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CMS to Release Stage 2 Meaningful Use proposals

February 27th, 2012 by Cheryl Miller

CMS and the Office of the National Coordinator for Health IT have just announced proposed regulations for Stage 2 Meaningful Use and Medicare and Medicaid EHR Incentive Programs.

Incorporating recommendations from the Health IT Policy Committee, they stress the need for hospitals and physicians to improve quality and efficiency through HIT. The rules focus on increasing the electronic capturing of health information in a structured format, and increasing the exchange of clinically relevant information between providers of care at so-called “care transitions.”

At this time of writing, some of the new Stage 2 recommendations will include the following: the percentage of orders entered via computerized physician order entry (CPOE) will rise from 30 percent to 60 percent and include medications, labs and radiology; E-prescribing in the emergency department will increase from 40 percent to 60 percent; and recording objectives, such as problem lists, vitals and smoking status will increase from 50 percent to 80 percent.

The proposed Stage 2 regulations will keep some Stage 1 criteria unchanged, revise others, and include new requirements. Once published in the Federal Register, there will be a 60 day comment period; these regulations are expected to be released this summer.

In related news, the use of HIT by hospitals and physicians has more than doubled in the last two years and CMS reports that nearly 2,000 hospitals and more than 41,000 doctors have received $3.1 billion in incentive payments for ensuring meaningful use of health IT, particularly certified EHRs. EHR incentive payments can total as much as $44,000 under the Medicare EHR Incentive Program and $63,750 under the Medicaid EHR Incentive Program.

Want to know the secrets to launching a successful ACO pilot program? Thomson Reuters has published a report showing four key metrics that can predict success; the first metric is the number of attributed members. The others are detailed in this issue.

And unfortunately, there is no secret formula to reducing avoidable hospitalizations; according to a new study from Delta Health Technologies, which was based on data from more than 1,000 homecare agencies across the U.S., while most agencies are taking steps to reduce avoidable hospitalizations, with patient care a strong concern, there was no one magic formula for success in this area. But there were a number of findings on successful hospitalization reduction strategies.

And don’t forget to participate in our latest e-survey: our third annual Healthcare Case Management survey. Participants receive a free, downloadable executive summary of the results once compiled.

Posted in Accountable Care Organizations, Avoidable ER Use, Case Management, Health IT, Healthcare Costs, Uncategorized, e-Health | No Comments »

Meet Health Coach Judith Beaulieu: Network of RN Health Coaches Empowers Women and Children

February 8th, 2012 by Cheryl Miller

This month’s inside look at a health coach, the choices he or she has made on the road to success, and the challenges ahead.

Excerpted from the February 2012 Health Coach Huddle.

Judith Beaulieu, RN, BSN, MIS, Health Coach, President and CEO of FEMTIQUE Associates, Incorporated

HIN: What was your first job out of college and how did you get into health coaching?

Judith Beaulieu: When I graduated from Widener College in 1978 I had already been working as a nurse aide on an oncology unit in a city hospital. After passing my state boards and becoming a registered nurse, I continued to work as an oncology nurse. It was during this experience that I encountered coaching the family members of patients. Most of it was comprised of emotional support encompassing the spiritual realm of life (and death). Coaching patients to use relaxation techniques for their pain and anxiety was included in their care plans. These are only a few of the many ways nursing utilized coaching patients and their families.

Have you received any health coaching certifications? If so, please list these certifications.

February 2012 will be the completion of my 40-week webinar graduate level certification curriculum in health coaching from Health Coach Alliance. The standards of practice as well as the board certification are based upon the International Coaching Federation (ICF) of which I am a member.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

The professional term “Health Coach” is only five years old in the United States. RNs have been health coaching when teaching patients, implementing care plans, hospital discharge instruction, grievance counseling, breastfeeding counseling, and so on for as long as the vocation of nursing has been in existence. When the health coach profession surfaced into existence as a separate entity, I jumped into searching the opportunities for RNs to become credentialed as Certified Nurse Health Coaches. I discovered that there were only a few programs out there specific to nurses and that most health coaches did not encompass the education nor experience to be able to best serve the consumer about health and wellness information. This was the ah ha moment that created FEMTIQUE Associates Incorporated.

In brief, describe your organization.

FEMTIQUE Associates, Incorporated is incorporated under the non-profit corporation law of 1988 as a ((501)(c)(3). We are a healthcare advocate and health coach organization providing health and wellness care information and resources for women and children. Our services are provided by professionals who have accrued knowledge and skills grounded in their professional education, clinical training, and experience with the aim of achieving and maintaining better health outcomes for those we serve.

What are two or three important concepts or rules that you follow in health coaching?

1: Our ability to hold attention on what is important for the client, and to leave responsibility with the client to take action.
2: To make plan adjustments as warranted by the coaching process and by changes in the situation.
3. Develop the client’s ability to make decisions, address key concerns, and develop himself/herself (to get feedback, to determine priorities and set the pace of learning, to reflect on and learn from experiences)

What is the single most successful thing that your company is doing now?

Providing financial aid to RNs that affords them an opportunity to become certified health coaches through Health Coach Alliance. Providing to the consumer the availability of qualified professionals that have an optimal level of health coach knowledge, experience and continuing education training is FEMTIQUE’s primary goal.

Do you see a trend or path that you have to lock onto for 2012?

Health communication and health information technology is congruent with one of the Healthy People 2020 objectives and the one that FEMTIQUE is positioned to lock onto in 2012. The FEMTIQUE Web site, Healthcare De-Mystified blog and tweets are aimed at providing helpful health and wellness information ranging from the physical, psychological, spiritual, social, financial, environmental, professional/vocational and academic realms of life.

What is the most satisfying thing about being a health coach?

Using an appropriate amount of time to devote to the client’s needs. The client is the only entity to which a private practice RN health coach devotes time and energy. One client at a time and one goal for the health coach to help the client formulate and strategize within a 60-minute coaching session. Spending the time necessary to effectively help consumers achieve health and maintain wellness is not available in the medical care arena.

Where did you grow up?

I spent my elementary years growing up as an only child in a small suburban town in Southeastern Pennsylvania. My parents sent me to a Catholic boarding school for my high school education. I loved it. Living with other girls supplemented for the lack of siblings. We were very close to each other.

What college did you attend? Is there a moment from that time that stands out?

When I graduated from high school I wanted to become a nurse so I applied to about three or four nursing schools. My high school advisor helped me to apply to two diploma programs and two college programs but there were waiting lists only. I ended up getting into Widener College six years after high school graduation. What stands out for me during this time was what I fit into the six years of waiting. The first year I went to a community college for secretarial studies and ended up working as a secretary while continuing to take college business courses in night school. These courses transferred into the nursing curriculum at Widener. I applied the typing skills learned as a secretary into typing term papers for other students in order to make extra money. The college did not permit nursing students to work full-time while in the BSN program.

Are you married? Do you have children?

I am happily married to Russell J. Beaulieu for 19 years. No children.

What is your favorite hobby and how did it develop in your life?

I love to garden. It has always been in my family starting with my late grandfather who came to America in the early 1900s, bought a plot of land and cultivated a huge garden. When my cousins and I were old enough, our grandfather would take us out to the garden and teach us how to pick ripe berries, fruit and vegetables. It cultivated a love of nature as well as a healthy diet. We were never overweight in our families. Today, I live within an Amish community where I share with other women within the Amish culture many healthy recipes made with vegetables that we all grow from our gardens.

Is there a book you recently read or movie you saw that you would recommend?

There are so many that I have enjoyed it is hard for me to say which one stands out. Biographies and autobiographies are my favorite types of literature. My heroes are people such as:
Life Without Limits by Nick Vujicic
Mother Teresa by Kathryn Spink
Steve Jobs by Walter Isaacson
Beauty Fades, Dumb is Forever by Judge Judy Sheindlin
The Woman Behind the New Deal by Kirstin Downey
My favorite movie of all times is “The Miracle Worker” which is the story about Helen Keller. And recently I went to see “The Help” which I loved! I laughed and cried.

Posted in Case Management, Health Coach Profile, Health Coaching, Uncategorized | 1 Comment »

Q&A: HRHC Diabetes Collaborative Relies on Tiered Care Management, Registries

January 23rd, 2012 by Jessica Papay

Patient care partners, innovative weight management tactics, patient registries and even telepsychiatry are part of the team approach to diabetes management at Hudson River HealthCare (HRHC) Diabetes Collaborative. The New York-based network of FQHCs finds that tiered care management generates the best outcomes for its patients with diabetes, explains Kathy Brieger, RD, CDE, HRHC’s chief operations officer, prior to her presentation on Diabetes Management in the Medical Home.

HIN: The Hudson River HealthCare (HRHC) Diabetes Coalition uses a patient-centered team approach to manage diabetes in its more than 3400 adult patients with the disease. HIN recently did a survey to find out about disease-focused programs in particular, those that manage diabetes. Our respondents told us that weight management is the most challenging aspect of this disease. Would you concur? If so, how does HRHC address weight management in its population?

(Kathy Brieger): I would agree with this. Weight management is one of the most challenging focuses of this condition. In order to meet this challenge, we’ve had to look at programs from a variety of aspects. We started walking clubs in some communities to encourage physical activity. There’s also a Taking off Pounds Sensibly group, which is a Weight Watchers format but at a lower cost for patients who may be at a low income. We’ve done programs on mindful eating and general ways of looking at portions. We’ve also done a lot of work related to children and preventions. I think this is a big target. We focus on prevention and giving people the options of attending a variety of program formats for weight loss.

HIN: Over the last 12-18 months we’ve seen that case managers are increasingly employed on site, in primary care practices, to assist with the management of chronic illness. Are there any case managers in the HRHC mix?

(Kathy Brieger): This is a key question to diabetes management. We’ve found that a team-based approach to care is really the most effective. We have several team members who help to case-manage the patients. And that includes everyone from a dietician to people called patient care partners. Patient care partners may not have a clinical license, but are trained in motivational interviewing and help to serve as a bridge between the clinical team and the patient. We also have sophisticated, high-level RN care managers who work in a targeted way with patients who have diabetes. Those are usually the patients who have comorbidities and who may have poor control over their diabetes. At Hudson River HealthCare, we look at a team-based approach using different levels of care to get the best outcomes. We find that that really is the most effective.

HIN: The more sophisticated care managers are for the sicker patients with comorbidities. How do you assign patients to the other two levels of management?

(Kathy Brieger): We have some reporting systems because we do have an electronic health record; we use eClinical Works® (ECW). We have different cutoffs for the care manager. We’ve run the registries. For people who have hemoglobin A1Cs of over 8 or 9, the care manager reviews them and she’ll pull off people who may have some of those indicators. Also, the medical providers will tell us, “This person may not have a hemoglobin A1C of over 8 or 9, but they’ve been in and out of the hospital several times.”

Right now, we’re also working with hospitals to get us hospital discharge summaries so we can see if those people who may have some unstable situations that we’re not aware of can be pulled in. For every single person who has diabetes, their care is also managed by the patient care partners. We taught them how to use the registries, how to call people in for group classes and how to send letters out for our programs. These levels are done in a three-tiered approach using the care team so that the patient care partner who is assigned to the care team, the nurse who is assigned to the care team and the provider assigned to the care team would together be able to route or send people to the right place. The bulk of our patients are able to do the low-level patient care part. It’s just the top 15 percent that are having some issues.

HIN: It sounds like registries are important to the program.

(Kathy Brieger): Yes, they are. Over 10 years ago, we started with the Patient Electronic Care System (PECS) as part of the federal government’s move to get a population health underway, but it was a limited standalone registry. And then about three years ago when we became fully electronic, we were able to get our registries and our reports done on all patients with all conditions, and that is valuable. We’ve done a lot of work on training our staff on how to use registries; it’s not so helpful just to have registries; you have to know how to use them.

We’ve tried to use registries as a teaching tool for everyone from even clinical assistants in training all the way up to the providers. They know how they can use it to have more effective team-based care, more effective disease-based focus, and even prevention of things like, “When did you get your mammogram done last?”

HIN: And finally, are there any applications in telehealth, telemedicine or remote monitoring that you are using successfully in the management of diabetes?

(Kathy Brieger): Yes. We’re involved with telemedicine, focusing on telepsychiatry at one site. We have purchased equipment and are right now getting it cabled for six different locations, so that we’ll be able to expand our services in the telemedicine area. We do have some sites that are located in remote areas. We are unable to get some specialists that may help in the management of diabetes. We think telemedicine will be a great resource in improving some access to services that may not be available in some of those remote areas. Even though we’re in New York, people think we have all types of access to specialists, but there are areas where they do not exist, even in New York. We’re looking forward to having that happen.

Posted in Case Management, Disease Management, Health IT, Patient-Centered Medical Home, Telehealth & Telemedicine, Wellness/Prevention, e-Health | No Comments »

Q&A: How Aetna Redefines Case Management for Medicare Population

January 12th, 2012 by Jessica Papay

The purpose of case management is care completion, states Dr. Randall Krakauer, Aetna’s Medicare medical director. Prior to his presentation on Demonstrating the Value of the Embedded Case Manager for the Medicare Population, Dr Krakauer discussed in detail the purpose of case management, the act of combining the capabilities of the physician and the health plan to create something new, and the enhanced patient experience that results from the medical home partnership between Aetna and Emory Healthcare.

HIN: What is the purpose of case management?

(Dr. Randall Krakauer): The purpose of case management is to assist members in the management of their own health. Case managers provide advice and assistance to make sure that patients understand what they need to do and that their questions are answered to engage their own risk factors and manage them better. Case managers help members to engage their own chronic conditions and to manage them more properly, and to better navigate the healthcare system to their own benefit.

HIN: What is care management at the provider level?

(Dr. Randall Krakauer): Better care management would involve the provision of additional resources at the provider level. This includes data (which may not be available to a provider) and longitudinal contact. Providers generally assume and accept responsibility for management of their own patients’ illnesses. They don’t always have all the data, however, and they sometimes don’t have the outreach for longitudinal follow-up case ability. For example, they don’t always know what other physicians are doing. They don’t always know what other medications are being prescribed. Patients get lost in follow-up. Patients don’t always follow instructions or fill their own prescriptions. They leave a physician’s office and don’t necessarily understand the instructions as well as they should. The purpose of case management is care completion. When a physician sees a patient in the hospital and writes a set of orders, he has a very high level of confidence that this will all get done. That’s not the case with outpatients seen in the office. The purpose of case management is to improve the ability to manage the cases in that milieu.

HIN: How can the capabilities and skill sets of the health plan be combined with those of the provider to create something greater than the sum of its parts?

(Dr. Randall Krakauer): The health plans generally engage in case management and disease management for a population that they identify through their own means or algorithms. They try to coordinate and collaborate with physicians’ offices to whatever extent is possible, frequently by telephone. Physicians are likewise trying to manage their own patients and this includes incoming calls and occasionally outgoing calls, plus other types of contact. They each have information and data that the other may lack. The physician has knowledge of the case, the family and the milieu that the health plan lacks. The health plan has claims information, its own process and transaction data for the individual case, and also global information on outcomes for the provider’s patients in general. We also have an expertise in longitudinal case management and the ability to provide people who will, with experience, outreach to members in between office visits.

Combining the capabilities of the physician and the health plan can create something greater than the sum of its parts; that is, the physicians can identify cases better that could be in need of case management. Physicians, in collaborating with case managers, can give case managers instructions on types of follow-ups that are necessary. Case managers can provide physicians with information, transactions, etc. For example, “This patient left your office. What has happened that you should know about that requires your attention?” Or, “Your heart failure patient has put on a kilogram and a half of weight in one week.” “This prescription was not filled.” It is this interchange, exchange and collaboration that has the potential for creating something that is better.

HIN: Aetna recently announced a partnership with Emory Healthcare and a patient-centered primary care program that will use embedded case managers. You were quoted as saying that this medical home partnership would improve the patient experience. Can you describe how this will happen?

(Dr. Randall Krakauer): In collaborating with the Emory physicians and their staff, we will be able to keep in contact with our members, and/or their patients, when they leave the office to answer questions, to follow up on health issues, to follow up on prevention issues, to follow up on management issues, to bring issues that arise to the attention of the physicians, etc. Once again, we cannot create the milieu of an inpatient patient experience for someone who has gone home. We can try to improve the completion factor, the ability to complete the care that is ordered and provide feedback and information on the results of this care.

Posted in Case Management, Disease Management, Healthcare Administration, Healthcare Trends, Patient-Centered Medical Home, Physician Practices, Transitions in Care | No Comments »

Two Medical Home Approaches Behind $1 Billion in N.C. Medicaid Savings

January 9th, 2012 by Patricia Donovan

Aggressive care management and preventive care saved North Carolina Medicaid nearly $1 billion over four years, according to a new analysis by Milliman Inc., a national healthcare consulting firm.

This latest report of savings in the Tar Heel State from patient-centered medical homes (PCMH) links the cost reductions to reduced hospital admissions, readmissions and emergency room visits, many of which are avoided when patient care is managed more efficiently.

The savings update was announced in a press release this week by the office of the state’s office governor, Bev. Perdue.

To provide medical homes, the state continues to partner with the Community Care of North Carolina (CCNC), a nonprofit group of local healthcare provider networks that provide and coordinate care for Medicaid recipients. The 14 regional CCNC networks since 1998 have pooled their resources for technological and administrative purposes, which not only saves operational costs but also provides opportunities for cooperation and collaboration throughout the networks.

With financial support from The Commonwealth Fund, CCNC has created a 16-module toolkit on constructing a medical home approach for vulnerable and high-cost populations.

The modules span everything from program development and rollout to IT support and informatics to establishing a network pharmacist program. There are also modules dedicated to a pregnancy medical home, integration of behavioral health and other populations.

CCNC has also created a workbook and resources for organizations pursuing recognition as a patient-centered medical home.

The Milliman report found that the key to the success of medical homes approach is a strong emphasis on preventative care, and aggressive care management. Although the cost of frequent office visits and treatment of newly diagnosed conditions adds to program costs initially, the reduction of emergency room visits and hospital admissions, as well as capturing of efficiencies and improving quality of care, results in significant savings and better health for the recipient.

The report by the San Diego-based accounting firm examined the impact of the state’s support for primary care medical homes – a system to coordinate healthcare for Medicaid recipients. Milliman’s report, which was required by the General Assembly, found that recipients with a medical home get better care and consumed fewer Medicaid resources than those who lack a medical home. From fiscal year 2007-2010, N.C. Medicaid avoided spending $984 million by having 1.1 million of its members enrolled into medical homes. In just the last two fiscal years of the study – 2009 and 2010 – $677 million was saved.

As N.C. Medicaid enrolled higher numbers of its members into a CCNC medical home, Milliman found annual savings increased—$103 million in fiscal year 2007 (July 1, 2006-June 30, 2007); $204 million in FY 2008; $295 million in FY 2009; and $382 million in FY 2010.

Milliman also reported that N.C. Medicaid is on a successful path to decrease cost by enrolling aged, blind or disabled (ABD) members into a medical home. Those Medicaid populations are generally the least healthy overall and costliest to treat. Enrollment into medical homes initially would add to the cost of caring for them but pays off in the long term. Indeed, Milliman found that in FY 2006, medical home enrollment of ABD populations cost the state an additional $82 million. But by FY 2010, enrollment of ABD Medicaid recipients into medical homes had paid off with the state avoiding $53 million in costs.

Posted in Accountable Care Organizations, Avoidable ER Use, Case Management, Disease Management, Healthcare Costs, Patient-Centered Medical Home | No Comments »

3 Key Influencers in Improving Medication Adherence

January 4th, 2012 by Patricia Donovan

The big three players in programs to improve medication adherence are the primary care doctor, the pharmacist and the case manager, according to 2011 market research by the Healthcare Intelligence Network. The pharmacist is also being recruited in a big way to assist with these programs, both at the health plan and primary practice levels, according to 162 healthcare organizations that took the survey. Often it is the pharmacist in the patient’s local drugstore that is making the primary contact, frequently with the help of motivational interviewing, and the patients like this.

“The patient feedback is our secret weapon, because it does provide the patients with the opportunity to be able to say, ‘I felt I was heard and understood, my needs were met,’ explains Dr. Janice Pringle of the University of Pittsburgh School of Pharmacy. The university is a collaborator in a pilot that teaches retail pharmacists the principles of motivational interviewing, which they in turn use to screen customers for adherence issues. Other pilot participants are Rite Aid and CECity. “It’s not satisfaction,” she stresses. “A lot of people call it that. Satisfaction is more of a passive, evaluation of the process, where feedback is actually saying how they felt that their needs were met.

The University of Pittsburgh pilot participants are evaluating some of the interim results, she notes. “As a researcher, I’m very, very careful. However, I can say that there is an indication that there are statistically significant changes in adherence for the participating [pharmacy] sites. This will be borne out by our more thorough evaluation in mid-2012. We’ll be comparing not only changes over time amongst the intervention pharmacies, but also comparing to a group of pharmacies that we consider control pharmacies for the same time period and the same metrics.”

Pharmacist motivation and satisfaction with the effort is high, as well. Dr. Pringle shares a comment from one of the pharmacists in the pilot: “We have to do this project. All of us have been trained to work with patients and we have not been able to do that. This is the chance we’ve been looking for to have more contact with our patients and to make a difference in their lives.”

The prevalence of programs to monitor and improve medication adherence has remained steady from 2010 to 2011; this year’s survey identified just a slight uptick in adherence-related interventions. While the big five chronic conditions — ischemic heart disease, diabetes, COPD, asthma and heart failure — are still primary targets for these programs, there is also a move toward targeting individuals with dementia, stroke and osteoporosis.

The value of case managers in improving medication adherence levels is underscored by health plan respondents: 56 percent have given primary responsibility for these programs to case managers. Several future programs will embed case managers in physician practices for this purpose and/or step up case management of patients with chronic illness.

Posted in Case Management, Hospital Readmissions, Medication Management, Patient-Centered Medical Home, Reducing Readmissions, Uncategorized | No Comments »

Meet Case Manager Linda Conroy: Breaking Down Barriers Between the Hospital and Community

December 23rd, 2011 by Cheryl Miller

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

Linda Conroy, RN, BSN, Clinical Integration Case Manager for Hartford Physician Hospital Organization (HPHO)

HIN: What was your first job out of college and how did you get into case management?

Linda Conroy: I started my nursing career as an LPN and obtained a position as a case manager at a home care agency. I spent the next 15 years going to school part-time and working at home care agencies part-time. After obtaining my BSN. I went to work at Hartford Hospital in the Clinical Research Center as a clinical research associate. From there I accepted a position as a case coordinator/discharge planner and I am currently working at HPHO as a clinical integration case manager. I was able to get into case management as an LPN due to my recent employment at The CT Hospice in Branford. The home care agency at the time was starting a hospice program.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

I knew I was meant to be a case manager from the beginning. I found it to be both challenging and rewarding. I loved the process of identifying barriers to my patients’ health and researching resources.

What are two or three important concepts or rules that you follow in case management?

Always try and understand what the patient is feeling. Allow the patient/family to guide me in what they want and how they want to reach their goals. Do No Harm.

What is the single most successful thing that your organization is doing now?

The HPHO is working with Hartford Hospital to reduce the rate of readmissions for our patients that are discharged with a primary diagnosis of congestive heart failure. We are working with several home care agencies and skilled nursing facilities to provide improved transition of care and education to both family and patient.

Do you see a trend or path that you have to lock onto for 2012?

I plan to continue to work with the team to develop effective interventions to assist our patients in managing a chronic illness, and to break down silos both within the hospital and in the community.

What is the most satisfying thing about being a case manager?

Enabling patients and families.

What are your favorite hobbies, and how did they develop in your life?

I love to garden, play golf and knit. My mom taught me how to knit when I was seven and I have found it to be very relaxing and therapeutic. I love being outdoors and finding ways to make my yard fun. I play golf to be with my husband.

Is there a book you recently read or movie you saw that you would recommend?

Yes, “Still Alice” by Dr. Lisa Genova.

Posted in Behavioral Health, Case Management, Case Manager Profile, Disease Management, Reducing Readmissions, Transitions in Care, Uncategorized, Wellness/Prevention | No Comments »

Forget About the Pizza, What About the Sodium?

December 7th, 2011 by Cheryl Miller

Pizza is not a vegetable.

That’s the word from the American Heart Association (AHA) on Congress’s much publicized perceived push for pizza to move to the top of the school lunchroom’s food pyramid, a decision sure to disappoint children everywhere.

But reports have since shown that what Congress actually did was to maintain that the tomato paste in pizza sauce is a concentrated form of tomatoes, and should be counted as such. So that an eighth of a cup of tomato paste, the amount often used in a serving of pizza, should be considered equivalent to a half cup of vegetables. According to a recent article by Sarah Kliff in the Washington Post’s Wonkblog, the United States Department of Agriculture (USDA) did not want to credit a volume of fruits or vegetables that was more than the actual serving, and Congress blocked this.

The USDA’s proposed changes were the first changes in 15 years to the $11 billion school lunch program, according to USDA officials, as cited in an article in the New York Times, and were meant to reduce childhood obesity by adding more fruits and green vegetables to lunch menus.

And while no one can debate the benefits of tomatoes, Kliff’s article goes on to compare the nutritional facts of tomato paste, no salt added, with fresh fruits, and they appear similar, except for the sodium, where tomato paste outweighs the fruit by 33 mg to 1 mg.

And so the real culprit here is not Congress or even pizza, but the amount of sodium in foods, and whether or not it should be regulated.

Sodium has been proven to cause cardiovascular (CV) disease, a relationship recently reaffirmed by the CDC. And CV disease keeps increasing, according to the CMS: “Heart disease causes one of every three American deaths and constitutes 17 percent of overall national health spending, costing $444 billion every year in medical costs and lost productivity in Americans.”

The statistics for diabetes, a preventable disease often caused by poor lifestyle and unhealthy eating, are equally staggering: 78,000 children develop type 1 diabetes every year. The problem is so severe that the United Nations recently held its annual summit on non-communicable diseases, namely cancer, chronic respiratory diseases, CV disease and diabetes. It was the second of its kind to focus on a global disease issue; the first health-related UN Summit addressed AIDs.

And according to a recent study from the Commonwealth Fund, 32 percent of children ages 10 to 17 are overweight or obese.

So, given the amount of calories, fat and sodium in the pizza that contains the pizza sauce that contains the tomato paste, one of the last things our school kids need is more pizza in their diets.

What they do need is to be offered the tools to learn and make independent decisions not only outside the classroom, but inside the classroom as well, and the lunchroom is a good place to start.

But if Kliff is right, the lunchroom just might be the last place for kids to get a good education.

While the U.S. Department of Agriculture writes guidelines for what school meals should look like, few schools actually follow them. Just 20 percent of schools served meals that met federal guidelines for fat content, according to a 2007 USDA audit.

Posted in Behavioral Health, Case Management, Consumer-Driven Healthcare, Disease Management, Healthcare Costs, Healthcare Trends | No Comments »

Q&A: CDPHP Embedded Case Managers Usher In New Era of Healthcare

November 30th, 2011 by Jessica Papay

From the perspective of the health plan-provider relationship, CDPHP embedded case managers are an example of both parties working together in partnership, explains Lisa Sasko, MA, MBA, director of clinical transformation at CDPHP. Prior to their presentation on The Role of Embedded Case Managers in Clinical Transformation, Sasko, along with Charlene Schlude, director of case management, describe the functions of an embedded case manager, target populations and issues to address prior to embedding a case manager in a practice.

HIN: A news release on the CDPHP physician practice transformation program mentioned that the embedded case managers help practice staff better facilitate medical, behavioral and pharmaceutical services for patients. Can you provide, in more detail, their functions in these areas?

(Charlene Schlude): We have embedded RN case managers that work in the practices and their primary function and role is to assist the physicians and staff in the practice to identify, engage and outreach patients in their practice, whom they believe have many chronic and complex medical issues that may require special coordination of care. The addition of social work, perhaps because there may be some social concerns and financial constraints around having a chronic illness or maybe the loss of a job, help people to engage in a self-management plan. After the case management experience is over, the patients should be able to continue on with the education, adherence techniques, the understanding of their diagnosis and having a list of questions to bring with them to speak to their doctor about regarding their condition. The patient should be empowered and ready to help self-manage their chronic condition on an ongoing basis.

HIN: You mentioned complex patients as targets for the case management program. Are there other target populations, such as by disease state?

(Charlene Schlude): Yes, we target any patient with a complex illness. That could be someone in our commercial product or our self-insured product line; people who may have had a trauma or a catastrophic illness or event. We work closely with our transplant patients because they have significant social and emotional needs as well as medical and pharmaceutical needs. We work with anyone who has a great deal of barriers to self-managing their care, which could be that they have a situation in their home where they’re the caregiver for another patient or another member of their family.

HIN: What are the operational and cultural issues to address before embedding case managers in the practice?

(Charlene Schlude): We found that when we were going into the medical home as embedded case managers, we were going to have to be very flexible and open to the different nuances of each practice. We know that the underlying concepts around medical homes are the transition of the practice so that everyone has an integral part on the team. We knew that we had to be very open to the workflows in the practice. Our case managers are sensitive to that, but they do need to become an integral part of that practice as a member of the team. While they’re employed by the health plan, the message to the practice and to the members is that they are a part of that team and are involved with all of the decisions; they sit in on conferences and talk with the physicians directly. But again, we are being sensitive to the workflows because we did not want to go in and prescribe how things were going to be in one medical home to the other, and say that it had to be consistent.

(Lisa Sasko): From an operational standpoint — from a plan and provider relationship standpoint — some of the issues that were important for us to address, focused on recognizing and working with our practices to recognize that this is a new era of healthcare. We need to work together in partnership. CDPHP is supporting these practices to become these enhanced primary care practices through practice transformation, through the use of consultants, etc. In addition, CDPHP is putting these practices on a new payment model that gets them away from fee-for-service onto a risk-adjusted base capitation, which offers a lucrative, to some degree, bonus potential based on improving quality of care for the members and improving the efficiency of the resources utilized.

Posted in Case Management, Disease Management, Healthcare Administration, Patient-Centered Medical Home, Physician Practices, Transitions in Care | No Comments »

Q&A: Prepping a Practice for a Case Manager

November 21st, 2011 by Jessica Papay

Physician engagement is step one in the process of embedding case managers, says Robert Fortini, VP and chief clinical officer at Bon Secours Health System. There is much value in embedding a case manager in a primary care practice, including their influence on patients’ medication compliance. Prior to presenting for HIN’s August 10 webinar on Embedded Case Management in the Primary Care Practice: Program Design and Results, Fortini discussed preparing a practice for the arrival of a case manager.

HIN: How do you prepare a physician practice for the case manager’s arrival so that a supportive environment is created?

(Robert Fortini): We don’t do anything at the practice level until we have provider engagement. Any changes that are made to the workflow are thoroughly vetted through the entire provider staff — whether mid-level or physician — and we get consensus and agreement. Typically, we have an initial meeting where everything is thoroughly explained about the case manager’s role; everyone is given a copy of the job descriptions and workflows, protocols, goals and objectives, as well as competency checklists. And everybody is thoroughly prepared in advance.

Only at that point when we have consensus from the providers, do we then proceed with the HR hiring action. By the time that’s complete and the person gets on board, the practice is completely prepared for their role.

HIN: In the January issue of the “Healthcare Finance News,” you were quoted as saying that “newly formed Bon Secours care teams of doctors and nurses and the embedded case managers would do workflow rehearsals to make sure that all teams were performing care uniformly.” Can you talk about these rehearsals and any issues or challenges that they identify?

(Robert Fortini): This concept is more of a structured manner of doing an old concept. Not all the rehearsals are pertinent to the case managers. One of the workflow rehearsals is for a standard rooming protocol for support staff. In this particular event, we’re using EPIC, an electronic medical record platform. We will rehearse with a medical assistant or a licensed practical nurse (LPN) responsible for rooming the patient what the minimum data set to be captured will be. We want to make sure that weight and height is recorded, so BMI is calculated. We want to make sure that tobacco cessation screening and counseling are addressed. We want to make sure their vital signs are done appropriately, that a past medical history and past surgical history is captured, that medication reconciliation occurs, and that refills that are due are pended for the physician to sign. This way, by the time a physician gets in the room, all the busy work is done and most of the documentation has already been started. This streamlines the physician’s role. As you can see, a case manager might not be engaged in that workflow.

Another workflow that we rehearse is the concept of a daily huddle. This is literally a team meeting at the start of the day that runs for 7-10 minutes in the hallways that we expect the case manager to be a part of. This is a review of the day’s schedule — what’s coming in that day. This way, every member of the team is prepared in advance, including the case manager, who might have specific case management functions. For example, with an elderly patient coming in at 10 a.m. with multiple co-morbidities, poly-pharmacy and who is struggling, the expectation is that the physician is going to come in and address immediate medical needs and build a relationship with that patient.

But before the patient leaves the practice, he or she will sit with the case manager for medication management and adherence education. This is why the RN case manager should be prepared in advance for what’s coming in that day. The other value to that is that the immediate clinical support staff is also prepared. They all know in advance if that patient needs to have an EKG done. And so before the physician gets in the room, the EKG has been performed and the results are available for interpretation. It streamlines the visit and improves the efficiency.

The specific workflow can get more sophisticated as the team matures. Those are standard workflows. But then we have disease-specific protocols that we also rehearse with the staff.

HIN: To add to your response, are all of these workflows, especially the more specific ones, documented?

(Robert Fortini): Absolutely. We have a protocol for each one. And the expectation of performance is very clearly established with the staff; this is what the staff will do every single time a patient arrives.

HIN: You also said in the article that medication compliance would be a focus of these care teams. Do the embedded case managers have any duties in this area?

(Robert Fortini): Yes, and the example that I just used in my answer to the second question illustrates this. It is not uncommon, especially in a well-established internal medicine practice, for the needs of the geriatric patient to be prominent. Usually that means poly-pharmacy. If you’ve ever been in a situation where you’re taking more than two or three medications a day, it can be confusing. That 20 minutes of education that the case manager will perform with the elderly patient about what each medication does and how they should be taken is invaluable. We go right down to the basics. The case managers also set up pillboxes with the patients to help make complying with a medication regimen simple.

That’s just one illustration of medication compliance. We acknowledge the fact that 30 percent of all prescriptions are never filled and that of the remaining 70 percent, probably half of them are taken incorrectly, pills are split or days are skipped. Compliance with a medication record is of paramount importance for managing a chronic illness, and in certain categories, preventing readmission.

Posted in Case Management, Disease Management, Healthcare Administration, Healthcare Trends, Hospital Readmissions, Medication Management, Physician Practices, Transitions in Care | No Comments »

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