Archive for March, 2014

5 Population Health Tactics That Open the Door to Care Access

March 18th, 2014 by Patricia Donovan

remote patient monitoring

Remote patient monitoring is a phone call away.


Remote monitoring of patients, one of five Adventist Health approaches to improve access to care, can be as basic as a follow-up phone call or as high-tech as sensors placed around the home to monitor activities of daily living (ADL). Here, Elizabeth Miller, VP of care management at White Memorial Medical Center (part of Adventist Health), offers a set of population-based ideas to improve access to care.

First, consider embedding care professionals into the patient-centered medical home (PCMH). We do that for our highest risk patients. We embedded a nurse practitioner/social worker so that as the patients were on site, we talked to the primary care in the medical foundation to schedule their high-risk patients, the ones that we are going to population health-manage. We will embed our staff and come to you two days a week.

Second, consider home visits for homebound patients, although those are very intensive. I’ve done home visits; it takes about an hour and a half per patient.

Another option to consider is group settings; you may be able to reach out in your community and have group settings for the purpose of population health management. Also, consider going to a physician’s office for group settings.

There is also telehealth and monitoring from a distance. I can tell you that it doesn’t always go as well as face-to-face visits because sometimes some things are lost without the face-to-face. It is my personal preference to meet face-to-face, but we do monitor from a distance. A lot of this is just telephone calling to follow up.

We also send reminders. We phone to remind them of appointments; you can also send them letters or employ text messaging. It depends on your population and how savvy they are with social media and tools.

Excerpted from Population Health Framework: 27 Strategies to Drive Engagement, Access and Risk Stratification.

Readers, what do you think? Could remote monitoring extend care for the population you serve? Share your comments here, or Tweet questions @H_I_N and we’ll try to get them answered during this week’s webinar on Humana’s remote patient monitoring with telephonic case management to improve care coordination.

Infographic: How Certified Case Managers Navigate the Healthcare Landscape

March 17th, 2014 by Jackie Lyons

Board-certified case managers (CCMs) work in a variety of healthcare settings. The top three are hospitals (24 percent), worker’s compensation organizations (18 percent) and health plans (17 percent), according to a new infographic from the Commission for Case Management Certification (CCMC) and Health2 Resources.

This infographic also illustrates the roles of CCMs, the content and value of their knowledge, where CCMs are located in the United States and more.

You may also be interested in this related resource: 2013 Healthcare Benchmarks: Case Management. This 78-page resource provides actionable information from 118 healthcare organizations on the prominence, placement and responsibilities of case managers as well as case management-driven outcomes in healthcare utilization, cost and compliance.


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Infographic: Is the Future of Mental Health Online?

March 14th, 2014 by Jackie Lyons

The most common reason for not getting mental health (mHealth) treatment as cited by 39 percent of people is that it is too expensive, according to a new infographic from BestCounselingDegrees.net.

This infographic looks at a possible alternative to the traditional face-to-face therapy. It outlines the history and types of online mhealth treatment, as well as the pros, cons, challenges and examples of this growing trend.

You may also be interested in this related resource: Illness Management and Recovery (IMR): Personalized Skills and Strategies for those with Mental Illness. This 131-page resource helps people with severe mental illness identify personally meaningful goals and work to achieve these goals by addressing smaller, more manageable segments of those goals.


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4 Pillars of SNF/Hospital Partnerships

March 13th, 2014 by Cheryl Miller

Maintaining contact with patients long after the 30-day discharge period when the penalty phase ends for hospitals is one of the four pillars of Torrance Memorial Health System’s post-acute network philosophy, says Josh Luke, Ph.D., FACHE, vice president post-acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention. This can be done telephonically or in-person, and is usually conducted by an ambulatory case manager.

The main component of our post-acute network is to go into each of the seven SNFS once a week and meet with them for a half hour at the most, covering four tactics. The first is to review a list of all of the patients that have been sent from the hospital over to the SNF, specifically focussing on which ones are discharging that week.

The second tactic is to discuss their discharge disposition, and see if they’re going to a home health agency, and if so, if it’s one that we own, or another one in the community. We distinguish this so we can do what’s called ambulatory case management of the patient, which means we want to case manage them once they go home. We don’t just want to forget about them. We want to keep an eye on them and check in on them, whether it’s telephonically or in person, making sure that they continue to do well, not just through the end of the 30-day episode after discharging from the hospital when the penalty phase ends for hospitals, but also for their long term well-being.

The third tactic is to encourage each of our patients going home from the hospital and SNF to make an appointment at our post-acute clinic (CCC) with the physician who does medication reconciliation. She asks the patients to bring in all the medications they were on before they went to the hospital and all those they were prescribed at the hospital. They then sit and have a 45 minute conversation, including guidelines on what their medication plans are moving forward, which ones they should be taking, and which ones they shouldn’t, and making sure, with teach back methodology, that the patient has a clear understanding of what is expected from them in terms of consuming medication once they return home later that day. Those appointments normally take place within the last 72 hours.

The fourth tactic is to review what we call the ‘return to emergency room’ log. In the industry the common term is ‘return to acute’. We don’t allow our SNFs to use that term because we feel they’re responsible for the ‘return to the emergency department (ED)’. What we mean by that is we’re challenging our SNFs to say, “Take charge of what you can control. And what you can control is making sure that patient doesn’t leave your SNF unnecessarily.” We’re not here to say, “Did the patient get admitted or not to the hospital?” We’re here to ask the SNFs if they followed the guidelines that several organizations nationwide have provided that help avoid unnecessary transfers out to the hospital.

Excerpted from 5 Best Practice Prevention Protocols for Reducing Readmissions.

8 Challenges to Medical Home Success

March 12th, 2014 by Jessica Fornarotto

“What’s important about patient-centered medical homes (PCMHs) is that they’re patient-centered. PCMHs are a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients. And patients have the education and support they need,” explains Terry McGeeney, MD, MBA, director of BDC Advisors. Dr. McGeeney lists below the eight challenges in successfully changing to a PCMH.

The first challenge to PCMH success is that many 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. Sometimes this has to be trained and taught.

Next, 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. Another challenge is that some providers are not able to function effectively in a team environment. This needs to be supported and transformed with the appropriate training provided.

The next challenge is communication, which 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. The sixth challenge is that 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 that hasn’t always existed.

Next, 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.

The final challenge is there needs to be full recognition that PCMH transformation is not easy. It’s very difficult and time consuming, but in the end it’s highly rewarding.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

HINfographic: 9 Measures of ACO Success

March 12th, 2014 by Jackie Lyons

What is the mark of a successful accountable care organization (ACO)? For healthcare organizations, clinical outcomes topped the list of ACO success metrics.

This HINfographic depicts nine key ACO metrics identified by 138 healthcare companies. Also among the top three measures was patient satisfaction and health utilization.

9 Measures of ACO Success

 title= You may also be interested in this related resource: Guide to Accountable Care Organizations. This 160-page resource lays the groundwork for an ACO program. It includes a framework for clinical integration, a key ACO prerequisite that puts participating providers on the same performance and payment page, and much more.

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2014 Market Data: The Hospital Perspective on Palliative Care

March 11th, 2014 by Patricia Donovan


The majority of palliative care consults take place in hospitals, according to 62 percent of respondents to HIN’s 2014 survey on Palliative Care, although many responding healthcare organizations are working to separate these consults from the hospital bedside. In the meantime, there were several key areas where hospitals and health systems, which comprised almost half of survey respondents, stood out in terms of how they conducted palliative care programs.

For example, when asked to identify candidates for palliative care, this sector was least likely to rely on a diagnosis set (27 percent within this sector, versus a high of 78 percent and a mean of 45 percent) and direct member/patient referrals (33 percent for this sector, versus a high of 78 percent within the health plan and an overall mean of 55 percent). When listing components of their palliative care programs, this sector was also least likely to include a patient/provider liaison (44 percent versus a high of 78 percent and a mean of 68 percent) and clinical assessment (71 percent versus a high of 89 percent and a mean of 82 percent).

The composition of this sector’s palliative care team also varied, starting with the presence of primary care physicians, or PCPs: (52 percent of hospital palliative care teams versus a high of 77 percent and a mean of 63 percent); oncologists (19 percent versus a high of 67 percent and mean of 31 percent); geriatricians (19 percent versus a high of 56 percent for case managers and a mean of 33 percent); and physical therapists (13 percent of hospitals versus a high of 67 percent and mean of 34 percent). However, this sector was most likely to have a nurse practitioner on board (62 percent versus a low of 11 percent for health plans and an overall mean of 43 percent).

The timing of palliative care consults has shifted over the years. This sector is most likely to conduct them during a hospital stay (85 percent, versus a low of 44 percent and mean of 60 percent) and the least likely to conduct them during a home visit (21 percent versus a high of 79 percent for home health agencies, not surprisingly, and a mean of 47 percent).

Where to administer palliative care has also shifted, and this sector was twice as likely to conduct it on an inpatient basis (94 percent) as home health agencies, at a low of 50 percent, and typically least likely to conduct it via telephonic visits (10 percent), one fourth as likely as health plans, at 44 percent.

Excerpted from: 2014 Healthcare Benchmarks: Palliative Care

Infographic: The State of Mobile Technologies in Healthcare Today

March 10th, 2014 by Jackie Lyons

More progress needs to be made in developing a long-term financial approach regarding the ROI and payment of mHealth, according to a new infographic from HIMSS.

Only half of healthcare organizations who responded to HIMSS’ third annual analytics mobile survey formally measure ROI related to their mHealth investments, the infographic shows. The infographic also identifies mHealth technology, new care models, privacy, standards, interoperability, barriers and benefits.

You may also be interested in this related resource: mHealth: Global Opportunities and Challenges. This 310-page resource offers a groundbreaking and insightful overview of the field of mHealth as its unfolding globally in the 21st century.


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Infographic: The Pros, Cons and Costs of ICD-10

March 7th, 2014 by Jackie Lyons

The shift from ICD-9 to ICD-10 that will occur on October 1, 2014 will transition 14,000 codes to more than 68,000 codes.

Ninety-two percent of physicians are concerned with the overall cost of converting to ICD-10, according to a new infographic from Greenway. This infographic shows the pros, cons and costs of ICD-10 as well as the specific problems it presents.

You may also be interested in this related resource: A Best Practice Roadmap to ICD-10 Readiness. Want to learn more about how to make ICD-10 simple? This 24-page report documents the process BCBSM has established to resolve discrepancies between ICD-9 and ICD-10 codes, a milestone that has allowed the payor to complete its version of the General Equivalence Mappings (GEMs) — referred to as the Blue GEM Encyclopedia.


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New Rule for Patient Care Collaborations: There’s No ‘I’ in ‘Team’

March 6th, 2014 by Cheryl Miller

“Take your provider hat off and put on your patient hat for a moment. Do you feel as though you’re at the center of your own healthcare team, or that your mother or child has a healthcare team around them? Do you even feel as though there is a healthcare team?” asks Teresa M. Treiger, RN-BC, MA, CHCQM-CM/TOC, CCM, CCP, president of Ascent Care Management. Here, she lists the elements necessary to build an effective patient care team.

I always use the phrase, “There is no ‘I’ in the word ‘team,’” and it’s really true. True teams are precious; high functioning teams are a real rarity. I know there are organizations that deliver excellent team-based collaborative care, but it’s not a common occurrence because the concepts of teamwork are not necessarily covered in everyone’s curriculum or training. Nurses, social workers and allied health all come up within the perspective of being part of a team, but that is not codified into the curriculum at every institution.

Then we have to consider the patient. Supposedly the patient is at the center of the care team, but right now the center, I think, is a convenient place for the patient to be because then everyone can get their hands on them, so to speak. However, the patients that I speak to across the country are not feeling the love. They’re not feeling like they’re at the center of anything.

To demonstrate this, take your provider hat off and put your patient hat on for a moment. You’re all patients at some level, or your loved ones are. Do you feel as though you’re at the center of your own healthcare team, or that your mother or your child has a healthcare team around them? Do you even feel as though there is a healthcare team? If you can shift your perspective there, you can see where patients are not feeling that love necessarily.

Team building takes a tremendous amount of the time. It takes collaboration, it takes everyone at the table being accountable, and it takes everyone at the table being able to trust the other people sitting across from them. It’s not something that you can just decide to have — “Well, let’s have a great team.” It takes time. If anyone has worked in an emergency room, when you have a group of people working together on a shift that just clicks, when you know you can count on those people, that’s the kind of energy and positive interchange that I’m talking about when I talk about teams. That takes time; it didn’t just happen on day one. Trust is something that builds over time; similar to the interest on your bank account.

Excerpted from Case Management in Value-Based Healthcare: Trends, Team-Building and Technology.