Archive for the ‘Chronic Care Management’ Category

Infographic: Monitoring and Managing Chronic Disease

November 22nd, 2017 by Melanie Matthews

Patients with chronic conditions rely on their healthcare teams to help them manage their health, according to a new infographic by West Corporation.

The infographic examines the steps providers can take to monitor and manage chronic disease among their patient populations.

In the sphere of value-based healthcare, chronic care management (CCM) is a critical component of primary care and population health management. Targeting the Triple Aim goals of better health and care for individuals while reducing spending, CCM is viewed as a stepping-stone to success under Medicare’s Quality Payment Program that launched January 1, 2017.

2017 Healthcare Benchmarks: Chronic Care captures tools, practices and lessons learned by the healthcare industry related to the management of chronic disease.

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Guest Post: Combining Big Data, EHRs and IoT for Chronic Disease Management

November 7th, 2017 by Brian Geary, Senior Account Manager, AndPlus

Providers and developers can work together to create solutions that leverage big data, EHRs and the IoT.

Have you ever used a Fitbit® or an Apple Watch®, or downloaded a mHealth app? If so, are you using these tools as an integrated way to improve your health?

The more we use technology, the more we want it to do for us. With millions of people living with complex diseases such as diabetes, cancer and heart disease, the development of intuitive and secure chronic disease management tools has become indispensable.

Yet, these tools may not support successful, sustained disease management—at least, not without the help of providers themselves.

More than 40 percent of patients who had downloaded an mHealth app had stopped using it when the app failed to provide accurate, personalized and actionable strategies for achieving their health goals. High data entry burden, hidden fees, and poor usability were other sticking points for these patients.

Another study carried out by an international team of researchers tracked 800 people for a year to see what impact Fitbit had on their health. The experts concluded that such devices are unlikely to be a magic bullet for the early detection and monitoring of chronic diseases.

So how can providers and developers work together to create engaging and supportive solutions that leverage big data, electronic health records and the Internet of Things (IoT) to utmost effect?

Using Big Data to Make Wiser Medical Decisions

Big data analytics allow providers to discover certain patterns that assist them in making better predictions about certain diseases.

With the help of big data and IoT, including patient records, clinical trials, insurance claims, and wearables, providers can discern the extent to which each intervention, as well as its associated expenditures, contribute to the improvement of their patients’ health.

However, in order to achieve measurable cost savings and long-lasting chronic disease control for patients, software models are required to help clinicians organize the data, recognize patterns, interpret results, and set thresholds for actions.

For example, to avoid the failure of an EHR to keep up with one’s sudden healthcare changes, hospitals should look at its software as being only the foundation of their health information, risking a negative impact on patient care.

Through department-appropriate software customization, hospitals can cut down wasted time spent scrolling through irrelevant screens and unnecessary fields, tracking down patient histories and reviewing duplicate data.

Having an intuitive, user-friendly EHR software also helps patients be more informed about their own health and prevents potential issues. They can access test results to see when follow-up appointments are due or communicate with their doctors to bring up any issues that may show significant health problems.

5 Things to Look for When Choosing an EHR System

    • Firstly, your EHR system should integrate easily with other systems within the hospital, such as clinical discussion support systems, laboratory information systems and other tools.
    • Further to considering the individual and specific departmental needs in a hospital, the other important feature of EHR software is customization (e.g. streamlining manual data entry). This is also advantageous for patients, as a customizable EHR system can be tailored to suit specific needs for data access, education and portability.
    • To make the most out of technological advancements and the benefits of customization, constant performance reviews of the chosen EHR systems in real-life scenarios are highly important. For example, when Medica conducted a research study to identify how they could improve their blood gas analyzer product line, it found out that its user interface needed a refresh. The outdated push button control system caused a lengthy training process for new users, so it required a radically improved user interface.
       
    • Make EHR software accessible with smartphones and tablets and provide easy access from connected devices, freeing clinicians from their workstations and creating access to patient data remotely. With accessibility, productivity soars and doctors can provide better care and reduce the lag between diagnosis and treatment, while lowering healthcare costs and improving patient’s compliance with treatment through consistent two-way communication.
    • Last but not least, a customized solution for your EHR can align workflows with the current processes a staff is already following, which can save time and prevent confusion when training users on the new EHR.

    By ensuring all your staff members receive thorough training and have access to ongoing support when questions or problems arise, the risk of the EHR becoming outdated is also minimized. Situations such as missing patient history or test results, which can lead to delayed diagnosis, unnecessary tests or even a misdiagnosis, are avoided.

    IoT Benefits for Healthcare Providers and Patients

    Doctors, nurses, and caregivers are not the only benefactors of IoT and healthcare apps. These devices can alert medical staff to wandering patients, monitor ICU patients or potentially dangerous procedures and treatments.

    Moreover, if a patient with a chronic illness needs immediate attention, the IoT can alert medical experts, and even connect the two to talk them through an emergency.

    In terms of direct patient benefits, IoT devices can remind patients when to take their medications, alert them about pending prescription refills or train them about upcoming medical procedures, while transferring relevant medical information back to the patient’s healthcare provider.

    To sum up, big data, electronic health records, and IoT devices have the potential to save money and often, even people’s lives. Together they contribute to increased efficiency, improved patient satisfaction and more time to focus on patient care.

    About the Author: Brian Geary is a senior account manager for AndPlus, LLC. Brian is a true believer in the Agile process. He often assists the development process by performing the product owner role. In addition to his technical background, he is an experienced account manager with a background in sales and customer service, as well as graphic design and marketing. Brian’s role at AndPlus ranges from marketing to sales and everything in between. Brian brings 10+ years of graphic design, marketing and account management experience to AndPlus.

    HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

  • Patient Engagement Prerequisite: School Staff in Patient Activation, Health Literacy

    October 19th, 2017 by Patricia Donovan

    YNHHS embedded care coordinationEven after multiple years of patient engagement education, awareness training and related programming for its clinicians, PinnacleHealth Systems knew those efforts needed to continue if they were to move forward with new interventions. Here, Kathryn Shradley, director of population health, PinnacleHealth System, describes two key focus areas for clinician education.

    We wanted to level-set on the definitions of patient activation and health literacy and what these terms meant to the organization and to the teams within. In full transparency, I want to be very clear: I believe initiatives for health literacy, patient engagement, patient education and population health will be on our task list for as long as I’m employed, and that’s okay.

    We spent a lot of time educating front-line clinicians on health literacy, understanding who was using the Patient Activation Measure® (PAM®) and tools and attempting to broaden the language used around the health system. One of our initial goals was simply to have the words ‘health literacy’ be recognized and understood throughout the system. This is certainly still something we work on daily as a core piece of all of our engagement strategies. I’m happy to say that we have made progress.

    One of the ways we obtained buy-in for our patient engagement strategy was to talk about the financial bottom line of low levels of patient activation and low levels of patient health literacy. We demonstrated to our executive teams, directors and managers that no matter where they were building an initiative and what they were building, if they didn’t include an engagement strategy in their product or service line, they were likely to experience difficulty—a difficulty that could otherwise be mitigated if we addressed some of these issues in their programs.

    Source: Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians

    patient engagement

    Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians describes PinnacleHealth’s two-pronged strategy for prioritizing patient engagement among its clinicians and patient population, tactics that elevated key quality and clinical metrics in the process.

    Cityblock Health to Open First ‘Neighborhood Health Hub’ for Underserved Urban Populations in NYC

    October 6th, 2017 by Patricia Donovan

    Cityblock Health neighborhood health hubs for underserved urban populations: “Where health and community converge.”

    Cityblock Health expects to open its first community-based clinic for underserved urban populations, known as a neighborhood health hub, in New York City in 2018, according to a Medium post this week by Cityblock Health Co-Founder and CEO Iyah Romm.

    Cityblock Health is a spinout of Sidewalk Labs focused on the root causes of health for underserved urban populations. Sidewalk Labs is an Alphabet company focused on accelerating urban innovation.

    The neighborhood health hub, where members can connect with care teams and access services, is one of several key member benefits outlined on the Cityblock Health web site. Other advantages include a personalized care team available 24/7, a personalized technology-supported Member Action Plan (MAP), and a designated Community Health Partner to help members navigate all aspects of their care.

    According to Romm, who brings a decade of healthcare experience to the initiative, the neighborhood hubs will be designed as visible, physical meeting spaces where health and community converge. Caregivers, members, and local organizations will use the hubs to engage with each other and address the many factors that affect health at the local level, Romm said.

    For example, Cityblock Health states it will offer members rides to the hub if needed. Transportation, care access, and finances are among multiple social determinants of health that drive health outcomes, particularly for populations in urban areas.

    Where possible, the hubs will be built within existing, trusted spaces operated by its partners and staffed with local hires, he added. Cityblock envisions offering a range health, educational, and social events, including support groups and fitness classes.

    The hubs are part of Cityblock Health’s larger vision to provide Medicaid and lower-income Medicare beneficiaries access to high-value, readily available personalized health services in a collaborative, team-based model, Romm explained in his post. The organization will partner with community-based organizations, health plans, and provider organizations to reconfigure the delivery of health and social services and apply “leading-edge care models that fully integrate primary care, behavioral health, and social services.”

    Three key health inequities related to underserved urban populations motivated the formation of Cityblock Health: disproportionately poor health outcomes, interventions coming much later in the care continuum, and the significantly higher cost of interventions in urban areas as compared to other populations.

    Cityblock Health will use its custom-built technology to enhance strong relationships between members and care teams, while simultaneously empowering and incentivizing the health system to do better, he added.

    Data Analytics, SDOH Screenings Flag Disengaged and 12 More Patient Engagement Trends

    October 5th, 2017 by Patricia Donovan

    More than 70 percent of healthcare organizations have created formal patient engagement initiatives, according to 2017 benchmarks from the Healthcare Intelligence Network.


    To identify individuals that are poorly engaged in their health, nearly two-thirds (63 percent) of healthcare organizations mine clinical data analytics, according to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network, while 37 percent screen patients for social determinants of health related to housing, care access, transportation, nutrition and finances.

    Patients who screen positive for social determinants of health (SDOH) and individuals with diabetes are typically the most difficult populations to engage, according to 2017 survey benchmarks.

    Thirty-five percent of respondents to the September 2017 survey said the presence of SDOHs, which the World Health Organization defines as “conditions in which people are born, grow, live, work and age,” pose the greatest challenge to health engagement, while 26 percent said a diabetes diagnosis presents the top clinical challenge to engagement interventions.

    One-quarter report some resolution of SDOH factors resulting from engagement efforts.

    To improve engagement, 75 percent of respondents rely on education of patients, family and caregivers, supported with telephonic outreach (13 percent) and home visits (13 percent).

    Efforts by 71 percent of respondents to create a formal patient engagement program underscore the critical role of engagement in healthcare’s value-based care and reimbursement models, particularly in regards to chronic illness.

    In other survey findings:

    • Patient experience rankings are the most reliable measure of engagement program success, say 43 percent.
    • For one quarter of respondents, patient engagement is the primary domain of case managers.
    • Eighty-three percent saw quality metrics improve as a result of patient engagement efforts.
    • Half attributed a drop in hospital emergency room visits to their patient engagement interventions.

    Download an executive summary of the 2017 Patient Engagement Survey.

    Chronic Care Plus for the Chronically Homeless: ‘Recuperative Care on Steroids’

    September 28th, 2017 by Patricia Donovan

    Chronic Care Plus is designed for ‘Joe,’ a prototypical vulnerable client and frequent hospital user who for some reason has not connected to either his community or healthcare system.

    Illumination Foundation’s joint venture pilot, which began as an ER diversion project, now offers community-based stabilization following a hospital stay for medically vulnerable chronically homeless patients. Here, Illumination Foundation CEO Paul Leon describes the origins of Chronic Care Plus (CCP), which has been associated with a $7 million annual medical cost avoidance at all hospitals visited by the 38 CCP clients.

    Back in 2008 when we first started, we began to realize that housing was healthcare. With many of the patients we were seeing, although we experienced great success, we ended up discharging them many times back into a shelter or into an assisted living or sober living situation. And although these options were better than being in the hospital or being discharged to the street, we knew we could improve on this.

    So, in 2013, we implemented the Chronic Care Plus (CCP) program. Basically, CCP was recuperative care on steroids. It was recuperative care with more tightly wrapped social services and a longer length of stay. At that time, we began a pilot program in conjunction with UniHealth and St. Joseph’s Hospital in which we took the 28 most frequent users and kept them in housing for two years. We also brought these individuals through recuperative care, and wrapped them tightly with social services.

    These efforts would eventually lead us to create our ‘Street2Home’ program, which we’re working on now. It implements more bridge housing and permanent supportive housing that is supplied not only by us but by collaboratives in the community. We are able to link to these collaboratives to take our individual, our ‘Joe,’ from a street to eventual permanent housing.

    Source: Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing

    home visits

    Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing spotlights a California partnership that provides medical ‘bridge’ housing to homeless patients following hospitalization. This recuperative care initiative reduced avoidable hospital readmissions and ER visits and significantly lowered costs for the collaborating organizations.

    Empathy Interviewing Elicits Patient’s ‘Story,’ Uncovers Social Determinants of Health

    September 26th, 2017 by Patricia Donovan

    social determinants of health

    Healthcare must mitigate patient risk factors outside of the hospital, referred to as social determinants of health (SDOH).

    If healthcare hopes to move the needle on runaway expenses and improve the health of its communities, it must first focus on patients’ social and environmental circumstances, also known as social determinants of health (SDOH).

    That’s the advice of Cindy Buckels, director of population health for TAV Health, which helps healthcare organizations navigate the challenges of SDOHs.

    “When we don’t address these issues as we’re addressing someone’s health, we get high readmissions, negative outcomes and dissatisfaction. There’s also increased cost and increased risk,” noted Ms. Buckels during Social Determinants of Health: Using Empathy Interviewing To Help Care Teams Understand Factors Impacting Patient Health, a September 2017 webinar now available for rebroadcast.

    To encourage individuals to open up about economic, educational, nutritional, or community deficits they face that drive 60 percent of their health outcomes, TAV Health recommends care teams employ empathy interviewing, also known as motivational interviewing (MI).

    “With motivational interviewing, you’re entering into a relationship with a person, not as the expert, but as a partner coming alongside to help them find their own strengths, and affirming them as a person in order to affect positive change,” said Ms. Buckels. Her presentation included a review of the four core skills of motivational interviewing (“Listen for that positive nugget,” she urges), as well as ‘back pocket’ questions to ask when the conversation stalls.

    Finally, she outlined traps for care teams to avoid during an MI session, such as the urge to give advice. “Always ask permission to give information or advice. Don’t just assume that’s something that you can do, because you’ve picked up the phone and called them.”

    It may take time to master, but ultimately, motivational interviewing is more effective than healthcare’s typical “Chunk-Check-Change” education approach in transforming patient ambivalence and effecting positive behavior change, she said.

    Information gleaned from motivational interviewing, even minor details like a patient’s nickname or the presence of a cherished pet, should become part of the patient’s record so that every person along the care continuum who ‘touches’ that patient can access it.

    “For example, if a patient’s legal name is Charlene, but she goes by Michelle, if you really want to build a relationship with her and gain her trust, you start by calling her what she goes by, which is Michelle.”

    In closing, Ms. Buckels outlined a patient-centric workflow connecting all supportive organizations, healthcare providers, community organizations and family and friends within the patient’s circle of care, which places more eyes and ears on the individual. With communal oversight to report anything worrisome, the likelihood is much less that a socially supported patient will visit the ER or be admitted to the hospital.

    Listen to Cindy Buckels explain the advantages of motivational interviewing over the “Chunk-Check-Change” educational approach.

    SNF Visits to High-Risk Patients Break Down Barriers to Care Transitions

    September 21st, 2017 by Patricia Donovan

    For patients recently discharged from the hospital, a SNF visit covers the same ground as a home visit: medications, health status, preparing for physician conversations and care planning.

    The care transitions intervention developed by the Council on Aging (COA) of Southwestern Ohio for high-risk patients starts off in the hospital with a visit by an embedded coach, and includes a home visit.

    Additionally, to reduce the likelihood of a readmission, patients discharged to a skilled nursing facility (SNF) also can expect a COA field coach to stop by within 10 days of SNF admission. Here, Danielle Amrine, transitional care business manager for the COA of Southwestern Ohio, describes the typical SNF visit and her organization’s innovative solution for staffing these visits.

    We conduct the home visit within 24 to 72 hours. We go over medication management, the personal health record (PHR), and follow-up with specialists and red flags. At the SNF, we do the same things with those patients, but in regards to the nursing facility: specifically, do you know what medications you’re taking? Do you know how to find out that information, especially for family members and caregivers? Do you know the status of your loved one’s care at this point? Do you know the right person to speak to about any concerns or issues?

    We also ask the patients to define their goals for their SNF stay. What are your therapy goals? What discharge planning do you need? We set our SNF visit within 10 calendar days, because normally within three days, they’ve just gotten there. They’re not settled. There haven’t been any care conferences yet. We set the visit at 10 calendar days to make sure that everything is on track, to see if this person is going to stay at the SNF long-term. Our goal is to have them transition out. We provide them with all of the support, resources and program information to help them transition from the nursing facility back to independent living.

    For our nursing facility visits, we also utilize the LACE readmissions tool (an index based on Length of stay, Acute admission through the emergency department (ED), Comorbidities and Emergency department visits in the past six months) to see if that person would need a visit post-discharge.

    For our CMS contract, we are paid for only one visit. Generally we’re only paid for the visit we complete in the nursing home, but through our intern pilot, our interns do that second visit to the home once the patient is discharged from the nursing home. We don’t pay for our interns, and we don’t get paid for the visit. We thought that was a perfect match to impact these patients who may have a hard time transitioning from the nursing facility to home.

    Source: Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

    home visits

    In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) of Southwestern Ohio, describes her organization’s home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

    Infographic: An Assessment of Acute Unscheduled Healthcare

    September 20th, 2017 by Melanie Matthews

    A healthcare model providing care at a high cost and with high rates of emergency department utilization, no matter the level of quality, is not sustainable, according to a new infographic by Phillips.

    The infographic provides an assessment of acute unscheduled care, the demands on acute care providers, and use of the emergency department across 7 countries: Australia, Canada, Germany, the Netherlands, Switzerland, the United States, and the United Kingdom.

    In the sphere of value-based healthcare, chronic care management (CCM) is a critical component of primary care and population health management. Targeting the Triple Aim goals of better health and care for individuals while reducing spending, CCM is viewed as a stepping-stone to success under Medicare’s Quality Payment Program that launched January 1, 2017.

    2017 Healthcare Benchmarks: Chronic Care captures tools, practices and lessons learned by the healthcare industry related to the management of chronic disease.

    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.

    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.