Archive for April, 2011

How Geisinger Risk-Ranks Individuals for Case Management

April 21st, 2011 by Jessica Fornarotto

Geisinger Health Plan targets four key populations when identifying individuals for case management, according to Diane Littlewood, RN, BSN, CDE, and Joann Sciandra, RN, BSN, CCM, regional managers of case management for health services at Geisinger Health Plan.

Our approach to case management at Geisinger is focused on the identification of the high-risk population. Looking at our targeted populations, we focus on heart failure, COPD, the frail elderly and any patient with transition of care. The majority of our case referrals come through at hospital discharge and admissions. Anyone who is identified with a hospitalization and a discharge is automatically a high risk, with a risk rank of 5. We proactively use our claims system to identify other populations that would require case management. We look to enroll patients at the highest risk — patients with heart failure, COPD, frequent hospitalizations and ER visits — into case management.

The steps for case identification of the high-risk population — the sicker and the sickest — consist of post-hospital discharge and our predictive modeling tool to risk-rank patients and identify those high-ranking patients for enrollment. Another part of case identification is the primary care physician. After relationships are built, the physician will come back to the case manager and say, “I need you to meet Mr. Jones, who is in a room with heart failure, and enroll him into case management.” That’s what we look for — enrolling patients and engaging them as they come through the front door of our sites. It’s a little late post-hospital discharge. There are so many opportunities there, but to be able to engage that patient and possibly decrease the risk for admissions, teaching them and monitoring their heart failure from the get-go is the best route to follow.

Once we have our patients identified, our nurses provide a comprehensive assessment that identifies the driving issue behind the case and where we have to start with this patient to make a difference. We develop an action plan based on the issue. Having a case manager on-site gives us the ability to interact with the healthcare team managing this patient in our ProvenHealth Navigator site. Our case manager has the ability to sit down with the primary care site doctor and show them the action plan. That primary care site doctor then has the ability to make changes in that plan. It’s comprehensive and collaborative. We have found that our plans work better when the primary care site physician is brought into the plan from the beginning.

Templates built into our documentation are NCQA-driven and address the social, physical and behavioral needs and health history of the patient. We develop a patient-centered plan of care based on their risks and goals. We’re talking about short- and long-term patient goals as well as how we hope that their health status and the care that we deliver will move them to quality care and a good quality of life.

The 4 C’s of Reducing Readmissions

April 15th, 2011 by Patricia Donovan

Healthcare is using the four C’s — communication, care transitions, case management and collaboration — to reduce readmissions, according to new market research on Reducing Hospital Readmissions.

Our second annual survey on this topic found that across all sectors, healthcare companies are making sure that the information communicated to patients is clearly understood, especially in light of health literacy levels in older patients. Clear communication is never more critical than at discharge from the hospital, when the plan of care and medication instructions are conveyed to patients leaving the hospital.

For example, a seemingly simple intervention — a phone call placed to the newly discharged patient within the first few days — is an opportunity to clarify these instructions and confirm that doctors’ appointments have been made and kept.

Secondly, care transitions, including hospital discharge and transfers between care sites, are being closely scrutinized and improved. Communication again comes into play as organizations make sure that the patient data required to ensure a smooth handoff is included as part of the transfer.

Thirdly, more than a third of respondents assign chief responsibility for reducing readmissions to their case managers.

And lastly, many respondents report increased collaboration and partnerships with community clinics, home health and other providers to improve the quality of care delivery and overall patient experience.

These four strategies are at the heart of patient-centered models such as the medical home and accountable care organizations, and are already driving reimbursement and quality rewards.

On the horizon to further reduce readmissions: increased application of telehealth and home monitoring of chronic illness to intervene at the first sign of functional decline or adverse episode.

Efforts to Reduce Pneumonia-Related Readmissions Doubled in Last Year

April 15th, 2011 by Jessica Fornarotto

Efforts to reduce readmissions in pneumonia patients doubled from 2009 to 2010, according to new market research from the Healthcare Intelligence Network.

Heart-failure-focused efforts rose 20 percent from 2009 to 2010, according to HIN’s second annual Reducing Hospital Readmissions e-survey conducted in December 2010.

Management of key care transitions such as the hospital discharge continues to be the primary strategy of the survey’s 90 respondents for reducing avoidable rehospitalizations, with 65 percent — up slightly from 62 percent in 2009 — reporting care transition management programs. Overall, medication adherence remains the top barrier to reducing hospital readmissions.

Other highlights from the survey include:

  • About 60 percent of respondents have created specific programs to reduce hospital readmission rates.
  • Three-fifths of respondents use risk stratification to identify individuals most at risk for returning to the hospital.
  • About 30 percent of respondents said the case manager has primary responsibility for reducing hospital readmissions.
  • Many respondents revealed that follow-up visits and phone calls are among the most effective strategies for reducing readmission rates.
  • Some respondents are concerned with how readmissions will be tracked and determined to be “avoidable” versus “non-avoidable.”

8 Roles of ED Case Managers

April 7th, 2011 by Jessica Fornarotto

Gatekeeper is one key role of case managers embedded in emergency departments, according to Toni Cesta, PhD, RN, FAAN, senior vice president of operational efficiency and capacity management at Lutheran Medical Center. Other roles include:

  • Facilitate initiation of care

  • Start intake/utilization process
  • Encourage use of reimbursable diagnoses
  • Interface with community agencies
  • Create plans for high utilization patients
  • Refer patients to other/more appropriate hospital areas
  • Monitor and manage variances — elements that are misuse of resources or issues that may extend length of stay. For example, sending a patient to the ED for what would normally be an outpatient workup.

“When we talk about the roles and functions of the ED case manager, we have to consider that they’re very consistent with the roles and functions of an inpatient case manager, with a little bit of a twist on the theme. You might say that my inpatient case manager isn’t really a gatekeeper and doesn’t perform gatekeeping functions. But if you think about the role of the case manager in terms of patient flow and movement of the patient through the acute care episode — for example, on telemetry, off telemetry or in and out of the ICU — they really are gatekeeping the appropriateness of the movement of that patient through the acute care continuum. The same would apply to the ED case manager in that they are gatekeeping the patients that are being admitted to the hospital,” stated Cesta.

Competitors Collaborate in SNF Care Coordination Network

April 7th, 2011 by Patricia Donovan

Summa Health System’s partnership with dozens of SNFs proves competitors can partner to address a common goal — in this case, reducing adverse outcomes from poorly managed transfers and sharing accountability for the care of these patients.

Summa Health System reported that its SNF Care Coordination Network is reducing length of stay and mortality rates and improving outcomes for patients transferred between hospital and skilled nursing facilities during a “Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision,” sponsored by the Healthcare Intelligence Network.

The steps leading to the creation of the SNF care coordination network are a boilerplate for healthcare partnerships — from the development of the RFP and task force to the introduction of the network to the health system, according to Carolyn Holder, manager of transitional care for Summa Health System, and Michael Demagall, administrator of Bath Manor & Windsong Care Center, an SNF participating in the network. Both shared the challenges and details of the partnership and early results from this venture.

The network targets some of the key breakdowns in the transfer process, including incomplete patient assessment, lack of patient data and communication barriers between staff members, departments and sending/receiving entities. Program highlights include the introduction of a Physician Orders & Transfer Form to standardize transfers and the use of staff scripts to overcome patients’ and caregivers’ resistance to SNF care.

The goals and outcomes of the program — which include reduced admissions, readmissions and ED visits by this vulnerable population — also fit neatly within the definition of accountable care and the IHI’s Triple Aim initiative.

New Rules: ACOs Accountable for Patient Experience

April 5th, 2011 by Patricia Donovan

The wait is over for CMS rules governing ACOs for Medicare beneficiaries. Besides previously socialized goals of providing higher quality and better coordinated care, the rules state that future ACOs will be held accountable for the overall patient and caregiver experience. To reduce the potential for misleading Medicare beneficiaries and to maintain program integrity, participating ACOs must adhere to strict ACO marketing guidelines.

As industry stakeholders pore over the 429-page regulations, many ACOs are already up and running. This week’s Healthcare Business Weekly Update includes plenty of resources for startup ACOs, including an overview of CMS’s Shared Savings Program and eight tips for an effective ACO infrastructure that hold up well whether you plan to participate in the federal offering or explore a commercial ACO.

The philosophy and results associated with the patient-centered medical home align closely with those of ACOs. We invite you to take our fifth annual survey on the patient-centered medical home.

Avoiding the 5 Drivers of Low-Value Care

April 1st, 2011 by Jessica Fornarotto

HealthPartners’ multi-pronged approach to transforming healthcare includes the avoidance of the five drivers of low-value healthcare, explains Babette Apland, senior vice president of health and care management for HealthPartners.

HealthPartners is trying to achieve more Triple Aim results. We’re trying to do less of the primary drivers of low-value care, including the ‘more is better’ culture or a focus on volume rather than value of healthcare services. Second, we are avoiding supply-driven demand, which is rooted in Dartmouth’s work showing that the more supply or providers in a geography, the more volume or services that are delivered. Thirdly, we operate in many areas in healthcare without spending constraints, so having a view of total cost of care at the population level is important. Fourth, we have implemented and are increasingly enhancing a team-based approach to healthcare that is supporting doctors, but is not overly reliant on doctors. Finally, we also appreciate the need to create a system in healthcare that is consistent and reliable across the care continuum.

We see the keys to transforming healthcare through partnership and payment reform, reporting transparency and data analysis, clinical support, integrated population health management, and patient-centered care and innovation.

Looking at payment reform and our payment reform journey, HealthPartners began back in 1997 with our Partners in Excellence Program, creating bonus payments for providers achieving stretch quality of care goals. In 2001, we implemented a program that focused on improvement and added downside risk around quality improvement through a withhold. In 2009, we began implementing our total cost of care payment approach; today, in 2011, two-thirds of our claims as a health plan are from care systems with total cost of care agreements.

How Diabetes Patients Can See a Decrease in Medical Costs

April 1st, 2011 by Jessica Fornarotto

Could diabetes patients decrease their medical costs if they are more medication adherent? Read this week’s issue of the DM Update to find out, and also learn if patients with high-deductible health plans use fewer preventive care services.