Archive for the ‘Case Management’ Category

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.

18 Success Strategies from Seasoned Healthcare Case Managers for New Hires

September 14th, 2017 by Patricia Donovan

Advice from case management trenches: “Don’t do more work for your patient than they are willing to do for themselves.”

What does it take to succeed as a healthcare case manager? For starters, patience, flexibility and mastery of motivational interviewing, say veterans from case management trenches.

As part of its 2017 Healthcare Benchmarks Survey on Case Management, the Healthcare Intelligence Network asked experienced case managers what guidance they would offer to new hires in the field. Respondents were thoughtful and generous with their advice, highlights of which are shared here.

It’s important to note that in total, a half dozen veterans identified motivational interviewing as an essential case management skill.

We hope you find these tips useful. We invite all experienced case managers to add your tips in the Comments below.

  • “It’s hard work but satisfying. It takes a good year to get all resources and process, so don’t give up.”
  • “Learn the integrated case management model and get ongoing coaching in motivational interviewing.”
  • “Listen, think, develop, coordinate, adhere to plan benefits, and be honest.”
  • “Communicating and developing a relationship with members are key.”
  • “Be aware of and utilize telemedicine.”
  • “Be prepared to help patients with non-medical matters. Develop a trust bond, almost as a family member, and your medical-focused concerns will be that much easier to handle.”
  • “Always remain flexible. Listen and meet the patient where they are at in their disease and life process.”
  • “Understand both the clinical and financial impacts of healthcare on the patient.”
  • “Establish a good working relationship with your manager. Ensure you understand job expectations and identify a mentor.”
  • “Time management is crucial.”
  • “Stay visible within the practice; interact regularly with the care team; share examples of success stories.”
  • “Compassion and empathy are a must.”
  • “Don’t become overwhelmed by all that needs to be learned. Strive for sure and steady progress in gaining the knowledge needed.”
  • “Don’t let a fear of the unknown hold you back. Learn all that you can.”
  • “Get a good understanding of the population of patients you are working with. Study motivational interviewing and harm reduction.”
  • “This is a wide body of knowledge. Each case is different. It takes six months to a year to be fully comfortable in the practice.”
  • “Establish boundaries with your patients, and don’t do more work for your patient than they are willing to do for themselves.”
  • “Earn the trust of your patients and providers. LISTEN to your patients.”

One respondent geared her advice to case management hiring managers:

  • “Hire for coaching mentality and chronic disease experience.”

Excerpted From: 2017 Healthcare Benchmarks: Case Management

2017 case management benchmarks

2017 Healthcare Benchmarks: Case Management provides actionable information from 78 healthcare organizations on the role of case management in the healthcare continuum, from targeted populations and conditions to the advantages and challenges of embedded case management to CM hiring and evaluation standards. Assessment of case management ROI and impact on key care components are also provided.

HINfographic: Case Management Trends: Face-to-Face Patient Encounters Edge Out Telephonic

September 6th, 2017 by Melanie Matthews

As integrated care management takes hold, patients are much more likely to interact with a case manager at their healthcare provider’s office today than they were four years ago, say respondents to the 2017 Case Management Survey by the Healthcare Intelligence Network. The embedding or colocating of case managers within points of care rose from 54 percent in 2013 to 66 percent this year, the survey found.

A new infographic by HIN examines the top case manager-patient interactions, case management monthly caseloads, details on return on investment for case management programs and more case management trends.

At the point of care or behind the scenes, care coordination by healthcare case managers helps to elevate clinical, quality and financial outcomes in population health management and chronic care, the all-important hallmarks of value-based care.

2017 Healthcare Benchmarks: Case Management provides actionable information from 78 healthcare organizations on the role of case management in the healthcare continuum, from targeted populations and conditions to the advantages and challenges of embedded case management to CM hiring and evaluation standards. Assessment of case management ROI and impact on key care components are also provided.

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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.

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.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

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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.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today. Have an infographic you’d like featured on our site? Click here for submission guidelines.

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.