you will discover which U.S. residents may have a higher risk of dying from a stroke, how salt intake is linked to stroke risk and the medication patients are consuming to prevent repeat strokes.

How to Avoid the Top 5 Care Transition Breakdowns

December 11th, 2009 by Melanie Matthews

Gregg O. Lehman, Ph.D., president and chief executive officer of Health Fitness Corporation and former president and CEO of INSPIRIS, Inc., maps out when and how care transition breakdowns can occur for the Medicare population.

When do breakdowns in care transitions occur? First, breakdowns when moving from a primary care physician (PCP) to a specialty physician are common — often, information is not well documented. And because it’s common for the Medicare population to be cognitively impaired, it can be difficult for them to effectively communicate their symptoms to the physician. Therefore, physicians need to try to gather information such as changes in eating habits or low-grade fever through a brief physical check.

Second, breakdowns can also occur when moving patients within the hospital. For example, when moving a patient from the ER to another department such as surgical or the ICU, things can fall between the cracks. Treatment for one condition may exacerbate another, causing a more serious problem. Recidivism is also common, and patients usually end up back in an acute care setting.

Thirdly, discharges from the hospital to a home setting or an assisted- or skilled-living facility are often a huge challenge. Typically, these patients cannot take on a self-management role and ask the right questions, or they get confused and cannot remember what their PCP told them. It’s a challenge to maintain a consistent database. Many companies have implemented electronic medical records (EMRs) for this population. The database can be maintained on a virtual or real-time basis for the primary caregivers. Our company uses a registered nurse practitioner (RNP) as the lead person triaging care. The EMR helps to effectively disseminate appropriate information on a timely basis during the care transition process.

Fourth, ineffective communications are a huge problem when dealing with the Medicare population. Communication problems can lead to medication errors and delayed treatment. It can also lead to duplicate test results because records were not transferred in real time. In addition, there’s often a misunderstanding of the rules. For example, HIPAA is designated to protect patient information. However, it can work against patients in transition. Despite the fact that HIPAA permits provider-to-provider disclosure without patient authorization, some providers will not do this without prior patient authorization, and sometimes not without actual patient signatures. In many cases, the power of attorney or signature authorization belongs to a family member not even residing in the same state. That compounds the problems you’re already dealing with. A lack of common platforms for sharing data is also a big problem. Using real-time information that is accessible to the caregiver is critical in minimizing the breakdowns that occur.

Finally, for this population, there are problems inherent in the transition itself. If we move a patient out of a familiar setting &$151; where they’re comfortable with the staff — and into an acute-care setting, often they become disoriented. This commonly results in a downward spiral of the individual’s overall health status. The frail elderly are frequently at various stages of cognitive impairment or the early stages of dementia or Alzheimer’s. A low-grade fever can cause a spike in the patient’s confusion. However, it may not get noticed since the caregiver may attribute it to their other cognitive impairments. This lack of treatment can be the beginning of a decline in the patient’s health.