Archive for the ‘Cardiac Care’ Category

AMITA Health Places Patient at Center of Care Management Redesign

February 2nd, 2017 by Patricia Donovan
AMITA Health care management redesign

AMITA Health's care management redesign began in one patient unit on one floor.

In rolling out a new connected care management strategy across its nine-hospital system, AMITA Health aimed to keep its target patient population at the heart of the initiative—unit by unit, floor by floor. Here, Susan Wickey, vice president, quality and care management at AMITA Health, shares one of the guiding principles of the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO).

The key component for us in our redesign was making sure that the patient was at the center of everything we did. With that in mind, we developed structured processes and programs that would span the care continuum while retaining the patient at the center. We wanted to establish relationship-based care with the patient and the primary care physician. We wanted to be able to use available data to help drive our decisions. We wanted to ensure that our patients had regular access to care, and that we leveraged what we currently had in place.

Our congestive heart failure clinic was key in this process. Navigating through the care continuum is not an easy process for many of our patients. We wanted to make sure we could help them through that, and construct some processes for them to be able to navigate. We wanted to make sure we were continuing to build the health literacy of our patients and our families. We wanted to establish interventions for the most vulnerable population of patients. We wanted to make sure we had a dedicated, multidisciplinary team to help us. We had psychiatrists, dieticians, pharmacists, primary care physicians and physician champions along the way to help us.

We began implementation very slowly, starting with a specific cohort of patients on one specific unit. This cohort was small; the number of people touching the cohort at the time was small. As we went along, we were able to define problem areas where we needed to intervene, quickly readjust and then go down the right path.

Slowly, over a period of time, we were able to add additional floors in our acute care hospitals, which then meant adding additional staff. Those additional staff then became the super users who helped us roll out the program on the next floor.

Source: Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations

Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations

Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations describes how the nine-hospital system inventoried, reexamined and revamped its care management resources, ultimately implementing a centralized care management model.

Accessibility, Visibility Reasons to Embed Case Managers into Primary Care, Workplace

April 30th, 2015 by Cheryl Miller

When case managers are embedded into primary care workplaces, both patients and staff benefit, says Melanie Fox BSN, RN, director of embedded case management with Caldwell UNC Healthcare. Instead of delaying a patient's request for care, staff workers are more likely to address it by going directly to the case manager on site. And some patients are more likely to directly ask the case manager, who they might previously have contacted telephonically.

Some people have embedded case managers but they might not be embedded in the practices. Our case managers are on site. They are available. They are visible. That makes it easy for the staff and the patients because sometimes they’ll think that patient may need something, but are unsure how to make that happen for that patient.

Then they see us or they remember we’re here. They’ll come to us and ask for help, trying to get that patient what they need, whether it be hospice services, VNA services, or just watching a patient’s blood pressure or hemoglobin A1C. If you’re there visible, it makes it so much easier for the staff and as well as the patients.

We have patients that drop by our offices just to see who we are because we’ve talked to them over the telephone. The visibility from us being in the office is great. We seem to be more accepted by the providers and the staff because of that, as well as the patients because they see us as part of the team. They see us working in the office. Sometimes, when we make a phone call to the home, they may accept it sometimes a little better because we’re calling from our clinics. When we mention where we are calling from and the name of the doctor we’re working with, then they’ll talk to us a little more willingly.

It makes that easier. It also helps to engage the patients in the office because they are here. A staff member will pull us into an office and let us know that one of the patients is here to talk to them. We have found that just being in the office is a great asset for the doctors as well as ourselves. It makes our jobs a little bit easier.

Source: Embedded Case Management in Primary Care and Workplace Clinics: Skill Sets, Stratification and Protocols

5 Trends in Chronic Care Management by Physician Practices

March 17th, 2015 by Cheryl Miller

One hundred percent of physician practices rely on face-to-face and telephonic visits to administer chronic care management (CCM) services, according to respondents to the Healthcare Intelligence Network's 10 Questions On Chronic Care Management survey administered in January 2015.

A total of 119 healthcare organizations described tactics employed, 17 percent of which were identified as physician practices. A sampling of this sector's results follows.

  • Less than half of physician practices (46 percent) admitted to having a chronic care management program in place. But they overwhelmingly agree (100 percent) that CMS’s CCM initiative will drive similar reimbursement initiatives by private payors.
  • This sector’s criteria for admission to existing chronic care management programs is on par with other sectors except for asthma; just 17 percent of physician practices use this as an admitting factor versus 49 percent of all respondents.
  • Not surprisingly, this sector assigns major responsibility for CCM to the primary care physician, versus 29 of all respondents. This sector also relies on healthcare case managers (40 percent versus 29 of all respondents) and advanced practice nurses (APNs) (20 percent versus 8 percent overall) to assist with CCM.
  • This sector relies most heavily on face-to-face visits for CCM services (100 percent versus 71 percent for all respondents) and telephonically (100 percent versus 87 percent of all respondents).
  • Among the biggest challenges for this sector is reimbursement (33 percent versus 20 percent overall) and documentation (17 percent versus 2 percent overall). Unlike other sectors, patient engagement is not a major challenge (17 percent versus 33 percent overall).

Source: 2015 Healthcare Benchmarks: Chronic Care Management

http://hin.3dcartstores.com/2015-Healthcare-Benchmarks-Chronic-Care-Management_p_5003.html

2015 Healthcare Benchmarks: Chronic Care Management captures tools, practices and lessons learned by the healthcare industry related to the management of chronic disease. This 40-page report, based on responses from 119 healthcare companies to HIN's industry survey on chronic care management, assembles a wealth of metrics on eligibility requirements, reimbursement trends, promising protocols, challenges and ROI.

5 Features of the Patient-Centered Medical Home

October 23rd, 2014 by Cheryl Miller

Patient-centered medical homes (PCMHs) are not about pigeon-holing certain diseases or illnesses, says Terry McGeeney, MD, MBA, director at BDC Advisors, but about delivering acute and chronic care prevention and wellness. Dr. McGeeney reiterated the five essential features of the medical home as the groundwork for a medical neighborhood.

Given many of the initiatives of the Centers for Medicare and Medicaid Services (CMS), coupled with the Triple Aim, many have gotten bogged down and probably overly focused on the name: patient-centered medical home (PCMH). What’s important are the features or attributes of the PCMH: first, its patient-centeredness, a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients and ensures patients have the education and support they need.

Secondly, in a PCMH, the care needs to be comprehensive. It’s a team of care providers who are wholly accountable for a patient’s physical and mental healthcare needs, including prevention and wellness, acute care, and chronic care.

Third, you will hear discussions about the PCMH being about a certain disease or illness. Please note that it’s acute and chronic care prevention and wellness. Pigeon-holing conditions, while important, is more of a chronic quality improvement initiative and not PCMH.

Fourth, under the PCMH, care needs to be coordinated. Care is organized across all elements of the broader healthcare system, including specialists, hospital, home healthcare, community service and support. There’s a lot of debate now about what we call ‘post-acute care’ or ‘transitions in care.’ Jonathan Blum, principal deputy administrator of CMS, recently spoke on the importance of post-acute care. This is what coordinated care particularly is all about.

Care has to be accessible. Patients are able to access services with shorter waiting times, after-hours care with access to EHRs, etc., and there has to be a commitment to quality and safety. Clinicians and staff need to enhance quality improvement with the use of health IT and other tools that are available to them.

We also need to be very careful that quality care is not equated with lower cost of care. Sometimes those two have a tendency to get muddled.

Source: Blueprint for a Medical Neighborhood: Building Care Coordination Between Specialists and PCPs

http://hin.3dcartstores.com/Blueprint-for-a-Medical-Neighborhood-Building-Care-Coordination-Between-Specialists-and-PCPs_p_4967.html

Blueprint for a Medical Neighborhood: Building Care Coordination Between Specialists and PCPs provides a framework in which to evaluate the patient-centered medical neighborhood (PCM-N) model. Pictured here is Terry McGeeney, MD, MBA, director of BDC Advisors, who navigates the landscape of the medical neighborhood, from the value-based payment realities of healthcare today to identifying and engaging specialists in a medical home neighborhood.

Community Health Network Retools Readmissions Ruler for High-Risk Heart Failure Patients

September 9th, 2014 by Patricia Donovan

From the many evidence-based health risk stratification tools available, Community Health Network has adapted a popular hospital readmissions indicator for use with medically complex patients at high risk of readmissions. Deborah Lyons, MSN, RN,NE-BC, network disease management executive director for Community Health Network, describes the adaptation process.

HIN: Where do home visits for heart failure patients enter the picture?

Deborah Lyons: We do a high-risk home assessment while we have patients in the hospital. Fully 100 percent of our patients that are admitted to inpatient status are automatically screened and ranked in terms of readmission risk. That’s where we use the LACE/ACE tool. We embedded that tool in our software so it can predictively tell us which patients to focus on.

HIN: How did you decide on the LACE tool? Is the ACE tool different than the LACE tool?

Deborah Lyons: The LACE itself is evidence-based. We work with the advisory board. And they had just done an analysis of all the predictive models out there in terms of readmission risk when we started this work. There were only two tools that were moderately predictive for risk. LACE was one of them. LACE looks at length of stay (L), acute admission (A), (meaning they came in through the emergency room), their Charleston Comorbidity score (C) and the number of ED visits (E) they’ve had in the past six months.

All this information was easily available to us at the time that we did this because we were on a different computer system. But the concern was that the L factor (length of stay), might lead us to place the patient at high risk when they were leaving the hospital. Maybe they started at low risk and then on the fourth day of stay, because they had been there four days, now they moved to high risk but they’re being discharged. You really can’t do anything at day of discharge. We first set a threshold for LACE, which we tested and validated and then ran a correlation and asked ourselves, “If this threshold is a LACE high risk, what would a correlating threshold be if we dropped the length of stay?” That’s how we moved to an ACE score.

Source: Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics

Stratifying High-Risk Patients


Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics
Reviews 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.

Profiting from Payment Bundles: Post-Acute Care Presents Opportunities

June 2nd, 2014 by Patricia Donovan

On the landscape of opportunity for hospitals to profit from bundled payments, the potential lies in post-acute care, advises Kelsey Mellard, vice president of Partnership Marketing and Policy with naviHealth.

Preoccupied with such urgencies as avoiding CMS readmissions penalties and adhering to meaningful use requirements, most hospitals haven't taken the time to examine potential cost savings from engaging post-acute providers in bundled payment initiatives, Mrs. Mellard explained during a May 2014 webinar on opportunities from bundled payments.

But recruiting high-performing skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals into its post-acute care (PAC) network has helped to drive down SNF, IRF and LTAC per member per month (PMPM) costs for naviHealth, which bills itself as a risk partner for health systems and health plans managing PAC utilization and spend.

naviHealth is also an awardee convener for model 2 and model 3 of the CMS Bundled Payments for Care Improvement (BPCI) pilot. Model 2 concerns itself with retrospective acute care hospital coupled with post-acute care episodes, while model 3 is restricted to care episodes involving retrospective post-acute care only.

While there are more than 300 healthcare organizations participating in the BPCI pilot, naviHealth is most engaged in model 2, whose bundled reimbursement rewards efficiency, communication, accountability, Ms. Mellard noted.

The naviHealth model of coordinated, data-driven care has helped to reduce its average post-acute care costs in the Medicare population to $53 per member per month (PMPM)— almost half the national average.

"We impact and work with the discharge planners to identify the most appropriate setting for our beneficiaries and the duration of the setting, and then manage that readmission risk and prevention program that follows."

To identify potential participants for its PAC network, naviHealth has created dashboards that evaluate efficiency, quality and other metrics such as volume obtained from CMS. They also consult with care managers for recommendations, then invite the post-acute care providers to a 'town hall meeting' with our hospital partners to provide an overview of the bundled payment program.

"It's been fun to see the level of excitement of how the business model is fundamentally changing. Everyone wants to be at the table, because they know that we are entering a risk-bearing phase of our business and within healthcare in general."

While CMS has closed the opportunity to sign up for bundled payments for the moment, the time is still ripe to engage with providers already participating, she said.

Overall, given the level of activity, conversation, and pending legislation associated with episodic-based reimbursement, the future for bundled payments looks bright, concluded Ms. Mellard.

Listen to an extended interview with Kelsey Mellard.

Care Coordination Compacts: Establishing Accountability, Clarity between Physicians and Specialists

May 22nd, 2014 by Cheryl Miller


It's a scenario that occurs time and time again, and is a deep source of frustration for all involved: a physician refers a patient to a specialist, but hears nothing back from that specialist. In fact, they learn that the visit happened only when the patient returns for his primary care visit, but without any necessary information.

Or, a specialist receives a patient who has none of the pre-work or test results necessary for an effective visit, which ends up delaying care for the patient. Or, on the flip side, the specialist receives patients that had numerous unneeded and avoidable tests done prior to the referral.

The culprit? Lack of accountability and clarity, the foundations of the Care Compact, an agreement between two practices that outlines the roles and responsibilities of each in order to promote patient-centered care, says Robert Krebbs, director of payment innovation at WellPoint, Inc., during Care Compacts: Forming the Foundation of Care Teams with PCPs and Specialists, a May 2014 webinar now available for replay from the Healthcare Intelligence Network.

The Care Compacts (also known as Care Coordination Agreements and/or Referral Agreements) are key to WellPoint’s patient-centered medical home neighborhood (PCMH-N) pilot, Patient-Centered Specialty Care (PCSC). The program was launched in January 2014 with a select number of pilot practices, ranging in size from solo practices to large group practices in markets where there is a strong patient-centered medical home (PCMH) foothold, says Krebbs.

PCSC is a value-based reimbursement program developed for three types of specialties with clear care coordination alignment opportunities with PCMHs: cardiology, endocrinology, and OB/GYN. These specialists work with existing patient-centered medical home partners to improve quality and coordinate care guided by cost and efficiency measures, Krebbs continued, ensuring the following:

  • Effective two-way communication between primary and secondary providers;
  • Appropriate and timely referrals and consultations with prompt feedback of findings / recommendations;
  • Effective co-management of patients when necessary; and
  • Commitment to practice in a patient-centered fashion across all physicians delivering care to a patient.

The reason these care agreements work is because they provide a standard set of processes for roles in care coordination, truly defining what care coordination is between two practices. While many practices across the country agree they need care coordination, they don't always agree on what the concept of care coordination is, Krebbs continues.

At their simplest, they help to clearly outline who's going to do what in a referral or consult situation. By cutting out inappropriate duties and maintaining appropriate ones, they help to curb healthcare spend and improve patient care, Krebbs says.

“The care compact isn't intended to solve all the world's problems. It’s not going to make care coordination perfect, but it's a starting point. Just like the patient-centered medical home (PCMH) provides a foundation for the medical neighborhood, the care compacts provide a foundation for care coordination between practices. It's an essential starting point to further care coordination expectations across that medical neighborhood," says Krebbs.

Listen to an interview with Robert Krebbs.

6 Criteria for Evaluating Vendor Partners for Remote Patient Monitoring

April 22nd, 2014 by Patricia Donovan

Just as there are guidelines for identifying individuals most likely to benefit from remote monitoring, healthcare organizations must also choose remote monitoring vendor partners with care, advises Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, who shared lessons gleaned from vendor selection for Humana's nine separate pilots of remote patient monitoring.

I want to share how Humana chose the partners that we work with in these programs, because there are so many potential vendors to work with in the remote monitoring space. We had been evaluating companies off and on for about a year. We ended up doing a request for information (RFI) process with the top 25 we had identified internally. They weren't necessarily the biggest vendors or the companies with the strongest balance sheet, but rather those that met the different capability criteria we were looking for and possessed the flexibility and creativity to work with us.

Some think that it’s a good idea to warn people when you’re going to be working with a large entity like Humana, so that the companies we choose are prepared to deal with our procurement and legal processes, and understand it will take some resources on their side. Since the change to the HIPAA rule in 2013 there iss more downstream liability, so we require additional business liability insurance, and our business information agreements are quite stiff. All of those things must be worked through before we can work with a vendor.

We were also looking for companies that could be easily scalable. You could have a great piece of equipment, but if it’s going to take ten months or a year to procure another thousand, that’s not going to work for us because we have to be thinking on a national basis. We also were looking for vendors willing to work with members with various home situations. We did not want to exclude anybody from our pilot.

For example, some of the equipment we looked at would only run if there were broadband in the home. We needed someone to put some type of device that they could plug in, that would help boost them or create a 4G or 3G network wherever they were. We needed to adapt to the different home situations that our individuals lived in.

Then, the equipment had to be senior friendly. We learned a lesson from a great study with Intel about three years ago. The results had some positives and some negatives, but one thing we learned was that the size of the equipment was important. At that time, the piece of equipment we were using weighed about 37 pounds. Because of the frail nature of some of our members, we had to hire an intermediary to do setup and delivery and then package it up and send it back afterward. It created a lot of extra cost and a little more confusion trying to arrange those deliveries and pickups.

One thing that we are dedicated to doing this time is making sure that whatever equipment we had in the home that we could manage it easily, and that hopefully the senior themselves or their caregiver would be able to set it up.

Excerpted from: Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population

Targeting Heart Failure Readmissions with Telehealth Monitoring

January 30th, 2014 by Cheryl Miller

To further investigate gaps in care, Central Maine Medical Center expanded a team already focused on outcomes improvement for 30-day readmissions to include providers, nurses, home care and hospice. The resulting intervention incorporated home health visits supplemented with telehealth, explains Susan Horton, DNP, APRN, CHFN, executive director of Central Maine Heart and Vascular Institute. This innovative work also led to other home-based interventions that were not always restricted to individuals identified by Medicare as homebound.

About that time our home care and hospice group approached us. They had the opportunity to write a grant for telehealth monitors. They wanted to know whether Central Maine would support that application so that they could then target these telehealth monitors for our heart failure population.

We supported that grant, and they got it. However, that decision caused us to determine that we needed to be more strategic in our partnership with home care and hospice. From that, we developed a job description and hired a full time equivalent: 20 hours on the medical center payroll, and 20 hours on the home care and hospice payroll.

That’s where the home visit program really took off. We were able to say that whether Patient A meets Medicare criteria for homebound or not, home care would go into the patient’s home as a guest of Central Maine Medical Center. We explained to each patient at the time of discharge that we wanted to evaluate their home situation to make sure they were safe.

This was important because we are looking at all-cause readmissions. If a heart failure patient living in an unsafe situation trips and falls and gets readmitted with a head injury, that’s still going to be a black mark for heart failure readmission. It’s all-cause readmission. We felt that we needed to assess what was going on in the home. Who was there for the patient? What were they doing in terms of support? Could they take their medication? Did they have a scale? Could they read the scale? And we would offer telehealth.

Excerpted from: Guide to Home Visits for the Medically Complex.

Collaboration, Medication Reconciliation, Yoga Key to Successful Population Health Management

January 30th, 2014 by Cheryl Miller


Zumba, yoga, Thank God it's Free Fruit Friday (TGIFF)?

Maybe not top-of-mind elements of accountable care, but all three are helping healthy employees to stay healthy, and luring others to engage in their own health self-management, the keys to successful population health management (PHM), says Elizabeth Miller, vice president of care management at White Memorial Medical Center, part of Adventist Health, in a recent webinar at the Healthcare Intelligence Network.

In Managing Risk in Population Health Management, Ms. Miller shared the key features of the PHM program at White Memorial, the program's impact on Adventist’s 27,000 employees and how the program was being rolled out to its patient population.

By incorporating elements of the Triple Aim, and collaborating with all stakeholders, including patients, providers, health plans, employers, hospitals and local community members, a PHM program can achieve optimal outcomes, including minimizing the need for ED visits, lowering costs, maintaining and improving individuals’ health across the continuum of care, and reducing readmissions, Miller says.

Medication reconciliation plays a key part in preventing populations from being admitted or readmitted to the hospital, Miller continues, because it is one of the chief causes for readmission. She cites numerous instances where nurse practitioners go into people’s homes to do medication reconciliation only to find that they are going to two cardiologists simultaneously and taking medications from both of them, not realizing how detrimental it is to their health.

Elements of the PHM program include using robust data sets, risk stratification, and predictive modeling to identify populations, and target high-risk individuals with one or more chronic diseases, including the top five: coronary heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma, diabetes, HIV. Once eligible populations are targeted and enrollment criteria met, analytics, intervention and program development are established for the top 5 percent, or very high risk, and 10 percent, or high risk, and then wellness programs for the 85 percent, or medium risk.

Ongoing assessments and evaluations of interventions follow, usually by care managers, including periodic reassessments of goals, and measuring outcomes with set metrics.

The goal of any PHM plan is to eventually graduate patients by setting up decision support and self-management tools that will help them do so. Offering employees the right incentives is a key contributor to this. White Memorial was able to engage 95 percent of its employee population in a PHM program by reducing monthly insurance premiums by $50 a month. That percentage grew to 98 percent when the reductions were extended to employees’ spouses,’ Miller says.

Ultimately, says Miller, “we really want to focus on the population and modify the behaviors so that we prevent illness in the future. Right now we have a disproportionate investment in illness after it has already occurred. Once it has occurred, it’s difficult to manage and treat…Our goal is to keep the population as healthy as possible.”

It can be labor intensive, Miller points out, but the outcomes are worth it. Improved health status leads to improved performance, and projected financial savings of $49 million by 2017.