Archive for the ‘Case Management’ 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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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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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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Home Visits Validate Predictive Analytics and 10 More 2016 Risk Stratification Trends

August 30th, 2016 by Patricia Donovan

Assuring data integrity is the top challenge to health risk stratification, according to a July 2016 healthcare benchmarks survey.


Two key trends emerging from a July 2016 survey on Stratifying High-Risk Patients highlight the need to occasionally eschew sophisticated tools in favor of basic, face-to-face care coordination.

As one survey respondent noted, “A key element [of stratifying high-risk patients] is building a trusting face-to-face relationship with each patient, knowing what they want to work on, coaching them and activating them.”

The first learning gleaned from the survey’s 112 respondents is that, despite the prevalence of high-end risk predictors, algorithms and monitoring tools, clinicians must occasionally step into the patient’s world—that is, literally enter their home—in order to capture the individual’s total health picture.

Fifty-six percent of respondents make home visits to risk-stratified patients; a half dozen identified the home visit as its most successful intervention for risk-stratified populations.

That inside look at the patient environment illuminates data points an electronic health records (EHRs) might never bring to light, including socioeconomic factors like limited mobility that could prevent a patient from keeping a follow-up appointment.

“I never know until the moment I enter the home and actually see what the environment is like whether we correctly predicted the need for high intervention (and get a return on it),” commented one respondent.

The second trend in risk stratification is the emerging laser focus on ‘rising risk’ patients, an activity reported by 72 percent of respondents. This scrutiny of rising risk populations helps to prevention their migration to high-risk status, where complex and costly health episodes prevail.

Other data points identified by the 2016 Stratifying High-Risk Patients survey include the following:

  • Almost four-fifths of 2016 respondents have programs to stratify high-risk patients, and the infrastructures of more than half of these initiatives utilize clinical analytics, predictive algorithms, EHRs and other IT tools to manage care for high-risk patients.
  • The reigning health risk calculator continues to be the LACE tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits), used by 45 percent in 2016, versus 33 percent two years ago.
  • For more than a quarter of 2016 respondents, assuring data integrity remains a key challenge to risk prediction.
  • A case manager typically has primary responsibility for risk stratification, say 52 percent of respondents.
  • Diabetes is the most prevalent clinical condition among high-risk patients, say 47 percent.
  • At least 70 percent report reductions in hospitalizations and ER visits related to risk stratification efforts.
  • Improvement in the highly desirable metric of patient engagement is reported by 74 percent of respondents.

Click here to download an executive summary of survey results: Stratifying High-Risk Patients in 2016: As Risk Prediction Prevails, Industry Eyes Social Determinants, Rising Risk.

AMITA Health Connected Care Management: Patients Transitioned But Never Really Discharged

August 23rd, 2016 by Patricia Donovan

Connected care includes AMITA Health front line staff, administrators, physicians, hospital executives and community partners.


Does a health system really need four types of care managers?

When AMITA Health set out to craft an ambulatory care coordination team for its highest-risk Medicare beneficiaries, it realized it didn’t.

As part of its thirteen-point plan to revamp care management across its continuum, the newly minted Medicare Shared Savings Program (MSSP) accountable care organization (ACO) reexamined the roles of its navigators, case managers, patient-centered home care managers and ACO care managers, ultimately abandoning its siloed approach in favor of a more human-centric model of care.

“We really needed a better way to care for our patients across the continuum,” explained Susan Wickey, vice president, quality and care management at AMITA Health, during Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care Management Strategy, an August 2016 webinar now available for replay. “We had to identify and remove those silos, and break down those barriers.”

AMITA Health’s decision to remake care management was a response to its MSSP program goal of fulfilling the Triple Aim: improving population health and experience of care while fostering appropriate utilization and cost. The initiative in no way devalued care managers’ contributions. “Our care coordinators across the continuum serve as our first responders when high risk patients need intervention,” said Ms. Wickey.

In the process of improving efficiencies, the nine-hospital system discovered that often, one could be more effective than four.

With help from Phillips Healthcare Consulting Division, AMITA inventoried its care management resources, then created a single centralized care management hub. Communication would occur via a single universal transfer form for each patient, for whom a single care plan would be developed. This power of one echoed throughout the transformation as AMITA restructured processes and programs.

AMITA rolled out the program initially with one unit of patients; today, all nine of AMITA Health’s hospitals operate with some component of this enterprise-wide redesign.

“We wanted to be a health system where our patients were transitioned but never really discharged from our healthcare system,” explained Ms. Wickey’s co-presenter, Dr. Luke Hansen, vice president and chief medical officer, population health for AMITA Health. “We never discharge a patient from our system; rather we transition our patients to the most appropriate setting.”

“This collaborative vision of connected care includes all of the front line staff, key administrators, physicians, hospital executives, along with AMITA’s community partners,” added Ms. Wickey.

In assessing its MSSP experience, Dr. Hansen said access to Medicare claims data enabled AMITA Health to track utilization, a first for the organization. Trends toward lower all-cause readmissions, lower admissions for ambulatory-sensitive conditions and emergency department visits were recorded, he said. And while he can’t definitely credit the MSSP for his organization’s improved quality scores in recent years, he takes pride in AMITA’s achievements of strengthening quality while holding costs relatively stable.

However, improvements have leveled off since 2013, its first MSSP performance year, which frustrates the population health CMO. “As those of you participating in MSSP know, year-over-year improvement is what you need to do to succeed.”

“We live that tension between our old models of care delivery, which were very successful for our organization, and new models, which we will have to adopt in a timely way to be successful in the future,” concluded Dr. Hansen.

Click here for an audio interview with Dr. Hansen.

6 Population Health Strategies to Set Stage for Physician Reimbursement

May 12th, 2016 by Patricia Donovan

Robert Fortini, PNP

A team-based, top-of-license approach is key to population health success, says Robert Fortini, PNP, Bon Secours Medical Group chief clinical officer.

In the last six years, Bon Secours Medical Group (BSMG) has deployed a half-dozen population health strategies as groundwork for its Next Generation Healthcare offering. Here, Robert Fortini, PNP, BSMG chief clinical officer, identifies the tactics his organization leverages to effect health behavior change.

The specific population health strategies Bon Secours has deployed over the last six years start with the patient-centered medical home (PCMH) concept. I’m an avid believer in the concept of a team of professionals working together, along with that ‘top of license’ aspect, where it’s not just the sole domain of the independent ‘cowboy’ physician taking care of the patients. It’s pharmacists, nurses, social workers, and registered dietitians. It’s the entire team, with everyone having a vested responsibility for practicing to the top of his or her license.

Next, access is huge. It is ridiculous to think we can manage chronic disease in four 15-minute visits a year scheduled between 8 a.m. and 5 p.m. Monday through Friday, while closing at lunchtime. It’s absolutely ludicrous. We are blowing that up by opening weekends and evenings and using technology to expand access, which is critical to affecting that behavioral change.

Third, know your population. Identifying effectively those who are most at risk with advanced analytics to make your efforts more efficient is very important.

Next is managed care contracting—aggressively coming to the table with our payors to help guide the conversations and craft the contracts and benefit designs that are attainable and achievable. That has been a new experience for Bon Secours in the last five years in particular. We have a CMS-based Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) covering about 30,000 attributed lives. We also have a number of commercial ACO-type contractual relationships with our commercial payors.

Fifth on the list: aggressive growth for palliative and hospice. We have invested very significantly in management of advanced illness that occurs at the end of life. The Medicare numbers around that are staggering: 40 percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible. Investing in the resources necessary to manage that effectively has been our strategic initiative at Bon Secours. We have a very large, well-versed palliative program that provides inpatient, outpatient and even home-based palliative services. And our hospice agency, which I am responsible for in addition to our medical group, has quadrupled in size in the last two years alone.

Then, finally, we manage the white space with powered care coordination, which includes health promotion, chronic disease management, care transition management, and more.

Source: Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care Management Revenue and Results

http://hin.3dcartstores.com/Physician-Reimbursement-in-2016-4-Billable-Medicare-Events-to-Maximize-Care-Management-Revenue-and-Results_p_5143.html

Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care Management Revenue and Results details the ways in which Bon Secours Medical Group (BSMG) leverages a team-based care approach, expanded care access and technology to capitalize on four Medicare billing events: transitional care management, chronic care management, Medicare annual wellness visits and advance care planning.

HINfographic: Care Plans Put Healthcare Team on Same Page

April 13th, 2016 by Melanie Matthews

Though supporting technologies may vary, most healthcare organizations develop detailed, evidence-based, sharable care plans that follow high-risk patients through clinical episodes and transitions of care, with the goal of enhancing care quality and engagement and reducing spend, according to the 2015 Care Plans survey by the Healthcare Intelligence Network.

A new infographic by HIN examines how care plans are distributed and stored, how long patients’ care plans are tracked and the frequency of care plan tracking.

2016 Healthcare Benchmarks: Care PlansDetailed evidence-based care plans that follow high-risk patients through clinical episodes and transitions of care help these patients and their providers assess the level of care needed, evaluate services available and empower patients with goals of care, a strategy that impacts quality, outcomes and patient experience and engagement.

2016 Healthcare Benchmarks: Care Plans examines care plan utilization strategies and successes from more than 75 healthcare organizations responding to the November 2015 Care Plan survey by the Healthcare Intelligence Network. Click here for more information.

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Bon Secours Next Generation Healthcare: Smart Tools Tell Care Transitions, Chronic Care Management Stories

February 4th, 2016 by Patricia Donovan

Next Generation Healthcare smart tools facilitate Bon Secours care plans for care transitions, chronic care management and Medicare wellness visits.


A key component of chronic care management is a comprehensive plan of care—the “refrigerator copy” patients can refer to, explains Robert Fortini, PNP, chief clinical officer for Bon Secours medical Group (BSMG).

Today, using smart tools built into its electronic medical record, Bon Secours nurse navigators document twelve-point care plans for the 50 patients they have enrolled via Medicare’s year-old Chronic Care Management (CCM) codes—a number Fortini expects will double this month.

The CCM assessment tool also captures frequently forgotten issues such as depression, pain and sleep problems that can derail care, Fortini said in a recent webinar on Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning.

Bon Secours’ seventy nurse navigators, embedded in physician practices, also tap these point-and-click smart tools to document transitions of care for patients recently discharged from the hospital. This Transition of Care smart note tracks 17 different aspects of patient care, including risk of readmission and medication reconciliation, and includes a placeholder for an advance medical directive.

Similar tools are in use for Medicare’s three types of wellness visits, he added.

“I have been in this business a long time, and the documentation that navigators produce using these workflows is extraordinary,” Fortini noted. “This is purposeful design. It tells a story and you have something actionable at the conclusion of reading it.”

The smart tools are but one aspect of Bon Secours’ Next Generation Healthcare initiative, which Fortini defined as “population health meets total access.” Next Generation Healthcare fortifies the team-based medical home foundation Bon Secours introduced six years ago with expanded care access and technology, among other components the organization leverages to improve clinical outcomes and value-based reimbursement.

In the Next Generation Healthcare model, the primary care physician is the quarterback of care, with embedded nurse navigators doing the “heavy lifting” of enrolling at-risk patients into care management, building comprehensive care plans, and scheduling Medicare beneficiaries for annual wellness visits, Fortini explained.

Additionally, Bon Secours has broadened its care access menu to include employee clinics, fast care and urgent care sites, self-scheduling, and virtual visits for primary care. The organization expects to expand virtual visits to specialist consultations and behavioral health in the near future, and also envisions virtual case management visits, allowing nurse navigators to conduct real-time medication reconciliations with at-home patients.

To round out its Next Generation Healthcare continuum, Bon Secours is training a portion of nurse navigators as facilitators in a Virginia advance care planning initiative called “Honoring Choices,” with the goal of formalizing the placement of advance directives in patients’ records.

Investing in resources necessary to manage end-of-life effectively is a critical aspect of Bon Secours’ strategic initiative, Fortini concluded. “Forty percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible.”

Listen to an interview with Robert Fortini in which he describes how Bon Secours nurse navigators have won over solo practitioners.

Infographic: 7 Critical Steps in Caring for High-Need, High-Cost Patients

November 13th, 2015 by Melanie Matthews

Patients with multiple health problems, often referred to as high-need, high-cost patients, often need assistance with areas outside of the typical medical environment, such as housing and everyday tasks in managing their health, according to a new infographic by The Commonwealth Fund.

The infographic looks at seven key features of programs that are effective in managing these patients.

7 Critical Steps in Caring for High-Need, High-Cost Patients

Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team. Having demonstrated the team’s bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations chronicles AltaMed’s four-phase rollout of care coordination for dual eligibles—a population with higher hospitalization and utilization and care costs twice those of any other population served by AltaMed.

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HINfographic: Patient Engagement Tactics to Drive Satisfaction, Care Plan Adherence and Quality

October 19th, 2015 by Melanie Matthews

Today’s value-focused healthcare models theorize that engaged patients not only are healthier and more satisfied but also may generate fewer costs than the non-engaged. Whether patient engagement translates to a healthy bottom line remains to be seen. In the meantime, the inaugural Patient Engagement survey by the Healthcare Intelligence Network identified a range of tactics in use by 133 healthcare organizations to improve overall population health engagement.

A new infographic by HIN examines the types of tools healthcare organizations use to engage patients and drills down on the use of patient portals within patient engagement programs.

2015 Healthcare Benchmarks: Patient EngagementTransformational patient-centered models emerging post-ACA are designed to succeed with a core of engaged, activated patients, yet enlistment of individuals in chronic care management, telehealth and other health enhancement interventions continues to challenge the healthcare industry.

2015 Healthcare Benchmarks: Patient Engagement documents strategies, program components, successes and challenges of engaging patients and health plan members in self-care from 133 organizations responding to the 2015 Patient Engagement survey by the Healthcare Intelligence Network. Click here for more information.

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