Archive for May, 2015

Remote Care Management: Self-Monitoring Enhances Care Transitions

May 14th, 2015 by Patricia Donovan

Encouraged by reductions in hospital readmissions and almost universal patient satisfaction from its small remote patient monitoring pilot, CHRISTUS Health scaled up the initiative to more 170 participants. Luke Webster, MD, vice president and chief medical information officer for CHRISTUS Health, and Shannon Clifton, CHRISTUS director of connected care, describe the patient’s responsibility in remote monitoring.

During the daily monitoring portion, the patient will do the daily self-care tasks. That includes their biometric readings, and answering questions related to their care plan, such as, how did they feel that day? Did they sleep well? Are they able to ambulate and get through their day normally or in good health? As long as they stay within those normal parameters, they will continue on with the daily monitoring and self-help management as they go.

Most patients monitor themselves in the morning, within 30 minutes of waking up. Some are directed to monitor themselves throughout the day depending on their risk: whether they’re low, medium, or moderate to high risk. That’s determined ahead of time by the nurse coach and/or the physician.

If for some reason there is an alert—such as a two- to three-pound weight gain, the patient’s not feeling well, or ran out of their prescription—any of those cues will alert the nurse that something has fallen outside that patient’s wellness parameters and their care plan. The nurse coach, at that time, will review all of the data; then the patient is called and the nurse coach will coach the patient back to their care plan.

We’ve had great success with that process; having all of that data has made the care transitions program more efficient, especially because the nurse coach has access to that day-to-day information; whereas before, our care transition program consisted of the nurse calling up to five times within 30 days.

Source: Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System

remote monitoring

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System chronicles the evolution of a remote patient monitoring pilot by CHRISTUS Health. This 25-page report reviews the multi-state and international integrated delivery network’s impressive early returns in cost of care, 30-day readmission rates and patient satisfaction from remote patient monitoring, as well as the challenges of program expansion.

Infographic: The Value of an Investment in Health Management

May 13th, 2015 by Melanie Matthews

Reduced employee health risk, followed by reduced healthcare costs and improved employee productivity are among the top reasons employer invest in health and wellness programs, according to a study by Optum and the National Business Group on Health, depicted in a new infographic.

The infographic also examines eight other emerging reasons for a health management investment by employers.

Profiting from Population Health Management: Applying Analytics in Accountable CareAs ACA reforms continue to impact healthcare, population health management (PHM) is fast becoming the new buzzword for the management, integration and measurement of all interventions across the health continuum, from the healthiest populations to those with catastrophic illnesses. Rooted in the IHI’s Triple Aim, PHM dives deep into health analytics to reduce risk and associated health spend and provide a strong foundation for accountable care in a value-based system.

Profiting from Population Health Management: Applying Analytics in Accountable Care provides both a primer in PHM, identifying the challenges and opportunities of a robust population health management program, and an advanced case study in the use of analytics in PHM.

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Infographic: Enterprise Population Health Management

May 11th, 2015 by Melanie Matthews

Healthcare risk is shifting from payors to providers, according to a new infographic by Caradigm.

The infographic outlines the different models that providers can use to assume risk and how organizations can coordinate care in an integrated community, which is critical to risk assumption.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability In today’s value-based healthcare sphere, providers must not only shoulder more responsibility for healthcare outcomes, cost and quality but also align with emerging compensation models rewarding these efforts—models that often seem confusing or contradictory. The challenges for payors and partners in creating a common value-based vision are sizing the reimbursement model to the provider organization and engaging physicians’ skills, knowledge and behaviors to foster program success.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability examines a set of provider compensation models across the collaboration continuum, advising adopters on potential pitfalls and suggesting strategies to survive implementation bumps.

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Infographic: Making Healthcare Data Work

May 8th, 2015 by Melanie Matthews

Healthcare data comes from everywhere and is massive—the human body produces up to 150 trillion GB of information, which can be collected in many ways, according to a new infographic by NetApp.

The infographic looks at how analytics are impacting and improving healthcare and potential savings from better use of data.

Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data AnalyticsHealthcare organizations employ a variety of tools and analytics to identify high-risk, high-cost patients for targeted population health interventions.

Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics presents a range of risk stratification practices to determine candidates for health coaching, case management, home visits, remote monitoring and other initiatives designed to engage individuals with chronic illness, improve health outcomes and reduce healthcare spend.

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13 Metrics on Care Transition Management

May 7th, 2015 by Cheryl Miller

Care transitions mandate: Sharpen communication between care sites.


Call it Care Transitions Management 2.0 — enterprising approaches that range from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.

To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of 116 respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care®, and other models.

Whether self-styled or off the shelf, well-managed care transitions enhance both quality of care and utilization metrics, according to this fourth annual Care Transitions survey conducted in February 2015 by the Healthcare Intelligence Network. Seventy-four percent of respondents reported a drop in readmissions; 44 percent saw decreases in lengths of stay; 38 percent saw readmissions penalties drop; and 65 percent said patient compliance improved.

Following are eight more care transition management metrics derived from the survey:

  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • Discharge summary templates are used by 45 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN’s fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

4 Behaviors of the Highly Activated Patient

May 7th, 2015 by Patricia Donovan

The success of a population health intervention depends upon participants’ level of self-engagement. The Patient Activation Measure™ (PAM) designed to assess an individual’s knowledge, skill and confidence in managing their health, consists of a 13-item scale that asks people about their beliefs, knowledge and confidence for engaging in a wide range of health behaviors. Here, PAM developer Dr. Judith Hibbard, MPH, Dr.PH, describes some of the traits associated with a highly activated, engaged patient.

It is important to understand exactly what is happening with individuals at different levels and what is going to help them. We did several studies to find out if activation predicts behaviors, and to determine which behaviors it predicts. We did a national probability study and then replicated that study in the United Kingdom. They found almost exactly the same results as we had in the United States. Since then, there have been many more studies.

We found that people who scored higher on this measure were more likely to:

  • Engage in preventive behaviors like screenings or immunizations.
  • Engage in healthy behaviors, such as regular exercise and having a healthy diet.
  • Engage in more disease-specific self-management behaviors, such as monitoring or adherence.
  • Engage in more health information-seeking behaviors.

Once we saw these results, we began to look at the data a bit differently. We realized from the data that some behaviors don’t start until people move further along that dimension of activation.

Source: Three Pillars of Health Coaching: Patient Activation, Motivational Interviewing and Positive Psychology
health coaching
Judith Hibbard, MPH, Dr.PH, is a professor of health policy at the University of Oregon. For more than 30 years, she has focused her research on consumer choices and behavior in healthcare. Dr. Hibbard is the lead author of the Patient Activation Measure™ (PAM) and advises many healthcare organizations, foundations and initiatives.

Infographic: Health Literacy

May 6th, 2015 by Melanie Matthews


One in two adults can’t use a BMI chart to find a healthy weight, understand a vaccination chart and/or read a prescription label, according to an infographic by GSW on health literacy.

The infographic details examples of low health literacy and the impact it has on patients and the healthcare system.

Advancing Health Literacy: A Framework for Understanding and ActionAdvancing Health Literacy: A Framework for Understanding and Action addresses the crisis in health literacy in the United States and around the world. This book thoroughly examines the critical role of literacy in public health and outlines a practical, effective model that bridges the gap between health education, health promotion, and health communication.

Step by step, Advancing Health Literacy: A Framework for Understanding and Action outlines the theory and practice of health literacy from a public health perspective. This comprehensive resource includes the history of health literacy, theoretical foundations of health and language literacy, the role of the media, a series of case studies on important topics including prenatal care, anthrax, HIV/AIDS, genomics, and diabetes.

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Infographic: The Doctor Will “e-See” You Now

May 4th, 2015 by Melanie Matthews

Eighty-four percent of people say their doctor’s offices have a patient portal, according to a new survey commissioned by eClinicalWorks and conducted online by Harris Poll among over 2,000 U.S. adults, in March 2015.

Of those whose doctors do have a patient portal, adults age 55+ (61%) are more likely to access their health information via this tool than adults age 18-54 (45%).

eClinicalWorks® has released an infographic on the study results, which also examines wearable use, online patient scheduling and physician-patient communication via online portals.

2015 Healthcare Benchmarks: Telehealth & TelemedicineThe world of digitally enabled care is exploding: the number of patients using telehealth services will rise to 7 million in 2018, according to IHS Technology; healthcare apps and ‘wearables’ are trending in technology circles and healthcare providers’ offices; and CMS’s new ‘Next Generation ACO’ model is expected to favor expanded telehealth coverage.

2015 Healthcare Benchmarks: Telehealth & Telemedicine delivers actionable new telehealth metrics on technologies, program components, successes and ROI from 115 healthcare organizations. This 60-page report, now in its fourth year, documents benchmarks on current and planned telehealth and telemedicine initiatives, with historical perspective from 2009 to present.

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Infographic: Mobile Delivers Healthcare

May 1st, 2015 by Melanie Matthews

Ninety percent of healthcare organizations use mobile health to engage patients, according to a new infographic by HIMSS.

The infographic examines the mobile health solutions organizations use, current capabilities, areas of impact and future trends.

Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging PopulationFrom home sensors that track daily motion and sleep abnormalities to video visits via teleconferencing, Humana’s nine pilots of remote patient monitoring test technologies to keep the frail elderly at home as long as possible.

When integrated with telephonic care management, remote monitoring has helped to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges.

In Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population, Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge, reviews Humana’s expanded continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.

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