Archive for the ‘Disease Management’ Category

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Meet Wellness Coach Christy LeMire: Educating Parents About Nutrition

January 13th, 2012 by Jessica Papay

Here we take an inside look at a wellness coach, the choices made on the road to success, and the challenges ahead.

Christy LeMire, certified holistic health coach and owner of Waterside Wellness.

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

Christy LeMire: For my first job out of college I was an assistant director for an early childhood education center in Roxbury, MA. I believe this experience planted the seed for wanting to work with people on a personal level and help children and families. I often spent time listening to single parents’ struggles to find balance juggling work and caring for their children. I also noticed the food limitations in the school regarding quantity and quality, and how it affected the children’s behavior, which made me concerned.

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

I am certified as a holistic health coach by the Institute of Integrative Nutrition and SUNY Purchase College. I will also become board certified as a holistic health practitioner by the American Association of Drugless Practitioners this year.

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

There have been many reassuring moments. Above all, seeing people start to value their bodies and their health through the education they receive in my program has been the most rewarding. It proves that a support system focused on the specific health of an individual does make a difference in their life and that health coaches are needed in our communities.

In brief, describe your organization.

Waterside Wellness offers personalized nutrition, wellness and lifestyle counseling. I tailor my program based on the particular needs and desires of my clients. We work together to determine their health goals and I support them to achieve those goals in realistic, enjoyable ways. Education is also a big part of my practice. I believe the more informed we are about how food and lifestyle affects our health and future, the better choices we make and the more satisfying those decisions are.

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

  • Bio-individuality — no one diet or way of living works for everyone.

  • Making changes step-by-step allows for sustainable healthy practices.

  • Food is not the only thing feeding us; our careers, relationships, exercise and spirituality all contribute to our health.

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

I currently offer a health coaching program designed specifically for brides-to-be who are looking to loose weight, manage time and stress, and start their marriage off as their most beautiful, healthy self. I find this is something all brides want and often need support in achieving while planning for their big day. It is also an opportunity to support women throughout changing times in their lives when they need support the most. Brides turn into wives who often turn into mothers. Finding balance between career and family can be challenging. Many women feel the need to be a “superwoman” and a little support and encouragement goes a long way.

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

Obesity and diabetes in children is more present than ever, mostly because of fast-food diets and sedentary lifestyles. It is predicted that many of today’s parents will outlive their children. I want to do my part in helping this issue by working with parents and making nutrition education accessible to schools.

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

Seeing clients find a renewed energy, positive outlook and achieve results toward their health goals is extremely satisfying. We are in control of our bodies and our happiness. We just need to be reminded sometimes.

Where did you grow up?

I grew up in a small town in Vermont where being active outdoors and eating home cooked meals with my family were big parts of my life.

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

I attended Emerson College. Trying to balance classes, homework, internships, work and eating healthy on a tight budget stands out as a challenge. Thinking back to that time helps me keep things in perspective and reminds me that people often have hectic lives, and expectations need to be simplistic and realistic when it comes to beginning to incorporate positive change.

Are you married? Do you have children?

I am married to my high school sweetheart. We look forward to having children when the time is right.

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

Regular yoga practice came into my life a couple of years ago as a way to relieve stress. Now, I can’t live without it. I also enjoy capturing emotion and natural beauty through photography.

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

The documentary, “Discover the Gift,” is a film about self-discovery and living a life you love. I think it will resonate well with anyone who is feeling lost in their life, career, or spiritual practice and in need of inspiration.

Any additional comments?

I invite you to visit my Web site and follow my blog for healthy tips, recipes and inspiration. You can also follow me on Facebook and Twitter. I offer free consultations for those interested in discussing their health goals and learning more about how a health coach can support them in achieving health and happiness.

Posted in Disease Management, Wellness Coach Profile, Wellness/Prevention | No Comments »

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

January 12th, 2012 by Jessica Papay

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

HIN: What is the purpose of case management?

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

HIN: What is care management at the provider level?

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

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

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

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

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

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

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

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

January 9th, 2012 by Patricia Donovan

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

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

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

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

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

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

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

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

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

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

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

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

Meet Wellness Coach Ramona Fasula: Driven by Dad’s Struggle with Diabetes

January 3rd, 2012 by Jessica Papay

Here we take an inside look at a wellness coach, the choices made on the road to success, and the challenges ahead.

Ramona Fasula, owner of Wellness by Ramona.

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

Ramona Fasula: My first job out of college was working for a mortgage company. I continued my path in the financial industry working in banking and then I worked as an analyst for an investment management firm. I was laid off during the financial crisis and it forced me to think about my life and what I wanted in my career. The day I was laid off, I had a conversation with a friend of mine, who said that I’ve always been into health and fitness and I was great with people. She encouraged me to follow my passion and start my own business. I always wanted to own my own business, but I wasn’t sure what I wanted to do. It took losing my job to figure it out. The next day, I enrolled at the Integrative Institute for Nutrition and got my health coaching certificate 11 months later. It was the best decision I ever made in my life. My father always told me that if you do not have your health, you have nothing, and that is true. Your health affects every aspect of your life. To be able to help other people live longer, healthier lives is rewarding. I could not ask for a better job.

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

I am a certified holistic health coach. Beginning this month, I will be attending an integrative nutrition cooking program for six months. I will also be working on becoming a certified aromatherapist. Once I finish those programs, I will be pursuing a PhD in naturopathic medicine.

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

I knew I was on the right track when one of my clients, who has fibromyalgia, told me that she had been through 10 specialists in one year and I was the only person who has been able to help her. She had lost 40 pounds, which is something that she hadn’t been able to do before she started working with me. Symptoms of the fibromyalgia had also started to disappear.

In brief, describe your organization.

My goal is to offer many different healing modalities to my clients. Starting this month, I will be expanding the business. In addition to health coaching, I will be offering healthy cooking classes, Reiki and raindrop therapy, which is an amazing technique invented by Dr. Gary Young, who owns Young Living Oils. I strongly believe in the power of education. The more education that I receive, the more I can offer my clients.

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

Every day, take the time to focus on your “primary foods” and evaluate what you are getting out of them. This includes career, spirituality and the relationships that you keep, among other things. If you are not getting out of them what you’d like to, then you need to make some changes in your life. Unfortunately, primary foods affect the types of foods that you eat. You want to make sure that you are nourishing your body, mind and spirit each day. They are all connected. I also strongly believe in the power of positive thinking. Positivity attracts positive things into your life, while negativity will do the opposite.

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

Right now, the focus has definitely been school; however, I have been working on developing relationships with the American Diabetes Association and the Juvenile Diabetes Association. Diabetes is an epidemic in this country and it needs to be stopped. The way to do that is through education. I am planning to do many diabetes workshops this year to teach people how to not only manage this disease, but to prevent it. Knowledge is power.

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

I will work with anyone who needs my help, but I would really like to focus on working with diabetics. My father passed away from complications of the disease 10 years ago and I’m convinced that if I knew then what I know now, he would still be alive today. There are 25.8 million Americans suffering from this disease and 8 million who go undiagnosed. That number is expected to triple by 2050. Diabetes is all about diet, and I believe that so many diabetics do not know how to eat for this disease. In memory of my father, I want to help people so that they don’t have to suffer the way that my father did.

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

To be able to wake up every day, knowing that you made a difference in someone’s life. That’s why I am a health coach — to make a difference.

Where did you grow up?

I was born in Staten Island, NY. I lived there for 10 years, moved to New Jersey for a year, and then to Pennsylvania where I still live today. I live right outside of Philadelphia.

What college did you attend?

I attended Millersville University in Lancaster, Pennsylvania for my undergraduate degree, which is in marketing. In December I finished up my MBA at UMASS-Amherst.

Are you married? Do you have children?

No, I’m not married yet. I believe that in order to have a successful marriage, you need to know who you are and what you want out of life. I feel like I’m just figuring that out right now.

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

Dance has always been my passion. I took dance lessons for many years. Thanks to the television show “Dancing with the Stars,” I really started getting into ballroom dance. I had to stop taking lessons for a while because my MBA became too time consuming.

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

I recently read “Battlefield of the Mind” by Joyce Meyer. Health is not just about what you eat, it is also about what you think. Thinking positive thoughts has a profound impact on your health, so we definitely need to make sure that we are guarding our mind and thinking positive, healthy thoughts. I would definitely recommend this book.

Posted in Disease Management, Health Coaching, Wellness Coach Profile, Wellness/Prevention | No Comments »

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

December 23rd, 2011 by Cheryl Miller

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

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

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

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

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

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

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

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

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

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

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

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

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

Enabling patients and families.

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

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

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

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

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

Hospital Initiative, GE-Microsoft Collaboration Target Healthcare-Acquired Conditions

December 19th, 2011 by Cheryl Miller

Hospitals are the targets of two of our stories this week: an initiative and collaboration both aimed at reducing the millions of preventable injuries and complications arising from hospital-acquired infections (HAI.) Ironically, this refuge for the sick is making people sicker; in the United States alone, an estimated 1.7 million HAIs occur annually, resulting in $35 billion in additional healthcare costs, and the loss of nearly 100,000 lives. As we reported in an earlier story this year, a University of Maryland report found that nearly half of the hospital rooms of patients who tested positive for a multi-drug resistant bacteria were contaminated with the bacteria.

In response to this, hospitals across the country will now have the resources and support to reduce HAIs: the HHS has launched a new initiative called the Hospital Engagement Network. Part of the Partnership for Patients initiative, a nationwide public-private collaboration to improve healthcare, $218 million will be awarded to 26 state, regional, national, and hospital system organizations to help develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety.

And a new collaboration between GE Healthcare and Microsoft is tackling this problem by pulling together data from disparate IT systems and identifying those patients most at risk for a given HAI. Hopefully their solutions will enable healthcare organizations to more effectively deploy their resources and deliver better care at lower costs.

And on a local level, a new ER unit designed solely for seniors is in place in HIN’s backyard, at New Jersey’s Monmouth Medical Center. To ease the increasingly complex needs of those 65 and up, the unit has special age-related features like wall sconces with dimmers and floor lighting to prevent falls. More in this issue.

In other news, a new study shows that disease registries can improve health outcomes and save the United States billions of dollars. Research on 13 registries in five countries, including the United States and Sweden, shows that these tools are becoming even more important under healthcare reform as payments for care are linked to effective treatments. According to our 2011 Survey on patient registries, 68 percent of respondents are using registries to improve care quality.

And lastly, a new report from Deloitte reveals that the majority of physicians do not think that PPACA will reduce costs by increasing efficiency, and they are predicting a continued shortage in primary care physicians as they seek administrative roles in health plans, hospitals and other settings.

These stories and more, in this week’s issue of Healthcare Business Weekly Update.

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Disease Management, Health IT, Healthcare Administration, Healthcare Costs, Healthcare Trends, Hospital Readmissions, Transitions in Care, Uncategorized | No Comments »

Forget About the Pizza, What About the Sodium?

December 7th, 2011 by Cheryl Miller

Pizza is not a vegetable.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

November 30th, 2011 by Jessica Papay

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

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

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

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

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

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

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

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

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

Got an Idea? CMS Offers $1 Billion in Health Care Innovation Challenge

November 28th, 2011 by Cheryl Miller

The CMS continues to reward innovation in healthcare; the latest initiative, the New Health Care Innovation Challenge, plans to award up to $1 billion in grant money to organizations that come up with creative ways to deliver healthcare, improve care and lower costs. The agency will take notice of projects that can be up and running within six months and that can hire, train and deploy workers rapidly. Funded by the PPACA, it’s a push for both creative healthcare solutions and increased healthcare job opportunities in as short amount of time as possible, contrary to the Innovation Advisors initiative launched in October, which seeks healthcare solutions over a year long, labor intensive period. All segments of the healthcare industry are encouraged to apply for the Innovation Challenge; December 19th is the cut off date for LOIs.

A quick, innovative, effective solution is also needed to alter the latest statistics on diabetes furnished by the IDF on World Diabetes Day (November 14th): studies show that one adult in 10 will have diabetes by 2030. Far too many are already afflicted with the preventable disease, including 78,000 children suffering with type 1; this despite the fact that the greatest number of diabetics fall within 40 to 59 years of age. The IDF is hoping that continued international awareness of this problem will help; and the agency is in the midst of a five-year campaign to promote diabetes education and prevention programs. Ironically, the CMS cited one health system that worked with community partners to decrease the risk of diabetes with nutrition programs as inspiration for its Healthcare Challenge initiative. Food for thought.

Another area of concern is the number of seniors receiving the wrong medication during their home healthcare visits. The Journal of General Medicine recently published a study stating that nearly 40 percent of patients 65 and over are prescribed potentially inappropriate medications (PIMs) at rates three times higher that patients who visit a medical office. Some of the blame can be placed on our fragmented healthcare system, researchers said: home health-based patients see multiple physicians who don’t communicate with each other, resulting in the wrong medication. Perhaps most troubling about this study is that the majority of these patients are taking 11 medications on average, and nearly half of them are taking at least one PIM, researchers say.

And lastly, one quick fix that should boost care access for patients: a new clinical affiliation between CVS Minute Clinics and Emory Healthcare. The stand alone clinics are open seven days a week in select areas throughout metropolitan Atlanta and have nurse practitioners on hand to administer wellness and preventive services and tend to common family illnesses. Patients who need care not provided at the clinics will be referred to Emory Healthcare. Both CVS and Emory hope to streamline the process with the use of EMR systems. These stories and more in this week’s issue of Healthcare Business Weekly Update.

Posted in Accountable Care Organizations, Avoidable ER Use, Bundled Payments, Disease Management, Health IT, Healthcare Costs, Healthcare Trends, Hospital Readmissions, Uncategorized, Wellness/Prevention | No Comments »

Mini Medical Homes Open Door to Disease-Based Patient-Centered Care

November 22nd, 2011 by Patricia Donovan

Call it Medical Homes 2.0: disease-specific ‘mini’ medical homes for high-risk, high cost patients with chronic diseases.

“We do see a trend right now with the medical home; especially in the Medicare area where the patient is assessed up front,” noted Steve T. Valentine during HIN’s eighth annual healthcare industry forecast. This approach generally focuses on but is not limited to the ‘big five’ chronic diseases: ischemic heart disease, diabetes, COPD, asthma and heart failure, Valentine said.

“For example, let’s just pick diabetics and move them into their own mini medical home. They would have a multidisciplinary team focused around those complex patients,” said the president of The Camden Group. “We see that as a bigger change that’s beginning to come. This model does help with throughput in terms of primary care in the medical home.

“A focus on population management and delivering superior value become critical strategies as we begin to move forward,” Valentine predicted during the healthcare publisher’s annual industry forecast.

The disease-specific approach is gaining followers as the industry navigates away from a fee-for-service environment toward a more evidence-based, protocol-driven approach that rewards not only clinical outcomes but an organization’s ability to deliver value-based healthcare.

HealthCare Partners Medical Group of California, which is experiencing its lowest hospital readmission rates in its history, uses a predictive modeling tool, a dollar tool predictor, and a hierarchical condition categories (HCC) or HCC-like modeling tool to risk-stratify their patients before placing them in the medical home that best suits their needs, explains Dr. Stuart Levine, corporate medical director.

This could be hospice and palliative care, or a home care program where teams of physicians, nurse practitioners, case managers and social workers take care of chronically frail patients at home, meeting all of their needs, Dr. Levine said.

HealthCarePartners also has a medical home program for patients with end-stage renal disease (ESRD). “All patients are seen at the dialysis center, and that’s where their medical home is. They no longer come into offices. They are seen by nurse practitioners with backup nephrologists.

“They’re not only getting their renal disease managed, but way more importantly, they’re getting all their primary care needs met.”

Some diabetes-focused medical homes are being constructed with a little help from corporate sponsors. The GE Foundation recently awarded a $3M grant to establish a Care Management Medical Home Center for 10,000 Miami Dade patients suffering from chronic diabetes and its costly and debilitating side effects. The grant is part of the GE Foundation’s Developing Health initiative.

The grant will enable Health Choice Network of Florida and its seven participating health centers to provide a centralized model staffed with medical professionals who will assist the health center teams in providing high quality, effective and efficient care management services that will decrease costly hospitalizations and emergency room visits.

In addition to the new jobs the funding will add, the center will leverage existing data warehouse infrastructure and electronic medical records to deploy real-time disease-specific patient panels, identify health trends and expects to improve diabetic patient outcomes by 10 to 20 percent in the first year.

The Camden (N.J.) Coalition of Healthcare Providers and the Cooper Foundation will receive $3.45 million over five years from the Bristol-Meyers Squibb Foundation to strengthen community-based components of its Camden Citywide Diabetes Collaborative care model by focusing on patient self-management, education and support, care coordination, food access and physical activity programs, and behavioral health and community engagement activities in order to bend the curve of the diabetes burden and healthcare costs in the city.

One of the goals of the diabetes collaborative is to Increase the capacity of community-based, primary care practices to provide comprehensive, proactive care to their patients with diabetes.

The Camden collaborative was one of eight organizations to receive grants from the Bristol-Meyers Squibb Foundation grants.

The mini medical home approach is not limited to the big five chronic diseases. Last week, Priority Health and Cancer and Hematology Centers of West Michigan (CHCWM) announced their intention to jointly explore an innovative oncology patient-centered medical home. The goal of the oncology medical home is to integrate and coordinate the many office visits, medical professionals, high-tech services and care decisions encountered by cancer patients to help streamline their care while ensuring better outcomes, Priority Health said in a press release.

“This project is a natural evolution of our extensive experience with medical homes,” said John Fox, M.D., Priority Health’s associate vice president of medical affairs. “Cancer patients experience complex medical needs and rely on an extensive network of interdisciplinary healthcare specialists. Having a medical home can ensure cancer patients receive optimal care.”

Both organizations have agreed to payment reforms and care enhancements. Under this new model, oncologists will be paid a care management fee and will share in savings resulting from reductions in emergency room visits, imaging and hospitalizations. Current fee structures pay physicians based on the costs of drugs administered, which results in higher payments for more costly drugs, not necessarily the physician’s time, expertise or resource utilization.

The care management fee will go directly for patient support services, such as end-of-life and financial counseling, case management, medication therapy management, survivorship programs and social work services.

Posted in Avoidable ER Use, Bundled Payments, Disease Management, Patient-Centered Medical Home, Physician Practices, Reducing Readmissions | No Comments »

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