Archive for 2011

Meet Case Manager Linda Conroy: Breaking Down Barriers Between the Hospital and Community

December 23rd, 2011 by Cheryl Miller

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

Linda Conroy, RN, BSN, Clinical Integration Case Manager for Hartford Physician Hospital Organization (HPHO)

HIN: What was your first job out of college and how did you get into case management?

Linda Conroy: I started my nursing career as an LPN and obtained a position as a case manager at a home care agency. I spent the next 15 years going to school part-time and working at home care agencies part-time. After obtaining my BSN. I went to work at Hartford Hospital in the Clinical Research Center as a clinical research associate. From there I accepted a position as a case coordinator/discharge planner and I am currently working at HPHO as a clinical integration case manager. I was able to get into case management as an LPN due to my recent employment at The CT Hospice in Branford. The home care agency at the time was starting a hospice program.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

I knew I was meant to be a case manager from the beginning. I found it to be both challenging and rewarding. I loved the process of identifying barriers to my patients’ health and researching resources.

What are two or three important concepts or rules that you follow in case management?

Always try and understand what the patient is feeling. Allow the patient/family to guide me in what they want and how they want to reach their goals. Do No Harm.

What is the single most successful thing that your organization is doing now?

The HPHO is working with Hartford Hospital to reduce the rate of readmissions for our patients that are discharged with a primary diagnosis of congestive heart failure. We are working with several home care agencies and skilled nursing facilities to provide improved transition of care and education to both family and patient.

Do you see a trend or path that you have to lock onto for 2012?

I plan to continue to work with the team to develop effective interventions to assist our patients in managing a chronic illness, and to break down silos both within the hospital and in the community.

What is the most satisfying thing about being a case manager?

Enabling patients and families.

What are your favorite hobbies, and how did they develop in your life?

I love to garden, play golf and knit. My mom taught me how to knit when I was seven and I have found it to be very relaxing and therapeutic. I love being outdoors and finding ways to make my yard fun. I play golf to be with my husband.

Is there a book you recently read or movie you saw that you would recommend?

Yes, “Still Alice” by Dr. Lisa Genova.

Click here to learn how you can be featured in one of our Case Manager Profiles.

ICD-10 Compliance from the Health Plan Perspective

December 23rd, 2011 by Jackie Lyons

A three-step process for resolving discrepancies between ICD-9 and ICD-10 codes has allowed Blue Cross Blue Shield of Michigan to complete its version of the General Equivalence Mappings (GEMs) and move closer toward ICD-10 compliance readiness.

However, not all health plans are as prepared for ICD-10 implementation, according to healthcare executives that participated in HealthEdge’s recent Payor Market Survey. With less than two years to go until ICD-10 must be fully implemented, only 22 percent of the respondents surveyed felt that their organizations were “completely prepared,” while 36 percent listed their organizations as “somewhat prepared,” and 37 percent reported that they were only “starting to prepare” for this important new standard.

“At this point, payors should be well on their way towards meeting ICD-10 mandates,” said Ray Desrochers, executive vice president of sales and marketing for HealthEdge, in a MarketWatch press release. “Our survey instead revealed that many organizations are behind schedule, and many payor executives are struggling to address business needs while simultaneously trying to avoid pouring more money into the remediation of their outdated technology infrastructure. It is critical that payors make evaluating and remediating their IT systems a priority in 2012, so that they are ready to both meet the 2013 ICD-10 deadline and the other rapidly evolving needs of the new healthcare marketplace.”

Dennis Winkler, ICD-10 technical program director at Blue Cross Blue Shield of Michigan, described where health plans should be on the ICD-10 timeline at the start of 2012.

“As we look at and enter into 2012, we really expect, and we would hope that most payors in the industry are in a position of taking their resulting maps and applying it to their internal infrastructure – whether it’s application programs or your analytics environment,” he said.

According to Winkler, organizations should have the incorporation of the business changed activites, such as the maps, laid into the operational infrastructure, such as the programs. Therefore, they can commence testing from an end-to-end standpoint in the second half of 2012. This leaves the remainder of 2013 to do external testing with the constituents.

Winkler will share the health plan’s mapping strategy along with other organizational readiness tactics during a 45-minute webinar on January 18, 2012.

Q&A: With Hospital Core Measures, 90% Doesn’t Cut It

December 22nd, 2011 by Jessica Fornarotto

Good core measure performance is good patient care, explains Dr. Steve Berkowitz, president at SMB Health Consulting and former chief medical officer for the central and west Texas division of HCA at St. David’s HealthCare. Prior to his presentation on Healthcare Performance Improvement: Exceeding Core Measure Targets for Value-Based Reimbursement, Dr. Berkowitz discussed the most challenging clinical measures to improve, tools for collecting core measure data and physician incentives to improve performance.

HIN: St. David’s healthcare system has specifically improved care related to heart attacks, heart failure, pneumonia and surgical care. What was the most challenging clinical measure among those to improve and what process changes sparked the improvement?

(Dr. Steve Berkowitz): Every one of those measures has unique challenges that we needed to handle. Frankly, a general challenge that we had was developing these protocols over eight hospitals in two different markets. Having said that, the most challenging measures are the surgical care improvement program (SCIP) measures because they are resource-intensive as well as require physician buy-in and input to make sure they get done appropriately. One thing I want the audience to come away with is a sense of enthusiasm that your organization can get it done. You can achieve virtual 100 percent performance with some hard work, checking and rechecking, and dedication of your physicians, nursing, pharmacy and administration. But most important, the establishment of good core measure performance is good patient care.

HIN: Can a hospital or health system that does not have an electronic health record share this type of data efficiently?

(Dr. Steve Berkowitz): Absolutely. When we first started this, we had very little of an electronic record at St. David, and that’s improving fast. What we were able to do was just develop internal processes to track those patients very early, have concurrent review of those patients, and get the data widely disseminated and available. Not only can we track our performance now, but we can use that data to identify outliers, whether they be physicians, nursing, pharmacists, etc., so that we can specifically target approaches to go for our goal of zero misses.

HIN: In the absence of the EHR, did you use registries at all to either collect the data or disseminate the data?

(Dr. Steve Berkowitz): We had some internal processes that we developed. But it really was a function of downloading all of the data from our system and then individually tracking and monitoring. I want to emphasize that to be excellent in core measures, it’s very labor intensive. You have to check, check and recheck, and there needs to be redundancies built into the system because we need zero misses. Ninety percent doesn’t cut it anymore, 95 percent doesn’t cut it anymore, and even 99.6 percent performance leaves a lot of dollars on the table.

HIN: What physician incentives were in place, or are in place, at St. David to encourage performance improvement?

(Dr. Steve Berkowitz): We have very little physician incentive there, although there is an incentive plan for the hospital lists because they are the driver of these measures, particularly with heart attacks, pneumonia and heart failure, and maybe less so with SCIP. But we instituted an incentive program for our hospital lists and they led the charge. They got us to outstanding performance quickly in those three categories.

Hospital Initiative, GE-Microsoft Collaboration Target Healthcare-Acquired Conditions

December 19th, 2011 by Cheryl Miller

Hospitals are the targets of two of our stories this week: an initiative and collaboration both aimed at reducing the millions of preventable injuries and complications arising from hospital-acquired infections (HAI.) Ironically, this refuge for the sick is making people sicker; in the United States alone, an estimated 1.7 million HAIs occur annually, resulting in $35 billion in additional healthcare costs, and the loss of nearly 100,000 lives. As we reported in an earlier story this year, a University of Maryland report found that nearly half of the hospital rooms of patients who tested positive for a multi-drug resistant bacteria were contaminated with the bacteria.

In response to this, hospitals across the country will now have the resources and support to reduce HAIs: the HHS has launched a new initiative called the Hospital Engagement Network. Part of the Partnership for Patients initiative, a nationwide public-private collaboration to improve healthcare, $218 million will be awarded to 26 state, regional, national, and hospital system organizations to help develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety.

And a new collaboration between GE Healthcare and Microsoft is tackling this problem by pulling together data from disparate IT systems and identifying those patients most at risk for a given HAI. Hopefully their solutions will enable healthcare organizations to more effectively deploy their resources and deliver better care at lower costs.

And on a local level, a new ER unit designed solely for seniors is in place in HIN’s backyard, at New Jersey’s Monmouth Medical Center. To ease the increasingly complex needs of those 65 and up, the unit has special age-related features like wall sconces with dimmers and floor lighting to prevent falls. More in this issue.

In other news, a new study shows that disease registries can improve health outcomes and save the United States billions of dollars. Research on 13 registries in five countries, including the United States and Sweden, shows that these tools are becoming even more important under healthcare reform as payments for care are linked to effective treatments. According to our 2011 Survey on patient registries, 68 percent of respondents are using registries to improve care quality.

And lastly, a new report from Deloitte reveals that the majority of physicians do not think that PPACA will reduce costs by increasing efficiency, and they are predicting a continued shortage in primary care physicians as they seek administrative roles in health plans, hospitals and other settings.

These stories and more, in this week’s issue of Healthcare Business Weekly Update.

Medicare Weighs in on Obesity Counseling for Seniors

December 15th, 2011 by Cheryl Miller

Call it Medicare meets the Biggest Loser.

CMS is now swallowing the costs of screening and counseling for beneficiaries considered to be obese, or at risk for obesity. Doctors determine patients’ eligibility, and those who meet the requirements, or have a BMI greater than or equal to 30 kg/m2, get to participate in the program.

Eligible “contestants” receive dietary and nutritional assessments and face-to-face counseling sessions in a physician’s office each week for a month, and then every other week for an additional five months. The “biggest losers,” or those that lose at least 6.6 pounds, or 3 kg during those six months, get continued sessions for up to a year.

The benefits of the program far outweigh the costs, given the burden that obesity places on states: a recent study from Duke University showed that obesity costs states $15 billion a year in medical expenses. And according to the CMS, over 30 percent of both men and women in the Medicare population are estimated to be obese, a condition that is directly and indirectly associated with many chronic diseases, including those that disproportionately affect racial and ethnic minorities such as cardiovascular disease and diabetes.

Efforts to help curb the epidemic aren’t new; as we reported in our recent survey on Obesity and Weight Management, nearly 72 percent of respondents said they were implementing programs to manage weight or prevent obesity. While adults accounted for the largest population target, 6.4 percent of respondents said that they were targeting the Medicare population with their weight control programs.

Unlike the “Big Reveal” on the network series, we won’t get to see the transformed patients, unless they land gigs with Weight Watchers or Jenny Craig. But the program might take an ever so small bite out of the existing healthcare costs facing us today, and the participants’ loved ones might get to hold onto them (figuratively?) for a little longer.

5 Key Trends for Physicians in 2012

December 12th, 2011 by Cheryl Miller

More than half of today’s physicians believe that healthcare reform will not improve patient care, according to a new trends report from the Physicians Foundation. The changing healthcare landscape is also pushing the majority of physicians to leave primary care practices for hospitals and group practices. These and other trends detailed in this issue.

Children with special healthcare needs are less likely to receive care that meets the criteria for having a medical home, according to a new national report from the Health Resources and Services Administration (HRSA), the first such report on this segment of the population and its counterparts: children without special needs. These children are also being exposed to less than ideal conditions at home; secondhand smoke and poor nutrition are just two situations cited in the report, which based their data on a national survey of more than 90,000 children in the United States.

Depression and diabetes can trigger dementia within three to five years of diagnosis, say researchers from the University of Washington and Kaiser Permanente. Contributors to the study, among the first and largest to date to examine dementia in diabetes patients with and without depression, hope these findings will ultimately slow the advent of dementia.

The CMS has issued a final rule that will give qualified organizations access to health claims data that can help them identify high quality healthcare providers, or create online tools to help consumers make educated healthcare choices. The final rule makes a number of important changes from the original proposed rule, one of them being that data is less costly than previously thought for qualified entities.

And we wanted to make you aware of our new complimentary e-book on the use of embedded case managers in healthcare, a trend embraced by Geisinger, Aetna, CDPHP, Advocate Physician Partners, Marshfield Clinic, Bon Secours and others. This downloadable e-book provides some early metrics on the emerging trend of placing case managers alongside care teams in physician practices and describes some of the benefits that can result.

These stories and more in this week’s issue of Healthcare Business Weekly Update.

Forget About the Pizza, What About the Sodium?

December 7th, 2011 by Cheryl Miller

Pizza is not a vegetable.

That’s the word from the American Heart Association (AHA) on Congress’s much publicized perceived push for pizza to move to the top of the school lunchroom’s food pyramid, a decision sure to disappoint children everywhere.

But reports have since shown that what Congress actually did was to maintain that the tomato paste in pizza sauce is a concentrated form of tomatoes, and should be counted as such. So that an eighth of a cup of tomato paste, the amount often used in a serving of pizza, should be considered equivalent to a half cup of vegetables. According to a recent article by Sarah Kliff in the Washington Post’s Wonkblog, the United States Department of Agriculture (USDA) did not want to credit a volume of fruits or vegetables that was more than the actual serving, and Congress blocked this.

The USDA’s proposed changes were the first changes in 15 years to the $11 billion school lunch program, according to USDA officials, as cited in an article in the New York Times, and were meant to reduce childhood obesity by adding more fruits and green vegetables to lunch menus.

And while no one can debate the benefits of tomatoes, Kliff’s article goes on to compare the nutritional facts of tomato paste, no salt added, with fresh fruits, and they appear similar, except for the sodium, where tomato paste outweighs the fruit by 33 mg to 1 mg.

And so the real culprit here is not Congress or even pizza, but the amount of sodium in foods, and whether or not it should be regulated.

Sodium has been proven to cause cardiovascular (CV) disease, a relationship recently reaffirmed by the CDC. And CV disease keeps increasing, according to the CMS: “Heart disease causes one of every three American deaths and constitutes 17 percent of overall national health spending, costing $444 billion every year in medical costs and lost productivity in Americans.”

The statistics for diabetes, a preventable disease often caused by poor lifestyle and unhealthy eating, are equally staggering: 78,000 children develop type 1 diabetes every year. The problem is so severe that the United Nations recently held its annual summit on non-communicable diseases, namely cancer, chronic respiratory diseases, CV disease and diabetes. It was the second of its kind to focus on a global disease issue; the first health-related UN Summit addressed AIDs.

And according to a recent study from the Commonwealth Fund, 32 percent of children ages 10 to 17 are overweight or obese.

So, given the amount of calories, fat and sodium in the pizza that contains the pizza sauce that contains the tomato paste, one of the last things our school kids need is more pizza in their diets.

What they do need is to be offered the tools to learn and make independent decisions not only outside the classroom, but inside the classroom as well, and the lunchroom is a good place to start.

But if Kliff is right, the lunchroom just might be the last place for kids to get a good education.

While the U.S. Department of Agriculture writes guidelines for what school meals should look like, few schools actually follow them. Just 20 percent of schools served meals that met federal guidelines for fat content, according to a 2007 USDA audit.

Medicare to Cover Screening and Counseling for Obesity

December 5th, 2011 by Cheryl Miller

Over 30 percent of both men and women in the Medicare population are estimated to be obese, and obesity is directly and indirectly associated with many chronic diseases. To address this problem, CMS recently announced that it will now cover screening and counseling for eligible beneficiaries who are obese, or are at risk for obesity. Face-to-face counseling sessions can last for up to 12 months if participants adhere to program guidelines and are successful in losing weight.

Thirty-day readmission rates have become a publicly reported quality performance measure for congestive heart failure, acute myocardial infarction, and percutaneous coronary intervention (PCI.) However, little has been known regarding the factors associated with 30-day readmissions after PCI. Researchers from Saint Marys Hospital, which is part of Mayo Clinic, identified nearly 16,000 PCI hospitalizations (elective or for acute coronary syndromes) from January 1998 through June 2008 and found that, within 30 days after discharge, about 10 percent of patients were readmitted, and nearly 1 percent resulted in death within days after discharge.

The mHealth application market is expected to exceed $40 million annually by 2016. Much of that growth will be triggered by the ability of mobile handsets to easily connect to wearable devices that enable new functionality and accuracy. Researchers predict that home monitoring systems for aging users will be among the populations to reap the benefits of this trend.

Employer-sponsored health insurance premiums increased by 50 percent in the last eight years, and per-person deductibles doubled across the country. But this increase in costs didn’t mean that health coverage increased as well; instead, people were generally asked to pay more for less, according to the Commonwealth Fund’s recent report on state trends in premiums and deductibles. If trends continue at this rate, the average premium for family coverage will rise 72 percent by 2020, to nearly $24,000, researchers say.

And lastly, what was the biggest challenge for your organization in 2011, and how have you addressed this challenge? Let us know, by participating in our Healthcare Trends for 2012 e-survey, which is open for just a few more days. You’ll receive a free executive summary of the compiled results, and your responses will be kept strictly confidential. One respondent will win a training DVD of the 2012 Healthcare Trends and Forecasts webinar recorded on November 2, 2011.

You can find these stories and more in this week’s issue of Healthcare Business Weekly Update.

Q&A: CDPHP Embedded Case Managers Usher In New Era of Healthcare

November 30th, 2011 by Jessica Fornarotto

From the perspective of the health plan-provider relationship, CDPHP embedded case managers are an example of both parties working together in partnership, explains Lisa Sasko, MA, MBA, director of clinical transformation at CDPHP. Prior to their presentation on The Role of Embedded Case Managers in Clinical Transformation, Sasko, along with Charlene Schlude, director of case management, describe the functions of an embedded case manager, target populations and issues to address prior to embedding a case manager in a practice.

HIN: A news release on the CDPHP physician practice transformation program mentioned that the embedded case managers help practice staff better facilitate medical, behavioral and pharmaceutical services for patients. Can you provide, in more detail, their functions in these areas?

(Charlene Schlude): We have embedded RN case managers that work in the practices and their primary function and role is to assist the physicians and staff in the practice to identify, engage and outreach patients in their practice, whom they believe have many chronic and complex medical issues that may require special coordination of care. The addition of social work, perhaps because there may be some social concerns and financial constraints around having a chronic illness or maybe the loss of a job, help people to engage in a self-management plan. After the case management experience is over, the patients should be able to continue on with the education, adherence techniques, the understanding of their diagnosis and having a list of questions to bring with them to speak to their doctor about regarding their condition. The patient should be empowered and ready to help self-manage their chronic condition on an ongoing basis.

HIN: You mentioned complex patients as targets for the case management program. Are there other target populations, such as by disease state?

(Charlene Schlude): Yes, we target any patient with a complex illness. That could be someone in our commercial product or our self-insured product line; people who may have had a trauma or a catastrophic illness or event. We work closely with our transplant patients because they have significant social and emotional needs as well as medical and pharmaceutical needs. We work with anyone who has a great deal of barriers to self-managing their care, which could be that they have a situation in their home where they’re the caregiver for another patient or another member of their family.

HIN: What are the operational and cultural issues to address before embedding case managers in the practice?

(Charlene Schlude): We found that when we were going into the medical home as embedded case managers, we were going to have to be very flexible and open to the different nuances of each practice. We know that the underlying concepts around medical homes are the transition of the practice so that everyone has an integral part on the team. We knew that we had to be very open to the workflows in the practice. Our case managers are sensitive to that, but they do need to become an integral part of that practice as a member of the team. While they’re employed by the health plan, the message to the practice and to the members is that they are a part of that team and are involved with all of the decisions; they sit in on conferences and talk with the physicians directly. But again, we are being sensitive to the workflows because we did not want to go in and prescribe how things were going to be in one medical home to the other, and say that it had to be consistent.

(Lisa Sasko): From an operational standpoint — from a plan and provider relationship standpoint — some of the issues that were important for us to address, focused on recognizing and working with our practices to recognize that this is a new era of healthcare. We need to work together in partnership. CDPHP is supporting these practices to become these enhanced primary care practices through practice transformation, through the use of consultants, etc. In addition, CDPHP is putting these practices on a new payment model that gets them away from fee-for-service onto a risk-adjusted base capitation, which offers a lucrative, to some degree, bonus potential based on improving quality of care for the members and improving the efficiency of the resources utilized.

Got an Idea? CMS Offers $1 Billion in Health Care Innovation Challenge

November 28th, 2011 by Cheryl Miller

The CMS continues to reward innovation in healthcare; the latest initiative, the New Health Care Innovation Challenge, plans to award up to $1 billion in grant money to organizations that come up with creative ways to deliver healthcare, improve care and lower costs. The agency will take notice of projects that can be up and running within six months and that can hire, train and deploy workers rapidly. Funded by the PPACA, it’s a push for both creative healthcare solutions and increased healthcare job opportunities in as short amount of time as possible, contrary to the Innovation Advisors initiative launched in October, which seeks healthcare solutions over a year long, labor intensive period. All segments of the healthcare industry are encouraged to apply for the Innovation Challenge; December 19th is the cut off date for LOIs.

A quick, innovative, effective solution is also needed to alter the latest statistics on diabetes furnished by the IDF on World Diabetes Day (November 14th): studies show that one adult in 10 will have diabetes by 2030. Far too many are already afflicted with the preventable disease, including 78,000 children suffering with type 1; this despite the fact that the greatest number of diabetics fall within 40 to 59 years of age. The IDF is hoping that continued international awareness of this problem will help; and the agency is in the midst of a five-year campaign to promote diabetes education and prevention programs. Ironically, the CMS cited one health system that worked with community partners to decrease the risk of diabetes with nutrition programs as inspiration for its Healthcare Challenge initiative. Food for thought.

Another area of concern is the number of seniors receiving the wrong medication during their home healthcare visits. The Journal of General Medicine recently published a study stating that nearly 40 percent of patients 65 and over are prescribed potentially inappropriate medications (PIMs) at rates three times higher that patients who visit a medical office. Some of the blame can be placed on our fragmented healthcare system, researchers said: home health-based patients see multiple physicians who don’t communicate with each other, resulting in the wrong medication. Perhaps most troubling about this study is that the majority of these patients are taking 11 medications on average, and nearly half of them are taking at least one PIM, researchers say.

And lastly, one quick fix that should boost care access for patients: a new clinical affiliation between CVS Minute Clinics and Emory Healthcare. The stand alone clinics are open seven days a week in select areas throughout metropolitan Atlanta and have nurse practitioners on hand to administer wellness and preventive services and tend to common family illnesses. Patients who need care not provided at the clinics will be referred to Emory Healthcare. Both CVS and Emory hope to streamline the process with the use of EMR systems. These stories and more in this week’s issue of Healthcare Business Weekly Update.