Archive for the ‘Chronic Care Management’ Category

Touting ‘Magic’ of Home Visits, Sun Health Dispels 5 Care Transition Management Myths

April 4th, 2017 by Patricia Donovan


With an average of 299 warm, sunny days a year, Phoenix is a mecca for senior transplants. However, as Phoenix-based Sun Health knows well, when an aging population relocates far from their adult children, there's a danger that if some of them experience cognitive decline or other health issues, no one will notice.

That's one reason home visits are the cornerstone of Sun Health's Care Transitions Management program. Visiting recently discharged patients at home not only tracks the individual's progress with the hospitalization-related condition, but also pinpoints any social determinants of health (SDOH) that inhibit optimum health.

"There are a number of social determinants of health that, if not addressed, could adversely impact the medical issue," explains Jennifer Drago, FACHE, executive vice president of population health for the Arizona non-profit organization. Ms. Drago outlined the program during A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay.

Identifying social determinants of health (SDOH) such as medication affordability, transportation, health literacy and social isolation are so important to Sun Health that SDOHs form the critical fifth pillar of its Care Transitions Program. Modeled on the Coleman Care Transitions Intervention®, SDOH identification and support balance Coleman's four pillars of education, medication reconciliation, physician follow-up visits, and personalized plan of care.

The belief that organizations can effectively execute transitions of care programs pre-discharge or by phone only is one of five care transition myths Ms. Drago dispelled during the webinar. "You will have an impact [with phone calls], but it won't be as great as a program incorporating dedicated staff and that home visit. I can't tell you the magic that happens in a home visit."

That "magic" contributed to Sun Health's stellar performance in CMS's recently concluded Community-Based Care Transitions Program demonstration. Sun Health was the national demo's top performer, achieving a 56 percent reduction in Medicare 30-day readmissions—from 17.8 percent to 7.81 percent—as compared to the 14.5 percent readmission rate of other demonstration participants.

Sun Health's multi-stepped intervention begins with a visit to the patient's hospital bedside. "Patients are a captive audience while in the hospital," explained Ms. Drago. That scripted bedside encounter, which boosted patients' receptivity to the program, addresses not only the reason for the hospitalization (hip replacement, for example) but also co-occuring chronic conditions, she continued.

"The thing that will have the greatest chance of going out of whack or out of sync in their recovery period is their chronic disease, because they're probably not eating the same, they're more sedentary, and their medications likely have been disrupted."

Ms. Drago went on to present some of the intervention's tools, including care plans, daily patient check-ins, and the science behind her organization's care transitions scripts.

After sharing six key lessons learned from care transitions management, Ms. Drago noted that while her organization participated as a mission-based endeavor, others could model Sun Health's intervention and benefit from those readmissions savings.

Listen to an interview with Jennifer Drago on the science behind care transition management.

Infographic: Improve Patient Engagement To Increase Medication Adherence

March 3rd, 2017 by Melanie Matthews

Chronic illnesses treated with long-term use of medications could be more successful with improved medication adherence rates, according to a new infographic by Fleming. Some 50% of patients do not take their medications as prescribed.

The infographic drills down on the factors related to non-adherence, the cost of non-adherence and the impact of technology on patient engagement.

Improve Patient Engagement To Increase Medication Adherence

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health SystemIntermountain Healthcare's strategic six-point patient engagement framework not only has transformed patient care delivered by the Salt Lake City-based organization but also has fostered an attitude of shared accountability throughout the not-for-profit health system.

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health System details Intermountain's multilayered approach and how it supports its corporate mission: Helping people live the healthiest lives possible.

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.

Infographic: Chronic Migraine Patients

March 1st, 2017 by Melanie Matthews

Chronic migraine patients have impaired socioeconomic status, reduced quality of life and reduced workplace productivity, according to a new study released by the Headache & Migraine Policy Forum. Moreover, chronic migraine patients commonly have other comorbid conditions that complicate their medical treatment.

The Headache & Migraine Policy Forum has released a new infographic based on the study's findings. The infographic examines the prevalence of chronic migraine patients, healthcare spending on migraine patients and the leading comorbidities associated with migraine patients.

EHR and Clinical Documentation Effectiveness

Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk PopulationsWhen AMITA Health set out to devise a more efficient method of moving its highest-risk Medicare beneficiaries across its care continuum, the newly minted Medicare Shared Savings Program (MSSP) accountable care organization (ACO) abandoned its siloed approach in favor of an enterprise-wide human-centric model of care.

Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations describes how the nine-hospital system inventoried, reexamined and revamped its care management resources, ultimately implementing a centralized care management model that would support the Institute for Healthcare Improvement's Triple Aim goals.

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.

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.

3 Priority Populations for Home Visits and 10 More House Calls Benchmarks

February 14th, 2017 by Patricia Donovan

More than half of home visits include screening for social determinants of health.

More than half of home visits include screening for social determinants of health.

Which patients should healthcare providers visit at home? A new survey on home visits identified three key populations that should receive home-based care management: the frail elderly and homebound (69 percent); the medically complex (69 percent); and individuals recently discharged from the hospital (68 percent).

In stratifying patients for these home visits, 62 percent rely on care manager referrals.

These were just two findings from the 2017 Home Visits survey conducted by the Healthcare Intelligence Network. Nearly three quarters of the survey's 107 respondents visit targeted patients at home, an intervention that can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit.

Who's conducting these home visits? In more than half of responding programs, a registered nurse handles the visit, although on rare occasions, patients may open their door to a primary care physician (4 percent), pharmacist (4 percent) or community paramedic (3 percent).

Once inside the home, the visit is first and foremost about patient and caregiver education, say 81 percent of respondents, with an emphasis on medication reconciliation (80 percent). Fifty-nine percent also screen at-home patients for social and economic determinants of health, factors that can have a huge impact on an individual's health status.

Patient engagement, including obtaining consent for home visits, tied with funding and reimbursement issues tied as the top challenges associated with in-home patient visits.

How to know if home visits are working? The most telling success indicator is a reduction in 30-day hospital readmission rates, say 83 percent of survey respondents, followed by a drop in hospital and ER utilization (64 percent). Seventy percent of survey respondents reported either a drop in readmissions or in ER visits.

Here are a few more metrics derived from HIN's 2017 Home Visits survey:

  • Eighty-five percent of respondents believe that the use of in-home technology enhances home visit outcomes.
  • Fifteen percent report home visits ROI of between 2:1 and 3:1.
  • Eighty percent have seen clients’ self-management skills improve as a result of home visits.

Download an executive summary of results from HIN's 2017 Home Visits Survey.

AMITA Health Places Patient at Center of Care Management Redesign

February 2nd, 2017 by Patricia Donovan
AMITA Health care management redesign

AMITA Health's care management redesign began in one patient unit on one floor.

In rolling out a new connected care management strategy across its nine-hospital system, AMITA Health aimed to keep its target patient population at the heart of the initiative—unit by unit, floor by floor. Here, Susan Wickey, vice president, quality and care management at AMITA Health, shares one of the guiding principles of the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO).

The key component for us in our redesign was making sure that the patient was at the center of everything we did. With that in mind, we developed structured processes and programs that would span the care continuum while retaining the patient at the center. We wanted to establish relationship-based care with the patient and the primary care physician. We wanted to be able to use available data to help drive our decisions. We wanted to ensure that our patients had regular access to care, and that we leveraged what we currently had in place.

Our congestive heart failure clinic was key in this process. Navigating through the care continuum is not an easy process for many of our patients. We wanted to make sure we could help them through that, and construct some processes for them to be able to navigate. We wanted to make sure we were continuing to build the health literacy of our patients and our families. We wanted to establish interventions for the most vulnerable population of patients. We wanted to make sure we had a dedicated, multidisciplinary team to help us. We had psychiatrists, dieticians, pharmacists, primary care physicians and physician champions along the way to help us.

We began implementation very slowly, starting with a specific cohort of patients on one specific unit. This cohort was small; the number of people touching the cohort at the time was small. As we went along, we were able to define problem areas where we needed to intervene, quickly readjust and then go down the right path.

Slowly, over a period of time, we were able to add additional floors in our acute care hospitals, which then meant adding additional staff. Those additional staff then became the super users who helped us roll out the program on the next floor.

Source: Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations

Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations

Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations describes how the nine-hospital system inventoried, reexamined and revamped its care management resources, ultimately implementing a centralized care management model.

Social Determinants of Health: Does Technology Connect or Isolate?

January 12th, 2017 by Patricia Donovan
social isolation

Only half of Americans with two or more chronic conditions actually go online.

Social determinants are areas of health that involve an individual’s social and environmental condition as well as experiences that directly impact health and health status. Here, Dr. Randall Williams, chief executive officer, Pharos Innovations, examines why, contrary to popular thought, technology advances may actually increase the gap between social connectedness and social isolation for certain populations.

In the age of the Internet, technology itself may become a barrier to being connected with others through social interactions. The Pew Research Center has done some nice work on health and the Internet. It turns out that three quarters of adults in the United States go online. That's probably not all that surprising, but what's more nuanced in this data is that the Internet access of individuals in the United States actually differs, depending on whether or not those individuals suffer from chronic health conditions.

It turns out that of Americans who have two or more chronic conditions, which by the way represents the vast majority of the Medicare population, only half go online. As it turns out, the very same groups that suffer most from social determinants of health, and not just from social isolation, also have the highest rates of chronic disease. And according to this research, they are the ones most likely to NOT have access to the Internet. This is called the Internet Divide.

We might be encouraged by the prevalence and penetration of mobile technologies, and maybe those would be the great bridge over the Internet Divide. Unfortunately, that may not be the case yet. According to this same Pew research, 90 percent of Americans who don't have a chronic condition actually own a cellphone. However, if you do have two or more chronic conditions, that number drops down pretty dramatically to 70 percent. That finding is a bit better than Internet access, but certainly not ubiquitous. If you look at those who have a cellphone, only 23 percent of them actually access text-messaging technologies on their cellphones, and smartphone apps fall well below that.

Source: Social Determinants and Population Health: Redesigning Care Management to Bridge Clinical and Non-Medical Services

social determinants of health

In Social Determinants and Population Health: Redesigning Care Management to Bridge Clinical and Non-Medical Services, care teams will learn that by asking patients the right questions and listening carefully to their responses, they can begin to identify and address social determinants, dramatically impacting patient outcomes as well as their own financial success under value-based care.

Infographic: 2017 Chronic Care Management Update

December 21st, 2016 by Melanie Matthews

The Centers for Medicare and Medicaid Services has updated the Chronic Care Management (CCM) rules for 2017 to improve adoption of CCM services by reducing the administrative burden on providers, according to a new infographic by CCM Navigator.

The infographic highlights these changes to CCM and new 2017 CCM codes.

2017 Chronic Care Management Update

A 2015 adopter of Medicare's Chronic Care Management (CCM) reimbursement program, The Center for Primary Care (CPC) quickly expanded its CCM initiative to qualifying Medicare beneficiaries at its nine locations. Today, with a detailed profile of its CCM population and the health improvements and revenue that resulted, the CPC is leveraging this Chronic Care Management experience for participation in MACRA.

Physician Chronic Care Management Reimbursement: Roadmap to MIPS Success Under MACRA describes how early adoption of Medicare's CCM Reimbursement program enhanced the Center's MACRA-readiness, laying the foundation for success under the Merit-based Incentive Payment System (MIPS) path.

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.

Value-Based Reimbursement Dominates Healthcare in 2016 and 11 More Industry Trends

December 15th, 2016 by Patricia Donovan

MACRA-Ready: 9 percent said they would participate in an Advanced Alternative Payment (APM) model in 2017.

ACA anxieties aside, value-based reimbursement wielded the most influence over the business of healthcare in 2016, according to the thirteenth annual industry trends snapshot by the Healthcare Intelligence Network (HIN).

Value-based reimbursement also topped the list of lucrative business development areas for 18 percent of respondents, HIN's industry survey found, followed by chronic care management (14 percent), integration of behavioral healthcare and primary care (11 percent), and telehealth (11 percent).

Sixty-nine percent of respondents consider themselves well positioned to succeed under value-based reimbursement models in the year to come. Additionally, 60 percent report that 2016 was a better year business-wise than 2015.

However, preoccupation with new models of care delivery and payment did not eliminate worry over the post-election fate of the Affordable Care Act (ACA), which President-elect Trump has vowed to repeal or replace. At least 10 percent referenced either the election, ACA uncertainty or the incoming presidential administration when identifying the greatest business challenges they expect to face in 2017.

The annual Healthcare Trends & Forecasts survey, administered in November 2016, captured year-end feedback from more than 100 hospitals, health plans, physician organizations, long-term care providers and others, pinning down the trends impacting the industry in the year to come.

A Look Back: Best and Worst Business Decisions of 2016

Community partnerships, training for integrated care and value-based payments, and participation in CMS Bundled Payment for Care Improvement (BPCI) were among the most successful business decisions of 2016, respondents reported. However, many cited lack of preparation for bundled payments and care delivery transformation, lack of communication, and lack of focus on quality as regrettable 2016 business decisions.

This 2017 roadmap for healthcare also identified the following metrics:

  • Respondents' pace of MACRA participation for 2017:
    • Eight percent will test MACRA's Quality Payment Program by submitting partial data in 2017 without fear of negative payment adjustments;
    • Six percent will participate for part of the calendar year;
    • Nine percent said they would participate for the full calendar year; and
    • Nine percent said they would participate in an Advanced Alternative Payment (APM) model in 2017.
  • Growth, hiring and recruitment, and sales and services were the three business areas most impacted by the 2016 economic climate.
  • Healthcare wearables, palliative care and health insurance exchanges had the least impact on respondents' 2016 business operations.

Download the complimentary HINtelligence report, "Healthcare Trends for 2017: ACA Anxieties Aside, Majority Well-Positioned for Value-Based Reimbursement.

Providers and ACO Data Analytics: Too Much Information Is Not Helpful

November 22nd, 2016 by Patricia Donovan
Add a different caption here.

Collaborative Health Systems believes the health data it distributes to its physicians should speak to the challenges providers see in the market.

As the largest sponsor of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs), Collaborative Health Systems (CHS) has learned a number of lessons about the integration of data analytics and technology. Here, Elena Tkachev, CHS director of ACO analytics, outlines three challenges her organization has faced in the rollout of health analytics to its provider base, and some CHS approaches to these hurdles.

What are some of the challenges we have identified, and some solutions? Number one is the availability and access to timely and accurate data. This has been a challenge for us. As an insurance company, we have a very strong expertise and access to the claims information Medicare provides to us, but we did face the challenge of incorporating electronic medical records (EMRs) into our data. We have been taking a phased approach, where we continue only adding and enhancing our data. If you are not at a point where you’re ready to consume everything, it doesn’t mean you should not do it until you have all the pieces together. It’s better to start with something and then you can grow from that point and improve it.

The second is related to the technology and capability—the ability to aggregate all this different data from different resources and have it be meaningful. For us, it’s really an investment in having strong technology data architect subject matter experts as well as the tools that can help us with that.

The third is display of meaningful results. This has been a challenge and we’ve reiterated it. Since I first started at CHS, the reports have drastically changed, because we learned from our providers that too much information is not helpful; just giving someone a spreadsheet with a lot of columns is not very useful.

Providers would rather see information summarized, and less is more. It’s really important to have information be very clear. The data needs to speak to the challenges the providers see in the market.

Source: Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results

http://hin.3dcartstores.com/Health-Analytics-in-Accountable-Care-Leveraging-Data-to-Transform-ACO-Performance-and-Results-_p_5185.html

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results documents the accomplishments of CHS's 24 ACOs under the MSSP program, the crucial role of data analytics in CHS operations, and the many lessons learned as an early trailblazer in value-based care delivery.