Archive for the ‘Care Coordination’ Category

HINfographic: Care Coordination Trends: Oversight of Complex Comorbid Spans Continuum

May 17th, 2017 by Melanie Matthews

Care coordinators organize patient care activities and share information among vested participants to achieve safer and more effective care, per the Agency for Healthcare Research and Quality (AHRQ). And for 86 percent of respondents to the 2016 Care Coordination survey by the Healthcare Intelligence Network, care coordination takes place across all care settings, including the patient's home.

A new infographic by HIN examines patient care coordination touchpoints, patients by diagnoses prioritized for care coordination and care coordination touchpoint frequency and reimbursement models.

2016 Healthcare Benchmarks: Care CoordinationCare coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient's care to achieve safer and more effective care, as defined by the Agency for Healthcare Research and Quality (AHRQ).

2016 Healthcare Benchmarks: Care Coordination examines care coordination settings, strategies, targeted populations, supporting technologies, results and ROI, based on responses from 114 healthcare organizations to the September 2016 Care Coordination survey by the Healthcare Intelligence Network.

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Top 2017 Chronic Care Management Modes and 13 More CCM Trends

May 2nd, 2017 by Patricia Donovan

Availability of chronic care management rose 14 percent from 2015 to 2017, according to new metrics from the Healthcare Intelligence Network.

The majority of chronic care management (CCM) outreach is conducted telephonically, say 88 percent of respondents to a 2017 Chronic Care Management survey by the Healthcare Intelligence Network (HIN), followed by face-to-face visits (65 percent) and home visits (44 percent).

This preference for telephonic CCM has remained unchanged since 2015, when HIN first canvassed healthcare executives on chronic care management practices. More than one hundred healthcare companies completed the 2017 CCM survey.

In addition, the April 2017 CCM survey captured a 14 percent increase in chronic care management programs over the two-year-span: from 55 percent in 2015 to 69 percent in 2017. Three-fourths of 2017 responding CCM programs target either Medicare beneficiaries or individuals with chronic comorbid conditions, with management of care transitions the top CCM component for 86 percent of programs.

In terms of reimbursement, payment levels for CCM services remained steady at 35 percent from 2015 to 2017. However, HIN's second comprehensive CCM survey determined that 32 percent of respondents currently bill Medicare using CMS Chronic Care Management codes introduced in 2015.

Forty percent of these Medicare CCM participants believe CMS’s 2017 program changes will reduce administrative burden associated with CCM, the survey documented.

Other metrics from HIN's 2017 CCM survey include the following:

  • A diagnosis of diabetes remains the leading criterion for CCM admission, said 92 percent;
  • Use of healthcare claims as the top tool for identifying or risk-stratifying individuals for CCM continues at 2015’s 70-percent levels;
  • Seventy percent of respondents target individuals with behavioral health diagnoses for CCM interventions;
  • Patient engagement remains the top challenge of chronic care management, with just under one-third of 2017 respondents reporting this obstacle
  • Responsibilities of RN care managers for CCM rose over two years, with 43 percent of 2017 respondents assigning primary CCM responsibility to these professionals (up from 29 percent in 2015); and
  • Two-thirds of respondents observed a drop in hospitalizations that they attribute to chronic care management.

Download an executive summary of 2017 Chronic Care Management survey results.

Infographic: Overcoming Barriers To Improve Care Transitions

May 1st, 2017 by Melanie Matthews

Leveraging the right technology can improve post-acute patient outcomes, according to a new infographic by Ensocare.

The infographic looks at: the impact of streamlining multiple, disparate workflows; and how to strengthen post acute networks, simplify ongoing post-acute follow-up communications and improve patient engagement during care transitions.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROIA care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program.

Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS's recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI explores the critical five pillars of the Arizona non-profit's leading care transitions management initiative, adapted from the Coleman Care Transitions Intervention®.

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HINfographic: Social Determinants of Health: Screenings Abound, But Support Services Scarce

April 26th, 2017 by Melanie Matthews

Social determinants of health like food insecurity, unsafe neighborhoods and even loneliness can impact quality of life and population health. Although more than two-thirds of healthcare organizations now screen populations for social determinants of health (SDOH) as part of ongoing care management, one-third are challenged by a lack of supportive services, according to the December 2016 SDOH survey by the Healthcare Intelligence Network.

A new infographic by HIN examines priority populations for SDOH screening, the greatest SDOH need and SDOH integration and tools.

2017 Healthcare Benchmarks: Social Determinants of HealthInitiatives such as CMS' Accountable Health Communities Model and other population health platforms encourage healthcare organizations to tackle the broad range of social, economic and environmental factors that shape an individual's health. To underscore the need to address social determinants of health, Healthy People 2020 included "Create social and physical environments that promote good health for all" among its four overarching goals for the decade.

In one measure of their impact, 2015 research by Brigham Young University found that the social determinants of loneliness and social isolation are just as much a threat to longevity as obesity.

2017 Healthcare Benchmarks: Social Determinants of Health documents the efforts of more than 140 healthcare organizations to assess social, economic and environmental factors in patients and to begin to redesign care management to account for these factors.

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Touting ‘Magic’ of Home Visits, Sun Health Dispels 5 Care Transition Management Myths

April 4th, 2017 by Patricia Donovan


With an average of 299 warm, sunny days a year, Phoenix is a mecca for senior transplants. However, as Phoenix-based Sun Health knows well, when an aging population relocates far from their adult children, there's a danger that if some of them experience cognitive decline or other health issues, no one will notice.

That's one reason home visits are the cornerstone of Sun Health's Care Transitions Management program. Visiting recently discharged patients at home not only tracks the individual's progress with the hospitalization-related condition, but also pinpoints any social determinants of health (SDOH) that inhibit optimum health.

"There are a number of social determinants of health that, if not addressed, could adversely impact the medical issue," explains Jennifer Drago, FACHE, executive vice president of population health for the Arizona non-profit organization. Ms. Drago outlined the program during A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay.

Identifying social determinants of health (SDOH) such as medication affordability, transportation, health literacy and social isolation are so important to Sun Health that SDOHs form the critical fifth pillar of its Care Transitions Program. Modeled on the Coleman Care Transitions Intervention®, SDOH identification and support balance Coleman's four pillars of education, medication reconciliation, physician follow-up visits, and personalized plan of care.

The belief that organizations can effectively execute transitions of care programs pre-discharge or by phone only is one of five care transition myths Ms. Drago dispelled during the webinar. "You will have an impact [with phone calls], but it won't be as great as a program incorporating dedicated staff and that home visit. I can't tell you the magic that happens in a home visit."

That "magic" contributed to Sun Health's stellar performance in CMS's recently concluded Community-Based Care Transitions Program demonstration. Sun Health was the national demo's top performer, achieving a 56 percent reduction in Medicare 30-day readmissions—from 17.8 percent to 7.81 percent—as compared to the 14.5 percent readmission rate of other demonstration participants.

Sun Health's multi-stepped intervention begins with a visit to the patient's hospital bedside. "Patients are a captive audience while in the hospital," explained Ms. Drago. That scripted bedside encounter, which boosted patients' receptivity to the program, addresses not only the reason for the hospitalization (hip replacement, for example) but also co-occuring chronic conditions, she continued.

"The thing that will have the greatest chance of going out of whack or out of sync in their recovery period is their chronic disease, because they're probably not eating the same, they're more sedentary, and their medications likely have been disrupted."

Ms. Drago went on to present some of the intervention's tools, including care plans, daily patient check-ins, and the science behind her organization's care transitions scripts.

After sharing six key lessons learned from care transitions management, Ms. Drago noted that while her organization participated as a mission-based endeavor, others could model Sun Health's intervention and benefit from those readmissions savings. She also shared a video on the Sun Health Care Transitions Program:

Listen to an interview with Jennifer Drago on the science behind care transition management.

How a Data Dive Makes a Difference in ACO Care Coordination Efficiency

March 30th, 2017 by Patricia Donovan

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UTSACN used data analytics to trim its home health network from more than 1,200 agencies to 20 highly efficient home health providers.

How does UT Southwestern Accountable Care Network (UTSACN) use information to inform and advance care coordination programming? As UT Southwestern's Director of Care Coordination Cathy Bryan explains, a closer look at doctors' attitudes toward a Medicare home health form initiated a retooling of the ACO's home health approach.

We realized our home health spend was two times the national average. When we reviewed just the prior 12 months, we identified more than 1,200 unique agencies that serviced at least one of our patients. With this huge number of disparate home health agencies, it was difficult to get a handle on the problem.

Our primary care doctors told us they found the CMS 485 Home Health Certification and Plan of Care form to be too long. The font on the form is four-point type; it's complex, so they don't understand it. However, because they don't want a family member or patient to call them because they took away their home care, they often sign the form without worrying about it.

As we began looking at these findings, we wondered what they really told us. Are some agencies better than others, and how do we begin to create a narrow network or preferred network for home care? We knew we couldn't work with 1,200 agencies efficiently; even 20 agencies is a lot to work with.

We began to analyze the claims. My skilled analyst created an internal efficiency score. She risk-adjusted various pieces of data, like average length of stay. For home health, there were a number of consecutive recertifications. We looked at average spend per recertification, and the number of patients they had on each agency. We risk-adjusted this data, because some agencies may actually get sicker patients because they have higher skill sets within their nursing staff.

We created a risk-adjusted efficiency score based on claims. We narrowed down the list by only looking at agencies with 80 percent or higher efficiency. That left us with about 80 agencies; we then narrowed our search to 90 percent efficiency and above, and still had 44. That was still too many, so we cross-walked these with CMS Star ratings to narrow it even more. Finally, after looking at our geographic distribution for agencies that serviced at least 20 patients, we eliminated those with one and two patients. We sought agencies that had some population moving through them.

Ultimately, we reduced our final home health network to about 20 agencies that were not creating a lot of additional spend, and not holding patients on service for an incredibly long period of time.

Source: Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives

advanced care coordination

During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a 2016 webinar available for replay, Cathy Bryan, director, care coordination at UT Southwestern, shares how her organization’s care coordination model manages utilization while achieving its mission of bridging the gap from where patients are to where they need to be to adhere to their care plan.

Infographic: Evidence-based Guidelines for Managing Low-Back Pain

February 15th, 2017 by Melanie Matthews

Evidence-based Guidelines for Managing Low-Back Pain

The complexity and intensity of treatment for lower back pain may vary depending on how likely it is that the patient will have a good, functional outcome, according to a new infographic by BMJ Publishing Group.

The infographic provide care pathways for patients by expected outcome.

When success in a fee-for-value reimbursement framework calls for a care coordination vision focused on the highest-risk, highest-cost patients, an organization must be able to identify this critical population.

2016 Healthcare Benchmarks: Stratifying High-Risk Patients captures the latest tools and practices employed by healthcare organizations across the care continuum as they risk-stratify patients and health plan members in preparation for care management.

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Physician Supplemental QRUR: Episode-Specific Patient-Level Data Tells Story of High Utilizers

February 7th, 2017 by Patricia Donovan

QRUR reports provide a mirror into physicians' cost and quality performance under MACRA.

As year one of MACRA unfolds, healthcare providers deterred by security hurdles associated with CMS Enterprise Portal access may want to reconsider. The wealth of aggregate quality and cost performance data available through the portal is well worth the trouble of accessing it, advises William Holding, consultant with PDA, Inc.

Specifically, Quality Resource and Utilization Reports (QRURs) downloadable from the portal are essential tools for physician practices that hope to succeed on MACRA-defined reimbursement paths, Holding said—even practices equipped with robust internal reporting systems.

"This is the same system that accountable care organizations (ACOs) use, and that CMS uses for many other things, so it's a good idea to get past those barriers," he explained during Physician MACRA Preparation: Using QRUR and Other CMS Data to Maximize Your Performance, a February 2017 webinar now available for replay.

Originally designed for CMS's value-based modifier, QRURs are good indicators of future cost performance under MACRA, via either Merit-Based Incentive Payment System (MIPS), where most physician practices are expected to fall initially, or Alternate Payment Models (APMs), he said.

After providing an overview of MIPS and APMs, including five essential prerequisites to MACRA preparation, Holding delved into the quality and cost metrics contained in QRURs, from aggregate data in the main report to detailed tables rich with patient-specific information.

The main QRUR report illustrates where a physician practice falls in relation to other practices on the overall composite for cost and quality. The QRUR's Quality portion shows scores for a series of domains, including effective clinical care and patient experience, which offer a great window into how a practice might perform with different selected measures in MIPS.

Next, QRUR cost performance indicates per capita costs for attributed beneficiaries, which will remain a cost measure in MIPS.

Drilling down, Holding characterized seven associated QRUR downloads—including one table on individual eligible professional performance on the 2015 PQRS Measures—as even more useful than the QRURs themselves.

And finally, he termed the downloadable supplemental QRUR "a very powerful tool" that drills down to the beneficiary level, providing a snapshot of some of the highest cost events occurring among a practice's patients.

"For high utilizers, for specific episodes, you can drill right down to the patient to try and understand the story. What's happening to your patient when they're not in your practice, and what can you do about it?" said Holding.

Having presented the available reports, Holding described four key benefits of using QRUR downloads, including as a priority setting tool, and then detailed the myriad of ways QRURs can be analyzed to improve MIPS performance.

However, Holding stressed, even physician practices with the most sophisticated reporting structures will not thrive under MACRA without the right team or culture of provider support in place. He closed his presentation with a formula for determining investment in performance improvement activities and a five-step plan for MACRA preparation.

Listen to an interview with William Holding on the use of QRURs to determine a physician practice's highest value referral pathways.

In Care Coordination of Medically Vulnerable Homeless Patients, Housing is a Form of Healthcare

January 17th, 2017 by Patricia Donovan

Chronic Care Plus recuperative care reduced ER visits by homeless patients by 84 percent, and avoided nearly $3 million in medical costs.

Most patients discharged from the hospital ultimately return to a secure home environment. Not so for homeless or unstably housed patients; disconnected from healthcare and their community, their lack of stable housing compounds their medical difficulties following a hospital stay.

Enter Chronic Care Plus (CCP), a safety net recuperative care program in California whose mission is to bridge this gap between hospital discharge and permanent supportive housing for homeless patients, or "Joes," as Illumination Foundation Founder and CEO Paul Leon characterized his client profile during a recent presentation.

"I'm sure you can identify the 'Joes' in your neighborhood," Leon told participants during Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients, a December 2016 webinar now available for replay. "They've come into the ER but are never quite connected with either a federally qualified health clinic (FQHC), your own hospital clinic or any available resources in your community."

The CCP program not only provides housing for recently discharged homeless or unstably housed individuals in model or dormitory-like settings but also reconnects them to the healthcare continuum. The program then wraps clients in a plethora of services, including housing placement, financial literacy, job placement, transportation and behavioral health support.

Back in 2008, Leon's organization was one of only about seven in the nation to provide recuperative care (also known as medical respite care). Recuperative care is care to homeless persons recovering from an acute illness or injury, no longer in need of acute care but unable to sustain recovery if living on the street or other unsuitable place, Leon explained. Today there are about 80 such programs in the United States.

Since then, his foundation created standards and best practices, and in 2013 launched CCP—"recuperative care on steroids, with tightly wrapped social services and a longer length of stay," Leon explained.

Originating as an ED diversion pilot aimed at 20 of the highest users of a local hospital ER, CCP has transformed discharge planning for the homeless and has served more than 2,500 patients since its inception.

During the presentation, Leon shared a host of program analytics, including recuperative care criteria client demographics and CCP statistics on medical, behavioral health, housing and other services provided. He also shared CCP's future plans, and some of the program's barriers and challenges, including medical management education and closing gaps in social services.

In terms of program outcomes, CCP has amassed significant savings as it closes gaps in care and reduces healthcare utilization, including 322 fewer ER visits by this population (a 84.3 percent decrease) and $2.8 million in medical cost avoidance at three participating hospitals.

"For Orange County hospitals as a total, we estimate that there was $5.2 million of savings," added John Kim, grants director of the Illumination Foundation. "If we compare the year prior on an annualized cost basis, that comes to over $7 million of savings to Orange County hospitals."

Click here for an interview with Paul Leon on Chronic Care Plus's challenges and lessons learned as it connects its medically vulnerable homeless to social services.

Infographic: Maternity Episodes of Care

January 16th, 2017 by Melanie Matthews

Maternity Episodes of CareThe cost of maternity care varies significantly by payer (commercial or Medicaid), by type of birth (vaginal or cesarean section), and by setting (hospital or birth center). Too often, women are not experiencing optimal outcomes in maternity care despite the significant resources spent, according to a new infographic by the Health Care Payment Learning & Action Network.

The infographic examines how an episode of care could be applied to maternity care—from an episode timeline for prenatal through postpartum care; episode parameters; operational considerations; and maternity care design elements.

Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) has awarded $3 million to 51 specialty medical practices as part of a shared savings arrangement through the company's Episodes of Care (EOC) program. The doctors, in five different specialty areas, earned the payments by achieving quality, cost efficiency and patient satisfaction goals in 2014 while treating more than 8,000 Horizon BCBSNJ members. As the largest commercial payor of Episodes of Care in the United States, Horizon BCBSNJ recently reported far lower hospital readmission rates and improved clinical outcomes for members in its EOC practices versus non-EOC practices in 2014.

During Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship, a March 31, 2016 webinar, available for replay, Lili Brillstein, director of the Horizon EOC program, shares the details behind the health plan's EOC program, from the episodes they have bundled to the goals and results from the program.

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