Archive for the ‘Care Coordination’ Category

4 Ways CMS 2018 Quality Payment Program Supports ‘Patients Over Paperwork’ Pledge

November 6th, 2017 by Patricia Donovan

“Patients Over Paperwork” is committed to removing regulatory obstacles that get in the way of providers spending time with patients.

Year 2 of the CMS Quality Payment Program promises continued flexibility and reduced provider burden, according to the program’s final rule with comment issued by the Centers for Medicare and Medicaid Services (CMS) last week.

The Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), is a quality payment incentive program for physicians and other eligible clinicians that rewards value and outcomes in one of two ways: through the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

A QPP Year 2 fact sheet issued by CMS highlights 2018 changes for providers under the QPP’s MIPS and APM tracks. The Year 2 fact sheet noted that stakeholder feedback helped to shape policies for QPP Year 2, and that  “CMS is continuing many of its transition year policies while introducing modest changes.”

In keeping with the federal payor’s recently launched “Patients Over Paperwork” initiative, QPP Year 2 reflects the following changes:

    • More options for small practices (groups of 15 or fewer clinicians). Options include exclusions for individual MIPS-eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries, opportunities to earn additional points, and the choice to form or join a virtual group.
    • Addresses extreme and uncontrollable circumstances, such as hurricanes and other natural disasters, for both the 2017 transition year and the 2018 MIPS performance period, by offering hardship exception applications and limited exemptions.
    • Includes virtual groups as another participation option for Year 2. A virtual group is a combination of two more taxpayer identification numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together ‘virtually’ (no matter specialty or location) to participate in MIPS for a performance period of a year. A CMS Virtual Groups Toolkit provides more information, including the election process to become a virtual group.
    • Makes it easier for clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end in the middle of a year. Updated QPP policies for 2018 further encourage and reward participation in APMs in Medicare.
  • CMS describes its Patients Over Paperwork effort as “a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies and improve the beneficiary experience. This effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients.”

    Healthcare Hotwire: Care Coordination

    November 2nd, 2017 by Melanie Matthews

    Care coordination organizes patient care activities and information for safer and more effective care.

    Care coordination involves deliberately organizing patient care activities and sharing information among all vested participants to achieve safer and more effective care, per the Agency for Healthcare Research and Quality (AHRQ).

    These patient care activities span all care settings, including the patient’s home, according to the Healthcare Intelligence Network’s Benchmark Survey on Care Coordination.

    Initiatives aimed at coordinating care for high-risk patients are reporting healthcare cost savings, reductions in expensive sites of care and improvements in quality, outcomes and patient satisfaction.

    In the new edition of Healthcare Hotwire, you’ll get details on enhanced care coordination Medicare savings, reducing emergency department utilization through care coordination and the impact of care coordination efforts on patient and provider satisfaction.

    HIN’s newly launched Healthcare Hotwire tracks trending topics in the industry for strategic planning. Subscribe today.

    2016 ACO Results: Majority of Next Generation and Pioneer ACOs Earn Shared Savings

    October 20th, 2017 by Patricia Donovan

    Six of eight Pioneer ACOs and eleven of eighteen Next Generation ACOs earned shared savings in separate initiatives in 2016, according to newly released quality and financial data from the Centers for Medicare and Medicaid Services (CMS).

    In 2016 Performance Year Five of the Pioneer ACO program, one of several new accountable care organization (ACO) payment and service delivery models introduced by CMS to serve a range of provider organizations, only Monarch HealthCare and Partners HealthCare were not among shared savings earners.

    Banner Health Network emerged as the top 2016 Pioneer ACO performer, earning nearly $11 million in shared savings based on care provided to its more than 42,000 beneficiaries.

    In order to receive savings or owe losses in a given year, Pioneer ACO expenditures must be outside a minimum corridor set by the ACO’s minimum savings rate (MSR) and minimum loss rate (MLR).

    The Pioneer ACO model is designed for healthcare organizations and providers already experienced in coordinating care for patients across care settings. It allowed these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with but separate from the Medicare Shared Savings Program (MSSP).

    The Pioneer ACO Model began with 32 ACOs in 2012 and concluded December 31, 2016 with eight ACOs participating.

    Meanwhile, at the conclusion of 2016 Performance Year One of the Next Generation ACO model, Baroma, Triad and Iowa Health topped the list of ACO earners in this program, with each organization accumulating more than $10 million shared savings.

    Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program, CMS’s Next Generation ACO Model sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.

    According to a CMS fact sheet, 18 ACOs participated in the Next Generation ACO Model for the 2016 performance year, and 28 ACOs are joining the Model for 2017, bringing the total number of Next Generation ACOs to 45. The Next Generation ACO Model will consist of three initial performance years and two optional one-year extensions.

    CMS’s ACO models are one of seven Innovation categories designed to incentivize healthcare providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality and efficient service delivery.

    Patient Engagement Prerequisite: School Staff in Patient Activation, Health Literacy

    October 19th, 2017 by Patricia Donovan

    YNHHS embedded care coordinationEven after multiple years of patient engagement education, awareness training and related programming for its clinicians, PinnacleHealth Systems knew those efforts needed to continue if they were to move forward with new interventions. Here, Kathryn Shradley, director of population health, PinnacleHealth System, describes two key focus areas for clinician education.

    We wanted to level-set on the definitions of patient activation and health literacy and what these terms meant to the organization and to the teams within. In full transparency, I want to be very clear: I believe initiatives for health literacy, patient engagement, patient education and population health will be on our task list for as long as I’m employed, and that’s okay.

    We spent a lot of time educating front-line clinicians on health literacy, understanding who was using the Patient Activation Measure® (PAM®) and tools and attempting to broaden the language used around the health system. One of our initial goals was simply to have the words ‘health literacy’ be recognized and understood throughout the system. This is certainly still something we work on daily as a core piece of all of our engagement strategies. I’m happy to say that we have made progress.

    One of the ways we obtained buy-in for our patient engagement strategy was to talk about the financial bottom line of low levels of patient activation and low levels of patient health literacy. We demonstrated to our executive teams, directors and managers that no matter where they were building an initiative and what they were building, if they didn’t include an engagement strategy in their product or service line, they were likely to experience difficulty—a difficulty that could otherwise be mitigated if we addressed some of these issues in their programs.

    Source: Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians

    patient engagement

    Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians describes PinnacleHealth’s two-pronged strategy for prioritizing patient engagement among its clinicians and patient population, tactics that elevated key quality and clinical metrics in the process.

    Cityblock Health to Open First ‘Neighborhood Health Hub’ for Underserved Urban Populations in NYC

    October 6th, 2017 by Patricia Donovan

    Cityblock Health neighborhood health hubs for underserved urban populations: “Where health and community converge.”

    Cityblock Health expects to open its first community-based clinic for underserved urban populations, known as a neighborhood health hub, in New York City in 2018, according to a Medium post this week by Cityblock Health Co-Founder and CEO Iyah Romm.

    Cityblock Health is a spinout of Sidewalk Labs focused on the root causes of health for underserved urban populations. Sidewalk Labs is an Alphabet company focused on accelerating urban innovation.

    The neighborhood health hub, where members can connect with care teams and access services, is one of several key member benefits outlined on the Cityblock Health web site. Other advantages include a personalized care team available 24/7, a personalized technology-supported Member Action Plan (MAP), and a designated Community Health Partner to help members navigate all aspects of their care.

    According to Romm, who brings a decade of healthcare experience to the initiative, the neighborhood hubs will be designed as visible, physical meeting spaces where health and community converge. Caregivers, members, and local organizations will use the hubs to engage with each other and address the many factors that affect health at the local level, Romm said.

    For example, Cityblock Health states it will offer members rides to the hub if needed. Transportation, care access, and finances are among multiple social determinants of health that drive health outcomes, particularly for populations in urban areas.

    Where possible, the hubs will be built within existing, trusted spaces operated by its partners and staffed with local hires, he added. Cityblock envisions offering a range health, educational, and social events, including support groups and fitness classes.

    The hubs are part of Cityblock Health’s larger vision to provide Medicaid and lower-income Medicare beneficiaries access to high-value, readily available personalized health services in a collaborative, team-based model, Romm explained in his post. The organization will partner with community-based organizations, health plans, and provider organizations to reconfigure the delivery of health and social services and apply “leading-edge care models that fully integrate primary care, behavioral health, and social services.”

    Three key health inequities related to underserved urban populations motivated the formation of Cityblock Health: disproportionately poor health outcomes, interventions coming much later in the care continuum, and the significantly higher cost of interventions in urban areas as compared to other populations.

    Cityblock Health will use its custom-built technology to enhance strong relationships between members and care teams, while simultaneously empowering and incentivizing the health system to do better, he added.

    Data Analytics, SDOH Screenings Flag Disengaged and 12 More Patient Engagement Trends

    October 5th, 2017 by Patricia Donovan

    More than 70 percent of healthcare organizations have created formal patient engagement initiatives, according to 2017 benchmarks from the Healthcare Intelligence Network.


    To identify individuals that are poorly engaged in their health, nearly two-thirds (63 percent) of healthcare organizations mine clinical data analytics, according to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network, while 37 percent screen patients for social determinants of health related to housing, care access, transportation, nutrition and finances.

    Patients who screen positive for social determinants of health (SDOH) and individuals with diabetes are typically the most difficult populations to engage, according to 2017 survey benchmarks.

    Thirty-five percent of respondents to the September 2017 survey said the presence of SDOHs, which the World Health Organization defines as “conditions in which people are born, grow, live, work and age,” pose the greatest challenge to health engagement, while 26 percent said a diabetes diagnosis presents the top clinical challenge to engagement interventions.

    One-quarter report some resolution of SDOH factors resulting from engagement efforts.

    To improve engagement, 75 percent of respondents rely on education of patients, family and caregivers, supported with telephonic outreach (13 percent) and home visits (13 percent).

    Efforts by 71 percent of respondents to create a formal patient engagement program underscore the critical role of engagement in healthcare’s value-based care and reimbursement models, particularly in regards to chronic illness.

    In other survey findings:

    • Patient experience rankings are the most reliable measure of engagement program success, say 43 percent.
    • For one quarter of respondents, patient engagement is the primary domain of case managers.
    • Eighty-three percent saw quality metrics improve as a result of patient engagement efforts.
    • Half attributed a drop in hospital emergency room visits to their patient engagement interventions.

    Download an executive summary of the 2017 Patient Engagement Survey.

    Empathy Interviewing Elicits Patient’s ‘Story,’ Uncovers Social Determinants of Health

    September 26th, 2017 by Patricia Donovan

    social determinants of health

    Healthcare must mitigate patient risk factors outside of the hospital, referred to as social determinants of health (SDOH).

    If healthcare hopes to move the needle on runaway expenses and improve the health of its communities, it must first focus on patients’ social and environmental circumstances, also known as social determinants of health (SDOH).

    That’s the advice of Cindy Buckels, director of population health for TAV Health, which helps healthcare organizations navigate the challenges of SDOHs.

    “When we don’t address these issues as we’re addressing someone’s health, we get high readmissions, negative outcomes and dissatisfaction. There’s also increased cost and increased risk,” noted Ms. Buckels during Social Determinants of Health: Using Empathy Interviewing To Help Care Teams Understand Factors Impacting Patient Health, a September 2017 webinar now available for rebroadcast.

    To encourage individuals to open up about economic, educational, nutritional, or community deficits they face that drive 60 percent of their health outcomes, TAV Health recommends care teams employ empathy interviewing, also known as motivational interviewing (MI).

    “With motivational interviewing, you’re entering into a relationship with a person, not as the expert, but as a partner coming alongside to help them find their own strengths, and affirming them as a person in order to affect positive change,” said Ms. Buckels. Her presentation included a review of the four core skills of motivational interviewing (“Listen for that positive nugget,” she urges), as well as ‘back pocket’ questions to ask when the conversation stalls.

    Finally, she outlined traps for care teams to avoid during an MI session, such as the urge to give advice. “Always ask permission to give information or advice. Don’t just assume that’s something that you can do, because you’ve picked up the phone and called them.”

    It may take time to master, but ultimately, motivational interviewing is more effective than healthcare’s typical “Chunk-Check-Change” education approach in transforming patient ambivalence and effecting positive behavior change, she said.

    Information gleaned from motivational interviewing, even minor details like a patient’s nickname or the presence of a cherished pet, should become part of the patient’s record so that every person along the care continuum who ‘touches’ that patient can access it.

    “For example, if a patient’s legal name is Charlene, but she goes by Michelle, if you really want to build a relationship with her and gain her trust, you start by calling her what she goes by, which is Michelle.”

    In closing, Ms. Buckels outlined a patient-centric workflow connecting all supportive organizations, healthcare providers, community organizations and family and friends within the patient’s circle of care, which places more eyes and ears on the individual. With communal oversight to report anything worrisome, the likelihood is much less that a socially supported patient will visit the ER or be admitted to the hospital.

    Listen to Cindy Buckels explain the advantages of motivational interviewing over the “Chunk-Check-Change” educational approach.

    SNF Visits to High-Risk Patients Break Down Barriers to Care Transitions

    September 21st, 2017 by Patricia Donovan

    For patients recently discharged from the hospital, a SNF visit covers the same ground as a home visit: medications, health status, preparing for physician conversations and care planning.

    The care transitions intervention developed by the Council on Aging (COA) of Southwestern Ohio for high-risk patients starts off in the hospital with a visit by an embedded coach, and includes a home visit.

    Additionally, to reduce the likelihood of a readmission, patients discharged to a skilled nursing facility (SNF) also can expect a COA field coach to stop by within 10 days of SNF admission. Here, Danielle Amrine, transitional care business manager for the COA of Southwestern Ohio, describes the typical SNF visit and her organization’s innovative solution for staffing these visits.

    We conduct the home visit within 24 to 72 hours. We go over medication management, the personal health record (PHR), and follow-up with specialists and red flags. At the SNF, we do the same things with those patients, but in regards to the nursing facility: specifically, do you know what medications you’re taking? Do you know how to find out that information, especially for family members and caregivers? Do you know the status of your loved one’s care at this point? Do you know the right person to speak to about any concerns or issues?

    We also ask the patients to define their goals for their SNF stay. What are your therapy goals? What discharge planning do you need? We set our SNF visit within 10 calendar days, because normally within three days, they’ve just gotten there. They’re not settled. There haven’t been any care conferences yet. We set the visit at 10 calendar days to make sure that everything is on track, to see if this person is going to stay at the SNF long-term. Our goal is to have them transition out. We provide them with all of the support, resources and program information to help them transition from the nursing facility back to independent living.

    For our nursing facility visits, we also utilize the LACE readmissions tool (an index based on Length of stay, Acute admission through the emergency department (ED), Comorbidities and Emergency department visits in the past six months) to see if that person would need a visit post-discharge.

    For our CMS contract, we are paid for only one visit. Generally we’re only paid for the visit we complete in the nursing home, but through our intern pilot, our interns do that second visit to the home once the patient is discharged from the nursing home. We don’t pay for our interns, and we don’t get paid for the visit. We thought that was a perfect match to impact these patients who may have a hard time transitioning from the nursing facility to home.

    Source: Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

    home visits

    In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) of Southwestern Ohio, describes her organization’s home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

    SDOH Video: Tackling the Social, Economic and Environmental Factors That Shape Health

    September 7th, 2017 by Patricia Donovan

    Initiatives 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 known as social determinants of health (SDOH) that shape an individual’s health.

    This video from the Healthcare Intelligence Network highlights how healthcare organizations address SDOH factors, based on benchmarks from HIN’s 2017 Social Determinants of Health Survey.

     

     

    Source: 2017 Healthcare Benchmarks: Social Determinants of Health

    SDOH benchmarks

    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. These metrics are compiled from responses to the February 2017 Social Determinants of Health survey by the Healthcare Intelligence Network.

    PinnacleHealth Engagement Coaches Score Points with High-Risk Patients, Win Over Clinicians

    September 7th, 2017 by Patricia Donovan

    PinnacleHealth’s targeted outreach, 24/7 nurse advice line and clinician coaching have helped to bring chronic disease high utilizers back to care.

    A dual engagement strategy by PinnacleHealth System that recruits both patients and providers is scoring significant gains in CAHPS® scores, clinical indicators in high risk patients, and the provision of health-literate care.

    Kathryn Shradley, director of population health for PinnacleHealth System, outlined her organization’s patient engagement playbook during A Two-Pronged Patient Engagement Strategy: Closing Gaps in Care and Coaching Clinicians, an August 2017 webcast now available from the Healthcare Intelligence Network training suite.

    The winning framework? Focused outreach and health coaching for high-risk, high utilizers that break down barriers to care, and a patient engagement coach to advise PinnacleHealth clinicians on the art of activating patients in self-management.

    PinnacleHealth’s engagement approach, aligned with its population health strategies and based on the Health Literate Care Model, began in its ambulatory and primary care arenas. Before any coaching began, the health system schooled its staff on the value of health literacy. “Moving to a climate of patient engagement is nothing short of a culture change for many of our clinicians,” said Ms. Shradley.

    To foster leadership buy-in, PinnacleHealth also strove to demonstrate bottom-line benefits of patient engagement, including lowered costs and staff turnover and increased standing in the community.

    Then, having combed its registry to identify about 1,900 chronic disease patients most in need of engagement, the health system hired a health maintenance outreach coordinator who built outreach and coaching pilots designed to break down barriers to care. At the end of the six-month pilot, higher engagement and lower A1C levels were noted in more than half of these patients. For the 23 percent that remained disengaged, the outreach coordinator dug a little deeper, uncovering additional social health determinants like transportation they could address with more intensive coaching and even home visits.

    At the same time, a new 24/7 nurse advice line staffed with PinnacleHealth employees continued that coaching support when the health coach was not available.

    Complementing this patient outreach is a patient engagement coach, a public health-minded non-clinician that guides PinnacleHealth providers in the use of tools like motivational interviewing and teach-back during patient visits to kindle engagement.

    “The engagement coach does a great job of standing at the elbow with our providers in a visit, outside of a visit, surrounding a visit, to talk about what life looks like from the patient side of view.”

    Providers and staff receive one to two direct coaching sessions each year, with additional coaching available as needed.

    With other elements of its patient engagement approach yet to be implemented, PinnacleHealth has observed encouraging improvements in HCAHPS scores for at least one practice that received coaching over seven months. It has also learned that by educating nurses on health-literate care interventions, it could increase HCAHPS communication scores.

    Listen to an interview with Kathryn Shradley: PinnacleHealth’s Patient Engagement Coach for Clinicians: Supportive Peer at Provider’s Elbow.