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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.

Posted in Behavioral Health, Case Management, Case Manager Profile, Disease Management, Reducing Readmissions, Transitions in Care, Uncategorized, Wellness/Prevention | No Comments »

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.

Posted in Behavioral Health, HIN Blog, Health Coaching, Wellness/Prevention | No Comments »

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.

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Behavioral Health, Healthcare Trends, Patient-Centered Medical Home | No Comments »

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.

Posted in Behavioral Health, Case Management, Consumer-Driven Healthcare, Disease Management, Healthcare Costs, Healthcare Trends | No Comments »

Healthcare Industry Not Prepared to Protect Patient Privacy; Data Breaches Rising

October 3rd, 2011 by Cheryl Miller

As new uses for digital health information emerge and access to confidential patient information expands, a majority of healthcare organizations are not prepared to protect patient privacy and secure data, says a new report from the Health Research Institute (HRI) at PwC US. And medical identity theft is on the rise; according to a recent PwC HRI survey, theft accounted for two thirds of total reported health data breaches over the past two years. Healthcare organizations need to update practices and adopt a more integrated approach to ensure that patient information doesn’t fall into the wrong hands, the report advises. We report on this story at length in this week’s Healthcare Business Weekly Update.

Annual premiums for employer-sponsored family health coverage increased to $15,073 this year, up 9 percent from last year, according to a recent Employer Health Benefits survey from the Kaiser Family Foundation/Health Research & Educational Trust (HRET). Premiums increased significantly faster than workers’ wages and general inflation.

To help its members navigate healthcare services and costs, BCBSF has introduced a new transparency tool, “Know Before You Go.” Designed to help its members navigate through the healthcare system, it provides information based on hospital data reported by CMS. The tool is customized to a member’s benefits and takes into account deductibles, copays and/or coinsurance amounts and estimates how much a treatment or procedure will cost.

And we are compiling research for our second annual survey on tactics to reduce avoidable emergency room visits. We will e-mail all respondents a summary of results once they are compiled. To participate, click here.

Posted in Affordable Care Act, Avoidable ER Use, Behavioral Health, Consumer-Driven Healthcare, Healthcare Administration, Healthcare Costs, Healthcare Toolkits, Healthcare Trends, Uncategorized | No Comments »

CDPHP Makes a Business Case for Embedded Case Managers

September 23rd, 2011 by Cheryl Miller

Three years ago primary care was in crisis, says Lisa Sasko, director of clinical transformation for CDPHP. There was a projected shortage of primary care physicians, due in part to a less than competitive earning potential, which was keeping physicians and graduating medical students at bay.

So CDPHP, a not-for-profit, physician-founded and guided health plan that has more than 350,000 members, designed a unique model that would provide enhanced reimbursement for current PCPs, and make it more attractive to medical students and health providers.

That enhanced primary care model was the subject of the Healthcare Intelligence Network’s (HIN) recent webinar The Role of Embedded Case Managers in Clinical Transformation. Together with Charlene Schlude, director of case management at CDPHP, Sasko described the evolution of their model, which incorporated a blend of payment reform and practice transformation, and also shared the following:

The operational and cultural issues critical to the success of the program

Results from the two-year analysis of the program

Planned enhancements of the initiative

Business reasons for developing an embedded case management program

The day-to-day interactions of embedded case managers with providers in a practice

CDPHP’s payment reform strategy uses a risk adjusted base capitation payment, plus bonus opportunities aligned with IHI’s Triple Aim initiative, so that patient satisfaction, quality of care, and cost effectiveness were targets for rewards.

CDPHP also “retooled the operations of the primary care practice,” said Sasko, focusing on care coordination, leadership development, team care, improved access and population management, with the goal of realizing NCQA Level II medical home certification. To achieve this, they integrated their resources, specifically case management, disease management, behavioral health, pharmacy reporting, and discharge notification.

Fundamental to the overhaul was embedding case managers in the physician practice, said Schlude.

“The fundamental concept of case management is that when individuals with complex diseases maintain optimum levels of health and functional capability, everyone benefits: the patients, their support systems, caregivers, healthcare delivery systems and payors. Embedded case managers are indicative of a new era of healthcare in which payors, providers and patients work together in partnership.”

To be most effective, case managers should have access to EMRs, physician support, aligned goals and be able to interact with patients face-to-face on a consistent basis, Schlude continued. Practices for embedded case management should have willing physicians, and the opportunity to improve quality metrics, and have strong stratification and prioritization techniques in place. Reducing avoidable hospital admissions, and empowering patients to successfully self manage their disease conditions and communicate effectively with their case managers and physicians were key objectives for the embedded case managers.

Currently one RN covers two enhanced primary care practices two times a week, Schlude said. There is a high focus on Medicaid and Medicare patients, direct documentation in EMRs, and face-to-face introductions with telephonic follow ups.

Case managers can play significant roles with diabetic patients, the frail elderly, comorbid chronic patients, and end stage renal failure disease (ESRD) patients; ESRD patients in particular consume a disproportionate amount of financial and healthcare resources. In all cases, Schlude said, embedded case managers can help to reduce hospitalizations and costs, and improve quality of life.

The size of the practice doesn’t matter, Schlude emphasized. Instead, to successfully embed case managers in a clinical practice, it is important to sustain ongoing communication among all, select a case manager that is a “good fit” in the practice, and maintain flexibility and an ability to modify the program model as needed.

For more information, watch our video Embedded Case Managers in Healthcare:

Posted in Avoidable ER Use, Behavioral Health, Case Management, Disease Management, Healthcare Costs, Patient-Centered Medical Home, Reducing Readmissions, Transitions in Care, Uncategorized | No Comments »

Four Transitions for Back-To-School

September 12th, 2011 by Cheryl Miller

It’s back to school time, and the healthcare industry is undergoing its fair share of transitions.

NCQA is launching a new accreditation program for ACOs this fall. The organization worked with consumer advocates, purchasers and other healthcare and managed care experts to develop seven standards by which it will evaluate ACOs. Early bird adopters of the accreditation effort can get reduced rates on survey fees, online education tools and promotion. Order the NCQA ACO standards.

The one-year report card on Cigna’s ACO approach with Medical Clinic of North Texas (MCNT) is in; and both healthcare systems are reporting excellent grades in four key areas: reducing avoidable emergency room visits, following evidence-based medicine, lowering medical costs and better controlling diabetes. Since the accountable care program began, MCNT has received the highest level of recognition from NCQA for meeting national quality standards for physician group medical homes. Cigna helped by sharing patient-specific data that identifies individuals who could benefit most from additional outreach and follow-up care.

Medical students, rather than teachers, are getting apples this year: Apple iPads. Many universities, including Yale Medical School, profiled here, are downloading curriculum onto the tablets in an effort to be more “green,” save money, and protect patient confidentiality. Computer security has been a particular concern for the Yale School of Medicine, and the iPad is compliant with security and privacy laws and does not carry the same risk of information loss that a laptop might, Yale officials say.

And finally, a lesson that can’t be taught enough: smoking just a few cigarettes can kill. A new report from the CDC shows that smokers are smoking less: the percent of daily smokers who smoke nine or fewer cigarettes per day rose to nearly 22 percent in 2010, up from an estimated 16 percent in 2005. But smokers need not be heavy or long-term smokers to be affected with a smoking-related disease, or suffer a heart attack or asthma attack, CDC officials say. And states with the toughest anti-smoking campaigns, like like Maine, New York and Washington, have the fewest smokers. Which just goes to show that even the most resistant students can be taught to change their ways.

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Behavioral Health, Case Management, Consumer-Driven Healthcare, Disease Management, HIN Blog, Health IT, Healthcare Costs, Healthcare Quality Ratings, Healthcare Trends, Hospital Readmissions, Telehealth & Telemedicine, Uncategorized, Wellness/Prevention, e-Health | No Comments »

Less is More When it Comes to Healthcare

August 19th, 2011 by Cheryl Miller

Less is more, at least when it comes to certain medical procedures.

That was the conclusion of a recent study by the American Heart Association (AHA) and reported here in a recent issue of Healthcare Business Weekly Update. Researchers compared the use of drug-eluting stents (DES) in 2004-06 to 2007, when their use decreased by nearly 25 percent. Using data from the Evaluation of Drug-Eluting Stents and Ischemic Events registry, the study found that limiting the use of DES did not increase the risk of death or heart attack, and only slightly raised the need for repeat angioplasty procedures. In fact, because the stents were reserved for use on higher risk patients, healthcare costs were reduced by an average of $410 per patient. When multiplied by the estimated 1 million angioplasty procedures performed annually, the United States is able to save nearly 400 million a year.

A recent story in Newsweek corroborates this research, and suggests that the use of DES weren’t the only medical procedures being overused. The article goes on to state that some common tests and procedures aren’t just expensive, but can do more harm than good.

“There are many areas of medicine where not testing, not imaging, and not treating actually result in better health outcomes,” says Dr. Rita Redberg, professor of medicine at the University of California, San Francisco, and editor of the Archives of Internal Medicine.

The problem is that “in otherwise healthy people,” screenings can lead to false positives, and cascading tests and procedures for possible problems that might have been harmless, or gone away on their own, the article says.

From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antiobiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo.

The article doesn’t dismiss the benefits of progressive medicine; instead, it lists the procedures that have saved lives and eased suffering for millions:

Screening tests like mammograms…can lead to early treatment of breast cancer, especially for women with hereditary risk or a strong family history of the disease. For cancer patients who report back pain, MRIs can prove invaluable for spotting tumors that have metastasized to the bones, allowing doctors to intervene before it’s too late. The years between 1980 and 2004 saw a 50 percent decline in the death rate from coronary heart disease thanks to better treatments and drugs that reduce cholesterol and blood pressure. At least 7,300 lives are saved every year thanks to colonoscopies.

But the flip side is that procedures are being overprescribed, like colonoscopies for the elderly, which can often harm them, and CT scans for the injured. A study published by John Hopkins noted the rise in MRIs and CT use in emergency departments over a 10 year period, from 1998 to 2007. The Hopkins team found that patients with injury-related conditions were three times more likely to get a CT or MRI scan in 2007 than they were in 1998. But the team also found that diagnosis of life-threatening conditions, such as a cervical spine fracture or liver laceration, rose only slightly.

Part of the problem is compensation: according to the Newsweek article, Medicare pays physicians more than $100 million a year for screening colonoscopies; still other procedures, like angioplasty, bypass surgery and stenting are not improving cardiac patients’ lives; but instead costing Medicare more than $1.6 billion a year.

The solution? The study published by the AHA didn’t directly identify which patients are the best candidates for DES, although other studies are currently underway using similar patient registries to address it. And research shows that low risk heart patients can benefit more from noninvasive treatments like drugs (beta blockers, cholesterol-lowering statins, and aspirin), exercise, and a healthy diet.

With the push for reducing healthcare costs while improving care, it’s an issue that will most probably continue to be explored.

Posted in Affordable Care Act, Avoidable ER Use, Behavioral Health, Consumer-Driven Healthcare, Disease Management, HIN Blog, Healthcare Costs, Healthcare Trends, Hospital Readmissions, Medication Management, Reducing Readmissions, Transitions in Care, Uncategorized, Wellness/Prevention | No Comments »

Adults’ Top 10 Health Concerns for Kids

August 17th, 2011 by Jessica Papay

Adults rate drug abuse and childhood obesity as the top health concerns for kids in their communities, according to the fifth annual survey of the top 10 health concerns for kids conducted by the University of Michigan C.S. Mott Children’s Hospital National Poll on Children’s Health.

In May 2011, the poll asked adults to rate 23 different health concerns for children living in their communities. The top 10 overall health concerns for U.S. children in 2011 and the percentage of adults who rate each item as a “big problem” are the following:

Childhood obesity: 33 percent
Drug abuse: 33 percent
Smoking and tobacco use: 25 percent
Teen pregnancy: 24 percent
Bullying: 24 percent
Internet safety: 23 percent
Stress: 22 percent
Alcohol abuse: 20 percent
Driving accidents: 20 percent
Sexting: 20 percent

The poll also found that adults’ perceptions of top health problems for children in their own communities differ by race/ethnicity. The poll found that for both blacks and Hispanics, drug abuse was their top health concern, at 44 and 49 percent, respectively. However, drug abuse for white populations came in second at 28 percent, while childhood obesity came in first at 30 percent. Meanwhile, 44 percent of both blacks and Hispanics chose childhood obesity as their concern. When ranking smoking and tobacco use, 36 percent of blacks and 22 percent of whites both ranked this issue at number three, and 35 percent of Hispanics ranked it at number eight.

According to Matthew Davis, MD, director of the poll and associate professor in the Child Health Evaluation and Research Unit at the U-M Medical School, “The perception of drug abuse as a big problem matches recent national data showing increasing use of marijuana and other drugs by U.S. teens. Meanwhile, although obesity remains atop the list of child health concerns for the fourth straight year, the level of public concern has declined over the last few years in our poll. This may be a warning to public health officials, because it indicates how the public is hearing national messages that previous increases in children’s obesity rates have recently leveled off.”

Posted in Behavioral Health, Disease Management, Health Coaching, Healthcare Trends, Wellness/Prevention | No Comments »

The Nurse’s Contribution to Discharge Planning

August 10th, 2011 by Cheryl Miller

Johns Hopkins’ nurses play an essential role in the discharge planning process, explains Chad Boult, MD, MPH, MBA, professor of public health, medicine & nursing and director of the Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health.

Question: What’s the role of the nurse in discharge planning for the comorbid population?

Response: In our model, the nurse doesn’t do the discharge planning. There are some transitional care models where the nurse does do it and every hospital has to have a discharge planner, but we rely on the discharge planner to make the plan. Our nurse interacts with the discharge planner to make sure that they know everything they need to know about the patient for whom they’re making the plan. Most discharge planners have no idea of the patient’s home circumstances. However, our nurse has been to the home and makes sure the planners know the capabilities at home and tries to ensure that a good plan is made. Importantly, our nurses visit the home the day of or day after discharge. That’s when the opportunity is greatest to resolve the confusion that’s almost always going on in patients who have complicated problems, have had their medications adjusted and then are sent home.

Posted in Behavioral Health, Case Management, Transitions in Care, Uncategorized | No Comments »

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