Archive for the ‘Diabetes Management’ Category

Medicare Chronic Care Management Reimbursement: Clarifying EHR Use and Electronic Requirements

October 22nd, 2015 by Patricia Donovan

Just one-fifth of U.S. physician practices participate in CMS's Chronic Care Management Program.

Nearly 70 percent of physicians nationwide admit they do not fully understand the Medicare Chronic Care Management (CCM) program, according to an August 2015 study by Smartlink Mobile Systems. The survey of 45,000 American physician practices determined that while 20 percent do participate in CCM, there is a great deal of confusion surrounding the CMS program designed to curb the cost of coordinating care for 34.4 million Medicare fee-for-service beneficiaries with two or more chronic diseases—particularly when it comes to meeting CCM’s electronic requirements.

The CCM initiative pays participating physician practices a monthly fee for twenty minutes of non-face-to-face patient care.

Earlier this year, Dr. Paul Rudolf, partner, Arnold & Porter LLP, and Nicole Liffrig, counsel, Arnold & Porter LLP, delved into CMS requirements and discussed approaches and challenges to meeting the CCM requirements, including a practice’s requirements for electronic health records (EHRs):

The CCM care plan is all the clinical staff needs to have access to in order to count time toward the 20 minutes. In terms of the EHR itself, the practice is only required for certain specified services within the Chronic Care Management. For example, the practice has to create a structured recording of demographics, problems, medications and allergies within the EHR, and then that information must inform the care plan. The care plan will include that type of information but doesn’t have to include everything that is in the EHR.

The practice also must put into the EHR a structured clinical summary record, which is discussed at some length in the final rule. In addition, the EHR must document that there’s written consent for the CCM services and all the other things the practice explained to the patient when the patient gave consent.

In addition, the care plan must be provided to the patient. That could be a hard copy or an electronic copy. The communication to and from home with community-based providers regarding their psychosocial needs and functional deficits also must be in the EHR.

Essentially, the electronic care plan is a distilled version of the EHR containing the pertinent information clinical staff would need to provide CCM services.

However, in spite of this interpretation, one Medicare contractor recently suggested that in order to count time toward the 20 minutes, the clinical staff has to have access to the EHR. We believe that is an incorrect interpretation of the rule. We believe the practitioners only need access to the electronic care plan.

The last thing I would like to mention about the EHR is that use of the EHR to provide care plans and other information to all off-site clinical staff and to other practitioners could theoretically raise privacy concerns. These are not new privacy concerns, but any practice that is going to provide CCM services needs to be cognizant of potential HIPAA issues and make sure they are in compliance. One thing that can be done in this regard is to have the individuals with EHR access sign business associate agreements.

Source: Chronic Care Management Reimbursement Compliance: Physician Requirements for Value-Based Revenue

http://hin.3dcartstores.com/Chronic-Care-Management-Reimbursement-Compliance-Physician-Requirements-for-Value-Based-Revenue_p_5027.html

Chronic Care Management Reimbursement Compliance: Physician Requirements for Value-Based Revenue sets the record straight on CCM reimbursement compliance, offering strategies for navigating obstacles and meeting requirements. In this 25-page resource, attorneys Dr. Paul Rudolf, partner, Arnold & Porter LLP, and Nicole Liffrig, counsel, Arnold & Porter LLP, drill down into chronic care management requirements outlined in the 2015 Medicare Physician Fee Schedule.

Infographic: Diabetes Drug Costs

August 17th, 2015 by Melanie Matthews

Primarily because of escalating drug costs, spending on insulin and other diabetes medications is expected to rise 8.3 percent over the next three years, according to a new infographic by the Alliance of Community Health Plans.

The infographic examines the percent increase of diabetes drug costs over the past five years and how this is impacting healthcare consumers, employers, healthcare providers and payors and the federal government.

Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care ManagementReal-time remote management of high-risk populations curbed hospitalizations, hospital readmissions and ER visits for more than 80 percent of respondents and boosted self-management levels for nearly all remotely monitored patients, according to 2014 market data from the Healthcare Intelligence Network (HIN).

Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management profiles a successful eight-year initiative by New York City Health and Hospitals Corporation’s (NYCHHC) House Calls Telehealth Program that significantly lowered patients’ A1C blood glucose levels.

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Mobile Apps Connect Community of Care Around High-Risk, Chronically Ill Patients

April 30th, 2015 by Cheryl Miller

Healthcare providers increasingly engage patients in self-management via the use of mobile apps and wearable devices.

Want to save lives? There’s an app for that.

Chances are the physician gazing intently at his or her smartphone isn’t checking out the latest sports stats or movie listings. Instead, a recent report from the MedData Group shows that three out of four physicians are using mobile apps to save time, lower costs, and improve their quality of care.

With more than 10,000 apps available in the healthcare category ranging from readmission risk predictors to chronic care management, physicians and other healthcare providers are turning to mobile apps for new ways to provide value-based care for patients, and help those patients become more engaged in their own care.

One such app, a set of condition-specific Readmission Risk Calculators, helps providers predict the 30-day readmission risk factors for a patient first entering the hospital. Developed by the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE), a national outcomes research center, which developed the publicly reported readmission measures for the Centers for Medicare and Medicare Services (CMS), the app is based on medical record data used for those measures.

Launched in 2012, the app predicts a patient’s readmissions risk based on certain specific criteria, including age, diagnosis upon initial admission (heart failure, heart attack, pneumonia), residence (i.e. nursing home), and mental status, among other data.

Improving patient engagement and self-management in patients with heart failure is at the core of a new cloud-based platform that bridges the transition of care from the hospital to home. Launched by iGetBetter and Brigham and Women’s Hospital (BWH), it is designed for patients with hypertrophic cardiomyopathy (HCM). Cardiologists at BWH monitor HCM patients and communicate their care plan instructions to them via mobile devices. These clinicians use data from biometric devices connected to the patients’ mobile devices, as well as patients’ self-reported data, to adjust their medications for optimal efficacy, and intervene if necessary to avoid hospital admissions or unnecessary office visits and reduce costs.

Patient and physician engagement is also integral to a new care management app from the Genesis Accountable Physician Network (GAPN), a clinically integrated subsidiary of Genesis Physicians Group. Through the deployment of BluePrint Healthcare IT’s Care Navigator™ platform, the mobile app provides patients and caregivers with real-time access to their care plans and care team members, as well as relevant patient questionnaires and educational materials.

By creating a connected community of care around high-risk, chronically ill patients, practices can provide a higher level of care, thereby improving safety, efficiency, and delivery.

Helping people with such chronic conditions as diabetes or asthma better manage their health is the focus of the CareCam self-management mobile app from Independence Blue Cross (Independence). The southeastern Pennsylvania-based payor offers the app for free to health plan members.

The CareCam generates a daily personalized schedule of healthcare activities designed to fit each individual’s lifestyle, allowing them to more easily adhere to the treatment plan recommended by their doctor. Because having a strong support network between doctor visits can help a patient with diabetes or asthma stay on track and ultimately lead a healthier life, users also may invite friends, family members, or caregivers to follow their progress on the app and provide support and encouragement to help ensure success.

Each day, CareCam reminds members to complete the activities necessary to effectively manage their diabetes or asthma, such as checking their sugar levels, measuring their peak flow (breathing) rate, taking medications and exercising. Users also receive real-time personalized feedback on how well they’re doing and have access to daily, weekly, and monthly summaries of their performance, which can be shared with their doctors during their next visit. The app is a way to provide these patients with a convenient, 24/7 resource for support in managing their care.

Overcoming ‘Clinical Inertia’ and 7 Other Barriers to Remote Patient Monitoring

February 26th, 2015 by Cheryl Miller

It’s important to identify potential barriers from both patients and providers before implementing a telehealth program, says Susan Lehrer, RN, CDE, associate executive director of the telehealth office for the New York City Health and Hospitals Corporation (NYCHHC), because both groups need to change behaviors. Resistance to change is universal, and if you’re changing any kind of work flow or communication, there will be initial resistance.

  • Slow buy-in and some resistance by clinicians (referrals).
  • Clinicians concerned with appearance of decreased productivity.
  • Resistance to change in clinic work flow.
  • Inability to “integrate” Web site data and electronic medical records (EMRs).
  • Language and literacy.
  • Complexity of chronic disease management.
  • Lack of protocols for use of email in coordination of care.
  • Not all clinicians utilize secure email system.
  • Source: Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management

    http://hin.3dcartstores.com/Remote-Monitoring-of-High-Risk-Patients-Telehealth-Protocols-for-Chronic-Care-Management_p_5008.html

    Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management profiles a successful eight-year initiative by New York City Health and Hospitals Corporation’s (NYCHHC) House Calls Telehealth Program that significantly lowered patients’ A1C blood glucose levels. Susan Lehrer, RN, BSN, CDE, associate executive director of the telehealth office for NYCHHC, shares key aspects of the real-time monitoring program, including how the program blends telehealth, electronic medical records, electronic communication with providers and direct communication with patients by nurse case managers, and much more.

    Remote Diabetes Monitoring: Magic is in the Phone Call, Not the Technology

    January 8th, 2015 by Patricia Donovan

    Using a blend of telehealth, access to electronic medical records, electronic communication with providers and direct communication with patients, nurse care managers with the New York City Health and Hospitals Corporation’s (NYCHHC) House Calls Telehealth Program significantly improved patient clinical outcomes and impacted healthcare costs for enrollees with diabetes. Here, Susan Lehrer, RN, BSN, CDE, associate executive director of the telehealth office for NYCHHC, shares some lessons learned from the eight-year-old program.

    We can achieve really significant clinical and financial outcomes with available simple technology. I want to say ‘simple’ because this is not rocket science. It’s a glucometer that transmits over a modem, a blood pressure cuff that transmits the information of blood pressure via Bluetooth® to us that we see on a Web site within seconds.

    That information is the first step, but providing the case management and communication back to providers is where the magic happens. Conducting effective patient interactions utilizing motivational interviewing can be done over the phone. We were all disbelievers in the beginning. “How can I do the same thing that I did face-to-face over the phone?” we asked ourselves.

    You can’t do the same thing, but over time, you can achieve the same outcomes, as long as you have providers seeing the patients and patients keeping their appointments.

    Technology enables us to give the feedback at the moment that the patient needs it. If somebody’s blood sugar is 58, and they don’t feel very well, calling them at that moment, which we do every day, prevents them from overcorrecting. Eventually, they learn how to treat their hypoglycemia. Giving that immediate feedback to a patient is where the dramatic clinical outcomes occur. Patients can learn self-management with very targeted interventions and support.

    To recap, it’s not about the technology, because the data comes to us every day, but it’s the magic that happens in the phone call back to the patient.

    remote diabetes management
    Susan Lehrer RN, BSN, CDE is the Associate Executive Director for the House Calls Telehealth program for the New York City Health and Hospitals Corporation. Ms. Lehrer joined HHC in 2006 to design and implement the Telehealth program to provide expert care management for Diabetics with poor control.

    Source: Diabetic Telehealth Monitoring: The Impact of Real-Time Data on High-Risk Patients (webinar available for replay)

    The Year in Healthcare Intelligence: Reimbursement, Value-Based Results Resonate with Readers

    December 29th, 2014 by Patricia Donovan

    Newswise, fee-for-value healthcare initiatives eclipsed fee-for-service models.

    When survival of healthcare providers hinges on payment for services rendered, it’s not surprising our 2014 readers closely tracked news of emerging payment models and results from patient-centered, quality-based initiatives.

    Here is a retrospective of stories that dominated our readers’ news feeds over the last 12 months:

    • We reported on results from many accountable care organizations (ACO) over the last year, but few generated interest like the Anthem Blue Cross-Healthcare Partners accountable care collaboration that saved more than $4 million. The program succeeded by sharpening its focus to those with two or more chronic diseases—the population that research shows can most effectively be helped by coordinated care, officials state. A dedicated staff of care managers and care coordinators identify hospitalized ACO patients, coordinate transitions of care, and ensure patient care and healthcare resources are accessible.

    • Heads also turned when the Centers for Medicare and Medicaid Services (CMS) proposed updated penalties and incentives for its Medicare Shared Savings Program (MSSP), an accountable care initiative for Medicare beneficiaries. The proposed rules are designed to strengthen MSSP by placing greater emphasis on primary care services and promoting transitions to performance-based risk arrangements. CMS is also suggesting a third ACO model,” track 3,” which integrates some elements from the Pioneer ACO model.

    • The patient-centered medical home (PCMH) model, a stepping stone to an ACO, garnered its share of readership, especially when the National Committee for Quality Assurance (NCQA) added five measures to its medical home criteria, the gold standard for patient-centered measurement.

      In its third iteration of PCMH standards since 2008, the NCQA added behavioral health integration and care management for high-need populations, among other new criteria.

    • The patient-centered model suffered a setback, however, when one of the first, largest, and longest-running multipayor trials of PCMHs in the United States was associated with limited improvements in quality and was not associated with reductions in use of hospital, emergency department (ED), or ambulatory care services or total costs of care over three years. Research by Rand Corporation and colleagues centered on patient-centered activities in the Southeastern Pennsylvania Chronic Care Initiative.

    • There was good news on the medical home front, however: A study published in September, 2014 attributed reductions in emergency room visits, principally by patients with chronic illness, to the PCMH approach. Research by Independence Blue Cross (Independence) and CTI Clinical Trial and Consulting Services (CTI), and published by Health Services Research, found that transitions to a medical home were associated with a 5 to 8 percent reduction in ED utilization. This finding is specific to patients with chronic illness(es) having one or more ED visits in any given year. These reductions were most evident among patients with diabetes.

    • Readers also paid attention when Geisinger Health System, an early adoptor of care coordination for chronic illness, announced that its all-or-none or “bundled” approach to primary care for patients with diabetes produced better health outcomes, and the benefits happened quickly for the more than 4,000 patients in the study. The system-wide approach was not easy, warned Geisinger: the model requires constant evaluation, and must be scalable across a variety of practice settings.

    • Also raising the bar for physician practices was Highmark, which shared six requirements for the “best practices” element of its successful pay-for-performance initiative. Physician practices can earn additional rewards for completion of an office-based best practice project, essentially a small pilot, that involves measurement and reporting.

    • On the flip side, reporting of some questionable hospital pricing strategies rated some page views as well. Data released early in 2014 by National Nurses United (NNU) and the Institute for Health and Socio-Economic Policy (IHSP) found that some U.S. hospitals charge more than 10 times their cost, or nearly $1200 for every $100 of their total costs. Public oversight or regulation seems to help constrain excessive pricing, researchers found; Maryland, probably the most regulated state in the United States, has the lowest average charges of all the states among its 10 most expensive hospitals.

    • Cost savings aside, readers seemed especially attuned to new approaches or technologies designed to streamline healthcare delivery and enhance the patient experience, such as an uptick in remote monitoring.

      One hundred percent of respondents to the Telehealth in 2013 Survey by the Healthcare Intelligence Network monitor weight and vital signs, up from a respective 79 and 77 percent in 2010. The health conditions monitored remotely remain the same from 2010, the top three being heart failure, COPD and diabetes.

    • And finally, as all eyes focus on care management interventions that span the healthcare continuum, many readers responded to a story on a CMS pilot that would give hospice patients more options in the type of care they wish to receive at the end of life. Under the Medicare Care Choices Model, individuals who meet Medicare hospice eligibility requirements could receive palliative care services from certain hospice providers while concurrently receiving services provided by their curative care providers.

    Were these stories on your news radar in 2014? Stay up-to-date in 2015 with the latest healthcare news, trends and benchmarks with a free subscription to the Healthcare Business Weekly Update.

    11 Statistics about Stratifying High-Risk Patients

    November 20th, 2014 by Cheryl Miller

    Healthcare organizations use a range of tools and practices to identify and stratify high-risk, high-cost patients and determine appropriate interventions. Most critical to the stratification process is clinical patient data, say an overwhelming 87 percent of respondents to the Healthcare Intelligence Network’s (HIN) inaugural survey on Stratifying High-Risk Patients. However, obtaining and verifying patient data remain major challenges for many respondents. Following are 10 more statistics from our survey.

    • „„Hospital readmissions is the metric most favorably impacted by risk stratification tools, according to a majority of respondents.
    • „„In addition to high utilization, clinical diagnosis is considered a key factor in stratifying high-risk patients, according to 16 percent of respondents.
    • „„Case management as a post-stratification intervention is offered by 83 percent of respondents; health coaching by 56 percent.
    • Reducing heart failure (HF), pneumonia (PN), and atrial myocardial infarction (AMI) are among the greatest successes of risk stratification programs.
    • Diabetes is considered the prominent health condition among high-risk populations, according to 37 percent of respondents; other prominent conditions include hypertension (20 percent) and mental health/psychological issues (15 percent).
    • Physician referrals are cited by 76 percent of respondents as an important input for stratification, followed by case/care manager referrals (71 percent).
    • „„Home health and/or home visits are available to risk-stratified populations of 56 percent of respondents.
    • „„LACE (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
    • Nearly half of respondents (45 percent) cite high utilization of the emergency department (ED) or hospital as the most critical attribute of high-risk patients.
    • „„While more than half of respondents have a program in place to identify and risk-stratify complex cases, the majority admit it is too early to tell the ROI achieved.

    Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

    http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Stratifying-High-Risk-Patients_p_4963.html

    2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement — data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry’s value-focused climate.

    Yale Online Forum Helps Teens with Diabetes “Not Look Like a Jerk”

    August 14th, 2014 by Cheryl Miller

    Being a teenager is hard enough; when it’s complicated by a chronic disease like type 1 diabetes, it’s even harder.

    Enter telehealth, in the form of a monitored discussion board for teens with the disease.

    Margaret Grey, DrPH, RN, FAAN, Dean and Annie Goodrich Professor at the Yale School of Nursing, has spent the majority of her career helping patients and families manage chronic conditions, and helping kids — teenagers in particular — manage their diabetes through their teen years so they can reduce their risk of long-term complications.

    “I’ve been studying these kids for 30 years,” says the pediatric nurse practitioner, who, prior to assuming the deanship in 2005, served as associate dean for scholarly affairs and was the founding director of the school’s doctoral program and the NIH-funded Center for Self and Family Management and a related pre- and post-doctoral training program. “Kids have black and white thinking — and have to manage how to ‘not look like a jerk’ by being given the skills to manage their disease, to think about it in a different way.”

    Grey and other researchers conducted several clinical trials: an advanced diabetic education project and a life skills program, which showed that teens with diabetes’ overall health and quality of life were better after going through both programs. Results showed that intensive therapy and better metabolic control reduced the incidence and progression of microvascular and neuropathic complications from diabetes from 27 percent to 76 percent.

    But how to maintain those results? According to researchers, “Metabolic control tends to deteriorate as a combined result of insulin resistance that accompanies the hormonal changes of adolescence and lower adherence to the treatment regimen often associated with the desire for autonomy.”

    “So we took those interventions and developed an online program kids could do at their leisure,” Grey says. It incorporated a monitored discussion board that allowed kids to communicate with others like them. Teens with diabetes overcome their fear of being stigmatized by logging onto the Web site,­ called TeenCope, ­with other teens with diabetes and engaging in self-management exercises. The online program simulates situations teenagers with diabetes might encounter by using graphic novel animations that illustrate coping skills lessons from the animated characters. “As kids transition to adolescence, they require more effort and thought,” Grey says.

    Peer support is an important component of maintaining a healthy lifestyle, as adolescents face pressures such as not wanting to reveal medical equipment in a social setting, or reveal their medical conditions in a social situation.

    In addition, the program will also integrate an online educational program aimed at problem-solving for teens with diabetes. Adolescence is a time when patients neglect self-monitoring, dietary recommendations, and pharmacologic treatments — not because of a lack of knowledge, but due to the decision-making difficulties characteristic of this life stage. Studies show that poor metabolic control in the teen years correlates to reduced self-management in adulthood, making adolescence a key period for developing healthy behaviors. And once teenagers can get a handle on their diabetes, they improve not only their own health, but their families’ quality of life.

    “This is a way to give them the skills to think about their condition in a different way,” Grey says.

    NYCHHC Telehealth Success Strategy: One Hand on Heart, the Other on Phone

    July 31st, 2014 by Patricia Donovan

    "We transform a conversation of chronic disease into something patients can look forward to." Susan Lehrer, RN, CDE, NYCHHC House Calls.

    Guided by the philosophy, “Be real to your patients, and let them be real to you,” the New York City Health and Hospitals Corporation (NYCHHC) House Calls telehealth program is as committed to participants’ “life bottom line” as it is to its own program ROI.

    In the House Calls telehealth program for diabetics, patients’ blood sugar, blood pressure and weight are transmitted via hand-size wireless modems to a team of specially trained nurses who provide feedback and education during pleasant telephone conversations at scheduled intervals.

    “We transform a conversation of chronic disease into something patients can look forward to,” explained Susan Lehrer, RN, CDE, associate executive director of telehealth care management. “If they’re not looking forward to the call, they won’t pick up.”

    A digital dashboard provides the telehealth nurses with a quick view of patients’ vitals and individuals who may be alerting. The telehealth technology enables immediate feedback that prevents overcorrection on the part of patients, Ms. Lehrer notes, while facilitating dramatic clinical outcomes.

    The telephonic exchanges augment regular patient visits and enhanced by the nurses’ use of motivational interviewing. The telephonic communications are “templated” to avoid long narratives.

    “Establishing that trust with patients over the phone is essential, because information received from people they believe care about them, and from people they trust, is information that is remembered,” said Ms. Lehrer. “It’s information that influences behavior.”

    Ms. Lehrer presented some of House Calls’ clinical outcomes for the 2,500 patients it has serviced since the program’s inception during a July 2014 webinar, Diabetic Telehealth Monitoring: The Impact of Real-Time Data on High-Risk Patients sponsored by the Healthcare Intelligence Network.

    Most House Calls participants are diabetics who spend an average of two years in the program, she explained. Of a random sampling of 769 participants, 76 percent improved their A1C almost every three months. Additionally, of patients in that sampling with A1Cs between 11 and 13, 91 percent improved A1Cs by an average of 2.9 percent.

    House Calls, which has experienced a side benefit of fewer appointment cancellations on the part of participants, has been so successful the program already has been rolled out for patients with heart disease; its use for the chronic obstructive pulmonary disorder (COPD) population is being discussed.

    However, Ms. Lehrer is quick to point out barriers to telehealth still exist. Physicians who treat a patient with diabetes for years without seeing any real change can develop “clinical inertia,” she says, although this quickly dissipates once the doctor sees a patient engaged in House Calls.

    There is also the occasional patient resistant to change, and the frustration of being unable to integrate patient data into an electronic medical record (EMR).

    Still, despite the program’s focus on technology and results, the nurses remind themselves that at its core, House Calls is about the person at the other end of the line.

    “The staff always talks about keeping our hands on our hearts so that when we speak to people, they don’t become the numbers.”

    Listen to an interview with Susan Lehrer here.

    Infographic: Diabetes on The Rise, Growing As Healthcare Concern

    May 28th, 2014 by Jackie Lyons

    The Center for Disease Control and Prevention predicts that one in three people will have diabetes by 2050. Furthermore, diabetes-related costs in 2012 totaled $245 billion, and the estimated cost of diabetes for 2020 is $500 billion, according to a new infographic from Tractivity.

    This infographic also shows the causes of diabetes, number of affected people, the costs related to diabetes and ways to prevent the chronic disease.

    You may also be interested in The Handbook of Health Behavior Change, 4th Edition. This resource contains chapters on lifestyle change and prevention and chronic disease management, with an intensive focus on specific behaviors (i.e. diet and nutrition, tobacco use) and chronic illness (i.e. diabetes, heart disease). It is organized around the specific behaviors and chronic illnesses with the most significant public health impacts in terms of morbidity and mortality.

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