Archive for the ‘Care Coordination’ Category

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.

MSKCC Integrated Case Management Enhances Efficiency, But Never At Patients’ Expense

August 29th, 2017 by Patricia Donovan

MSKCC’s service-based interdisciplinary team adheres to the four C’s of team-based care.

With a reputation synonymous with state-of-the-art cancer care, Memorial Sloan Kettering Cancer Center (MSKCC) shouldn’t have much to prove.

But like most healthcare providers, with the dawn of value-based care, MSKCC began to face tougher competition from hospitals with managed care contracts and limited networks. To attract and retain payors, MSKCC had to demonstrate that its care was both cost-effective and cost-efficient.

“Under managed care, you had to be able to prove your worth,” explains Laura Ostrowsky, MSKCC’s director of case management. “And worth was more than just best care, it was best care in a quality-effective manner.”

To accomplish this, MSKCC adopted a multidisciplinary, team-based care coordination approach, Ms. Ostrowsky explained during Integrated Case Management: A New Approach to Transition Planning, an August 2017 webinar now available as an on-demand rebroadcast.

Transition planning used to be referred to as discharge planning, she noted.

Integrated case management is at the heart of MSKCC’s service-based strategy, with MSKCC case managers  assigned by service. “That means that if a case manager is based on the tenth floor, which houses breast and GYN services, and one of those patients is in the ICU, they’re still being followed by the breast or GYN case manager.”

The variety of care settings is one of a half dozen reasons integrated case management is necessary, Ms. Ostrowsky added.

Communication among all team members is key, she continued, outlining the four ‘C’s’ of team-based care—so much so that some scripting has been created to keep all team members on message with patients.

However, a commitment to standards in communication and other areas should never override a patient’s need. “The clinical issues should always take priority,” Ms. Ostrowsky emphasized.

A day in the life of an MSKCC inpatient integrated case manager runs the gamut from reviewing and assessing new patients to orchestrating transition planning. “Our patients go out with all kinds of services, from infusion care to home chemotherapy to wound VACs.” Some patients are transferred to post-acute facilities, while others face end-of-life issues that include hospice care, which could be inpatient or home.

Hospice care was one area of focus for MSKCC—in particular, getting providers to speak frankly with patients about hospice and incorporating those services earlier on in the patient’s diagnosis when appropriate, both of which required a cultural shift. “Our patients didn’t come to Memorial to be told that there’s nothing that we can do for them,” she explained. “And our doctors didn’t come to work at Memorial to send people to hospice. They came here to cure cancer.”

In taking a closer look at end-of-life services, Ms. Ostrowsky found that physicians tended to refer to hospice later than she hoped that they would. “I wanted to really look at our length of stay in hospice as a way of identifying the timeliness of referral.” A longer hospice stay allows the patient to form relationships with their hospice caretakers rather than feeling abandoned and “left to die,” concluded Ms. Ostrowsky.

By placing case managers in inpatient areas and encouraging key case management-provider conversations that she shared during the program, MSKCC improved hospice referral timeliness and grew hospice length of stay. In turn, these quality improvements correlated with higher patient (and family) satisfaction.

Integrated case managers have also been key in identifying patients who can benefit from LTACH services and moving them there sooner, she added. “We can decrease length of stay within the hospital and get [patients] that kind of focused care that they need sooner.”

Listen to Laura Ostrowky describe the surprise question that can improve timeliness of hospice referrals.

Food for Thought: Nutrition Programs Reduce Hospital Visits and Readmissions by Vulnerable Populations

August 18th, 2017 by Patricia Donovan

Malnutrition is a social determinant of health that negatively impacts health outcomes.

It’s a difficult statistic to digest: one in three people enter the hospital malnourished or at risk of malnutrition, a state that impacts their recovery and increases their risk of health complications and rehospitalizations.

Two studies this week highlight the clinical benefits of addressing patients’ nutrition needs before and during hospital stays as well as savings that can result from identification of social determinants of health (SDOH) like access to nutrition that drive 85 percent of health outcomes.

In the first, a study of elderly Maryland residents by Benefits Data Trust, a national nonprofit based in Philadelphia, found that when it comes to low-income seniors, access to quality food via food stamps can also save money by reducing the number and duration of hospital visits and nursing home admissions.

In the second, research published in American Health & Drug Benefits journal and supported by Abbott found that when Advocate Health Care implemented a nutrition care program at four of its Chicago area hospitals, it showed more than $4.8 million in cost savings due to shorter hospital stays and lower readmission rates.

The Benefits Data Trust research found that participation by low-income seniors in the federal Supplemental Nutrition Assistance Program (SNAP) cut their odds of hospital admissions by 14 percent. The food stamps also reduced the need for ER visits by 10 percent, and cut their likelihood of going into a nursing home by nearly one quarter.

Finally, SNAP participation also led to an 8 to 10 percent drop in the number of days a patient who was admitted remained in one of these facilities.

As a result, hospitals and health care systems such as Advocate Health Care are looking at the value of nutrition to improve care and help patients get back to living a healthier life.

Starting in 2014, Advocate Health Care, the largest health system in Illinois and one of the largest accountable care organizations (ACO) in the country, implemented two models of a nutrition care program for patients at risk of malnutrition. The nutrition-focused quality improvement program, which targeted malnourished hospitalized patients, consisted of screening patients with a validated screening tool at admission, rapidly administering oral nutritional supplements, and educating patients on supplement adherence.

The leader in population health found that by doing so, it reduced 30-day readmission rates by 27 percent and the average hospital stay by nearly two days.

More recently, to evaluate the cost-savings of the Advocate approach, researchers used a novel, web-based budget impact model to assess the potential cost savings from the avoided readmissions and reduced time in hospital. Compared to the hospitals’ previous readmission rates and patients’ average length of stay, researchers found that optimizing nutrition care in the four hospitals resulted in roughly $3,800 cost savings per patient treated for malnutrition.

Given the healthcare industry’s appetite for value- and quality-based programs, SDOH screenings and the fortification of nutrition programs in both community and inpatient settings appear to be just what the doctor ordered. However, while a 2017 study on Social Determinants of Health identified widespread adoption of SDOH screenings by providers, it also documented a scarcity of supportive community services for SDOH-positive individuals.