Archive for the ‘Chronic Care Management’ Category

Guest Post: Analytics-Backed Wearables Provide Value Through Actionable Health Insights

July 18th, 2017 by John Valiton, CEO of Reemo Health

wearables for seniors

Analytics-enabled wearables offer opportunities for chronic disease management and delivery of value-based care.

The wearable market has experienced a growth rate of more than 20 percent and is estimated to reach over 213 million units shipped worldwide by 2020, according to IDC. These numbers likely don’t come as a surprise, as wearables have become an everyday tech accessory for nearly every generation — children, Millennials, Gen X, and even seniors. In fact, research by Accenture found that 17 percent of Americans over the age of 65 use wearables to track fitness — a percentage right on track with the 20 percent of those under the age of 65 that use wearables similarly.

But, while the value of utilizing wearables to track health has been tapped for the everyday consumer, it has yet to reach its full potential. Wearables can go far beyond heart rate monitoring and counting steps — especially for seniors. These devices, when connected with a data analytics platform, can provide the valuable insights needed to not only track health in real time, but predict potential threats and optimize care according to need. And the analytic insights, integrated with previous health records, not only benefit the senior, but give professional and family caregivers a deeper look into the behavior that can improve long-term health, streamlining delivery of care by mitigating the need for trial-and-error treatment planning.

With over 50 million seniors in the U.S., this offers a huge opportunity for care facilities to provide real value to the patients they serve, whether in a senior care facility where residents are monitored on an hourly basis, or still living independently where facilities provide data insights at scheduled check-ins. But, as more facilities adopt wearable and analytic solutions, they must acknowledge the importance of using the wearable-enabled analytics platform to keep users engaged by providing value through actionable insights, rather than simply mining data and pushing it out. If there are not real benefits for both the senior and care provider, that wearable device is likely to end up in a drawer in a matter of months.

As caregivers dive into these valuable insights, they can be applied to assist with everything from chronic disease management and health event recovery to reduce the chance of post-acute readmission, to predicting potential threats based on irregularities in activity levels and vitals — allowing providers to truly delivery value-based care. For example, through the analysis of activity data, caregivers can follow the pathway to a potential fall for a senior, and proactively take steps to avoid this often traumatic event. Additionally, urinary tract infections (UTIs) are a large risk for seniors, and often occur after a 72-hour period where light activity such as walking becomes increasingly painful and trips to the restroom increase. By tracking a senior’s activity levels through a wearable device, caregivers can strategically treat those with potential UTI issues.

Through these kind of applications, truly actionable wearable data can provide immense value for both seniors and the caregivers tasked with keeping them on the pathway to a positive aging experience. And for those still living independently, the integration of response systems — such as push-of-a-button 911 dialing — within the wearable devices can provide additional value in their daily life by providing peace of mind to the senior and their loved ones, and functionality in the case of an emergency.

The use of wearables in everyday life doesn’t have to be limited to tracking a morning walk or getting reminders to stand up when you’ve been sitting for too long. If used alongside a powerful analytics platform, these devices can truly improve seniors’ quality of life, while strengthening connections with caregivers through increased visibility into seniors’ daily activities and peace of mind for loved ones. And while the wearable revolution is sweeping the nation, it truly should be about more than wearables for seniors. Wearables, backed by powerful data analytics, can become invaluable for our aging generation while providing unmatched insights for both personal and professional caregivers.

John Valiton, CEO, Reemo Health

John Valiton, CEO, Reemo Health

About the Author: John Valiton is CEO of Reemo Health, a senior health technology solution designed to empower caregivers with actionable insights to improve the aging experience. As a 20-year business development veteran and entrepreneur, Valiton has developed partnerships with many national and international companies. He has been an avid technology enthusiast since an early age, and applied his interest in all things tech at the intersection of IoT, wearable technology, healthcare and data science through his position as a strategic advisor, chief revenue officer and now chief executive officer for Reemo.

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.

2017 ACO Snapshot: As Adoption Swells, Social Determinants of Health High on Accountable Care Agenda

June 29th, 2017 by Patricia Donovan

Nearly two-thirds of 2017 ACO Survey respondents attribute a reduction in hospital readmissions to accountable care activity.

Healthcare organizations may have been wary back in 2011, when the Department of Health and Human Services (HHS) first introduced the accountable care organization (ACO) model. The HHS viewed the ACO framework as a tool to contain skyrocketing healthcare costs.

Fast-forward six years, and most resistance to ACOs appears to have dissipated. According to 2017 ACO metrics from the Healthcare Intelligence Network (HIN), ACO adoption more than doubled from 2013 to 2017, with the number of healthcare organizations participating in ACOs rising from 34 to 71 percent.

During that same period, the percentage of ACOs using shared savings models to reimburse its providers increased from 22 to 33 percent, HIN’s fourth comprehensive ACO snapshot found.

And in the spirit of delivering patient-centered, value-based care, ACOs have embraced a whole-person approach. In new ACO benchmarks identified this year, 37 percent of ACOs assess members for social determinants of health (SDOH). In support of that trend, the 2017 survey also found that one-third of responding ACOs include behavioral health providers.

Since that first accountable care foray by HHS, the number of ACO models has proliferated. The May 2017 HIN survey found that, of current ACO initiatives, the Medicare Shared Savings Program (MSSP) from the Centers for Medicare and Medicaid Services (CMS) remains the front runner, with MSSP participation hovering near the same 66 percent level attained in HIN’s 2013 ACO snapshot.

Looking ahead to ACO models launching in 2018, 24 percent of respondents will embrace the Medicare ACO Track 1+ Model, a payment design that incorporates more limited downside risk.

This 2017 accountable care snapshot, which reflects feedback from 104 hospitals, health systems, payors, physician practices and others, also captured the following trends:

  • More than half—57 percent—participate in the Medicare Chronic Care Management program;
  • Cost and provider reimbursement are the top ACO challenges for 18 percent of 2017 respondents;
  • Clinical outcomes are the most telling measure of ACO success, say 83 percent of responding ACOs;
  • Twenty-nine percent of respondents not currently administering an ACO expect to launch an accountable care organization in the coming year;
  • 75 percent expect CMS to try and proactively assign Medicare beneficiaries to physician ACO panels to boost patient and provider participation.

Download HIN’s latest white paper, “Accountable Care Organizations in 2017: ACO Adoption Doubles in 4 Years As Shared Savings Gain Favor,” for a summary of May 2017 feedback from 104 hospitals and health systems, multi-specialty physician practices, health plans, and others on ACO activity.

Improve Medication Adherence, and Payors Pay Attention

June 20th, 2017 by Patricia Donovan
medication adherence

Training in motivational interviewing helps Novant health set medication adherence goals that are meaningful to patients.

Seeking additional dollars from managed care contracts? Work harder at getting patients to adhere to medication therapies, advises Rebecca Bean, director of population health pharmacy for Novant Health. Here, Ms. Bean describes ways her organization is improving medication adherence, including pharmacist referrals, while enhancing Novant Health’s bottom line.

Medication adherence is a huge focus for our organization. There are some quality measures related to adherence, including CMS Star measures. They are triple-weighted, which indicates they mean a lot to payors. Often, medication adherence is a way to get additional dollars through managed care contracts. Our pharmacists work hard at helping patients adhere to medication therapies.

We have found some benefit to using adherence estimators. Adherence estimators give you a better feel for what is causing the patient to have difficulty with taking their medication. The other finding is that oftentimes providers are unaware; they have no idea patients aren’t taking medications. This becomes a safety issue; providers may keep adding blood pressure medications because they are not getting that blood pressure to goal. If for whatever reason the patient suddenly decides to take a medication they weren’t taking before, there could be a serious issue with taking all of those blood pressure medicines at one time.

The other benefit to estimating adherence and identifying root causes is that it frames the discussion with the patient. I don’t want to spend an hour talking to a patient about why it’s important to take this blood pressure medicine when it’s actually a financial issue. If I know it’s a financial issue, then I can make recommendations on cost-saving alternatives. It helps you to be more efficient in your conversation with the patient.

The other challenge of adherence is that patients are reluctant to be honest about this issue. You have to be creative to get the answers you need or get to the truth about adherence. If you flat out ask a patient if they’re taking their medications, most of the time they will say yes.

One other helpful strategy when working with patients to set adherence goals is to have them set goals that mean something to them. It’s not helpful for me to set a goal for a patient. If I ask them to tell me what they’re going to do, then they’re accountable for that. It is very helpful to get your staff trained in motivational interviewing. This trains them to meet the patients where they are and to understand what is important to that patient, which helps you frame the medication therapy discussion.

Source: Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations

pharmacists and medication adherence

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations examines Novant Health’s deployment of pharmacists as part of its five-pronged strategy to deliver healthcare value through medication management services.

Shared SNF Patients, Common Readmissions Goals Unify Three Competing Health Systems

June 15th, 2017 by Patricia Donovan

A common desire to reduce SNF readmissions resulted in the formation of Michigan's Tri-County SNF Collaborative.

A common desire to reduce SNF readmissions resulted in the formation of Michigan’s Tri-County SNF Collaborative.

Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations decided to set competition aside to collaborate and reduce rehospitalizations from SNFs. Here, Susan Craft, director of care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, describes the origins of Michigan’s Tri-County SNF Collaborative, of which her organization is a founding member.

I want to talk about the formation of the Tri-County SNF Collaborative between Henry Ford Health System, Detroit Medical Center, and St. John Providence Health System. As quality and care transition leaders from each of the health systems, we see each other frequently at various meetings. After some good conversation, we learned that each of us was partnering with our SNFs to improve quality and reduce readmissions.

We all required that they submit data to us that was very similar in nature but not exactly the same, which created a lot of burden for our SNFs to conform to multiple reporting requirements. We knew we were working with the same facilities because geographically, we are all very close to each other. We recognized that this was really a community problem, and not an individual hospital problem. Although we are all competing healthcare systems, those of us with very similar roles in the organization had very little risk from working together. And because we had so much in common, it just made sense that we create this collaborative.

We also worked with our MPRO (Michigan Quality Improvement Organization) and reviewed data that showed that about 30 percent of our patient population was shared between our three health systems. We decided it made sense to move forward. We created a partnership that was based on collaboration and transparency, even within our health systems. We identified common metrics to be used by all of our organizations and agreed upon operational definitions for each of those. We all reached out to our SNF partners to tell them about the collaborative and invite them to join, and then engaged MPRO as our objective third party. We created a charter to solidify that cooperation and collaboration.

Source: A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics

reducing SNF readmissions

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics examines the evolution of the Tri-County SNF Collaborative, as well as the set of clinical and quality targets and metrics with which it operates.

Infographic: The Battle for Medication Adherence

May 24th, 2017 by Melanie Matthews

Patient adherence to a prescription regimen can reduce costs and improve the quality of life, according to a new infographic by Medical Marketing & Media.

However, healthcare providers and pharmaceutical companies struggle to find the best tools, words and technologies that will improve adherence rates among patients with chronic conditions.

The infographic examines the impact of non-adherence and how text messaging and “polypills” can impact adherence.

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk PopulationsWhen it comes to medication management for Medicare beneficiaries, there are more than 25 different factors that can complicate proper use of prescribed medicines—from affordability issues, even among the insured, to fear of a drug’s side effects to potential dangers from high-risk medications or health conditions.

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations examines Novant Health’s deployment of pharmacists as part of its five-pronged strategy to deliver healthcare value through medication management services.

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HINfographic: Care Coordination Trends: Oversight of Complex Comorbid Spans Continuum

May 17th, 2017 by Melanie Matthews

Care coordinators organize patient care activities and share information among vested participants to achieve safer and more effective care, per the Agency for Healthcare Research and Quality (AHRQ). And for 86 percent of respondents to the 2016 Care Coordination survey by the Healthcare Intelligence Network, care coordination takes place across all care settings, including the patient’s home.

A new infographic by HIN examines patient care coordination touchpoints, patients by diagnoses prioritized for care coordination and care coordination touchpoint frequency and reimbursement models.

2016 Healthcare Benchmarks: Care CoordinationCare coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care, as defined by the Agency for Healthcare Research and Quality (AHRQ).

2016 Healthcare Benchmarks: Care Coordination examines care coordination settings, strategies, targeted populations, supporting technologies, results and ROI, based on responses from 114 healthcare organizations to the September 2016 Care Coordination survey by the Healthcare Intelligence Network.

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Top 2017 Chronic Care Management Modes and 13 More CCM Trends

May 2nd, 2017 by Patricia Donovan

Availability of chronic care management rose 14 percent from 2015 to 2017, according to new metrics from the Healthcare Intelligence Network.

The majority of chronic care management (CCM) outreach is conducted telephonically, say 88 percent of respondents to a 2017 Chronic Care Management survey by the Healthcare Intelligence Network (HIN), followed by face-to-face visits (65 percent) and home visits (44 percent).

This preference for telephonic CCM has remained unchanged since 2015, when HIN first canvassed healthcare executives on chronic care management practices. More than one hundred healthcare companies completed the 2017 CCM survey.

In addition, the April 2017 CCM survey captured a 14 percent increase in chronic care management programs over the two-year-span: from 55 percent in 2015 to 69 percent in 2017. Three-fourths of 2017 responding CCM programs target either Medicare beneficiaries or individuals with chronic comorbid conditions, with management of care transitions the top CCM component for 86 percent of programs.

In terms of reimbursement, payment levels for CCM services remained steady at 35 percent from 2015 to 2017. However, HIN’s second comprehensive CCM survey determined that 32 percent of respondents currently bill Medicare using CMS Chronic Care Management codes introduced in 2015.

Forty percent of these Medicare CCM participants believe CMS’s 2017 program changes will reduce administrative burden associated with CCM, the survey documented.

Other metrics from HIN’s 2017 CCM survey include the following:

  • A diagnosis of diabetes remains the leading criterion for CCM admission, said 92 percent;
  • Use of healthcare claims as the top tool for identifying or risk-stratifying individuals for CCM continues at 2015’s 70-percent levels;
  • Seventy percent of respondents target individuals with behavioral health diagnoses for CCM interventions;
  • Patient engagement remains the top challenge of chronic care management, with just under one-third of 2017 respondents reporting this obstacle
  • Responsibilities of RN care managers for CCM rose over two years, with 43 percent of 2017 respondents assigning primary CCM responsibility to these professionals (up from 29 percent in 2015); and
  • Two-thirds of respondents observed a drop in hospitalizations that they attribute to chronic care management.

Download an executive summary of 2017 Chronic Care Management survey results.

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. She also shared a video on the Sun Health Care Transitions Program:

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.

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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.

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