Archive for the ‘Elder Care’ Category

Use Annual Wellness Visit to Screen for Social Determinants of Health in High-Risk Medicare Population

December 13th, 2016 by Patricia Donovan

The social determinant of social isolation carries the same health risk as smoking, and double that of obesity.

With about a third of health outcomes determined by human behavior choices, according to a Robert Wood Johnson Foundation study, improving population health should be as straightforward as fostering healthy behaviors in patients and health plan members.

But what's unstated in that data point is that the remaining 70 percent of health outcomes are determined by social determinants of health—areas that involve an individual's social and environmental condition as well as experiences that directly impact health and health status.

By addressing social determinants, healthcare organizations can dramatically impact patient outcomes as well as their own financial success under value-based care, advised Dr. Randall Williams, chief executive officer, Pharos Innovations, during Social Determinants and Population Health: Moving Beyond Clinical Data in a Value-Based Healthcare System, a December 2016 webinar now available for replay.

"The challenge is that few healthcare systems are currently equipped to identify individuals within their populations who have social determinant challenges," said Dr. Williams, "And few are still are structured to coordinate both medical and nonmedical support needs."

The Medicare annual wellness visit is an ideal opportunity to screen beneficiaries for social determinants—particularly rising and high-risk patients, who frequently face a higher percentage of social determinant challenges.

Primary social determinants include the individual's access to healthcare, their socio- and economic conditions, and factors related to their living environment such as air or water quality, availability of food, and transportation.

Dr. Williams presented several patient scenarios illustrating key social determinants, including social isolation, in which individuals, particularly the elderly, are lonely, lack companionship and frequently suffer from depression. "Social isolation carries the same health risk as smoking and double that of obesity," he said.

While technology is useful in reducing social isolation, studies by the Pew Research Center determined that segments of the population with the highest percentage of chronic illness tend to be least connected to the Internet or even to mobile technologies.

"Accountable care organizations (ACOs) and other organizations managing populations must continue to push technology-enhanced care models," said Dr. Williams, "But they also have to understand and assess technology barriers and inequalities in their populations, especially among those with chronic conditions."

In another patient scenario, loss of transportation severely hampered an eighty-year-old woman's ability to complete physical rehabilitation following a knee replacement.

Dr. Williams then described multiple approaches for healthcare organizations to begin to address social determinants in population health, including patients' cultural biases, which may make them more or less open to specific care options. This fundamental care redesign should include an environmental assessment to catalog available social and community resources, he said, providing several examples.

"This is not the kind of information you're going to find in a traditional electronic health record or even care management platforms," he concluded.

Infographic: Caregivers Key to Patient Engagement

January 8th, 2016 by Melanie Matthews

While non-professional caregivers realize technology for seniors can enrich the lives of older adults in their care, many of these caregivers are the unintentional barriers to the actual technology's adoption, according to a new infographic by Philips.

The infographic looks at how caregivers help improve the lives of older adults in their care, how caregivers and older adults are using technology and the potential benefits of technology in the care of older adults.

From home sensors that track daily motion and sleep abnormalities to video visits via teleconferencing, Humana's nine pilots of remote patient monitoring test technologies to keep the frail elderly at home as long as possible. When integrated with telephonic care management, remote monitoring has helped to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges.

In Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population, Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, reviews Humana's expanded continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you'd like featured on our site? Click here for submission guidelines.

One-Fourth Operate Post-Discharge Clinics to Curb Hospital, Post-Acute Readmissions

June 4th, 2015 by Patricia Donovan

Dedicated post-discharge clinics address medication concerns so high-risk patients don't end up back in the hospital.


Almost one-quarter of healthcare organizations—24 percent—operate dedicated post-discharge clinics for patients recently discharged from the hospital, nursing home or ED, according to the April 2015 Care Transitions Management survey by the Healthcare Intelligence Network.

A post-discharge clinic is designed to address issues related to a patient's recent hospitalization and ensure that the individual's transition from hospital or post-acute facility to their primary care doctor is smooth.

In a 2014 presentation, Torrance Memorial Health System described the typical operation of its follow-up clinic, the Coordinated Care Center, which is focused on medication management, a key driver of avoidable hospital readmissions. The health system stressed that the clinic is not a replacement for follow-up primary care following a hospitalization:

“One tactic [for reducing readmissions] is to encourage each of our patients going home from the hospital and SNF to make an appointment at our post-acute clinic with the physician who does medication reconciliation. She asks the patients to bring in all the medications they were on before they went to the hospital and all those prescribed at the hospital.

"They then have a 45-minute conversation, discussing medication plans moving forward, which ones they should take and which they shouldn’t, making sure with teach-back methodology the patient has a clear understanding of expectations in terms of consuming medication once they return home later that day. Those appointments normally take place within the last 72 hours.”

A dedicated post-discharge clinic is one way to plug glaring gaps in care transition management: insufficient follow-up. More work is needed during the actual patient handoff to break down the top barrier to smooth care transitions identified by HIN's fourth annual care transitions management assessment: communications between care sites.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN's fourth annual analysis of these cross-continuum initiatives examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

13 Metrics on Care Transition Management

May 7th, 2015 by Cheryl Miller

Care transitions mandate: Sharpen communication between care sites.


Call it Care Transitions Management 2.0 — enterprising approaches that range from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.

To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of 116 respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care®, and other models.

Whether self-styled or off the shelf, well-managed care transitions enhance both quality of care and utilization metrics, according to this fourth annual Care Transitions survey conducted in February 2015 by the Healthcare Intelligence Network. Seventy-four percent of respondents reported a drop in readmissions; 44 percent saw decreases in lengths of stay; 38 percent saw readmissions penalties drop; and 65 percent said patient compliance improved.

Following are eight more care transition management metrics derived from the survey:

  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • Discharge summary templates are used by 45 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

Making a Case for Embedded Case Management: 13 Factors Driving Onsite Care Coordination

April 16th, 2015 by Patricia Donovan

Compliance with Triple Aim goals, participation in CMS pilots to advance value-based care, formation of multidisciplinary teams and avoidance of CMS hospital readmissions penalties are among the factors driving placement of case managers at care points, according to HIN's 2014 healthcare benchmarks survey on embedded case management.

Participation in the Medicare Physician Group Practice Demonstration, the Comprehensive Primary Care Initiative, and the Multi-Payer Advanced Primary Care Practice demonstration has prompted a number of the survey's 125 respondents to embed case managers in primary care practices, hospital admissions and discharge departments and emergency rooms, among other sites.

To help organizations make the case for embedded case management, here are nine more program drivers, in respondents' own words:

  • "Face-to-face contact with complex patients and their family to build trust and relationships, working directly with providers and staff."
  • "Five to 8 percent of patients account for 40 to 60 percent of costs. It is logical. Second, ED visits and discharges represent at-risk patients where interventions can make a difference. Third, focus needs to be placed on fostering better screening results. Effort to reduce utilization."
  • "Pursuing medical home model and team-based care, along with continuum care coordination."
  • "Integration work between medical and behavioral healthcare."
  • "Employer, health system, and payor collaboration to provide population health management in a medical home-like model. Also working on reducing readmissions for high-cost, high-risk conditions such as heart failure, and hospital wanted to develop an ambulatory component to reduce readmissions and improve patients’ quality of life and satisfaction."
  • "Increased care fragmentation related to transitions in care, challenges in utilization between military and civilian network access-to-care, increased need for complex care coordination, etc."
  • "We felt we needed to ensure the case managers were considered a part of the patient-centered medical home (PCMH) team."
  • "Research shows [case managers] embedded at the point of care caring for the whole person in all healthcare environments produces better outcomes."
  • "As a rural hospital, it made sense to make the best use of resources."

Source: 2014 Healthcare Benchmarks: Embedded Case Management

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Embedded-Case-Management-_p_4985.html

2014 Healthcare Benchmarks: Embedded Case Management provides actionable data from 125 healthcare organizations leveraging embedded or co-located case management to improve healthcare quality, outcomes and spend—including those applying a hybrid embedded case management approach.

Infographic: Healthy Aging

April 1st, 2015 by Melanie Matthews

By 2030, one out of every five people will be age 65 or over, according to the Massachusetts Healthy Aging Data Report by the Tufts Health Plan Foundation.

An infographic developed by Tufts examines key findings from the study, including details on factors driving health status in those over 65, the impact of racial disparities on health and community recommendations for healthy aging.

Comprehensive Care Coordination for Chronically Ill AdultsBreakthroughs in medical science and technology, combined with shifts in lifestyle and demographics, have resulted in a rapid rise in the number of individuals living with one or more chronic illnesses.

Comprehensive Care Coordination for Chronically Ill Adults presents thorough demographics on this growing sector, describes models for change, reviews current literature and examines various outcomes.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you'd like featured on our site? Click here for submission guidelines.

Countering 5 Remote Monitoring Cautions in Face of mHealth Uncertainty

March 24th, 2015 by Cheryl Miller

remote_patient_monitoring

Physician champions and legislative advocates can spur remote patient monitoring success.

Physician skepticism about mHealth is a frequently cited barrier to implementing remote monitoring. But once physicians understand they can allot in-person visits for those who truly need them, then use their other time remotely monitoring other patients to wellness, they might be more willing to buy in to mHealth.

It's all about educating the physician, advises Dr. Luke Webster, vice president, chief medical information officer, CHRISTUS Health, who shared how CHRISTUS responded to these challenges during its remote patient monitoring pilot.

  • Unclear ROI: There are always questions around ROI. We look at pre-implementation costs and pre-enrollment costs versus post-costs, including all project costs. What does that ROI mean for your organization?
  • Limited Resources: With care transitions, we took remote patient monitoring and put it on top of the care transitions program. That added additional responsibilities to the already busy workflow process. Whether you’re looking at an E-Hub model or expanding these programs into other areas of your organization, it’s important to review that budget up front. What’s expected of your outcome goals? How will you do that from a day-to-day process and biweekly performance outcomes and measures so you meet that targeted overall outcome, whether it’s reducing length of stay, cost of care, or 30-day readmissions?

    You want all of that to match. Your resources have to be identified upfront. We have been very fortunate to have our providers as champions. They buy into it; they understand it. They didn’t buy into it initially because the nurse coach thought it necessary to make that patient home visit. Sometimes it is. But she has found, with these tools, that she can better do that from her office and manage more patients.

  • Physician Skepticism: It is important to understand your champions, your available resources, backup, etc., when issues come up and you need those resources. We’re finding — and statistics state this — that physicians are still more comfortable doing face-to-face visits. Keeping those patients healthier and at home means we’re keeping them out of the facilities. The physicians and primary care providers may have some skepticism regarding that as well. They have less hands-on training with the equipment so perhaps don’t fully understand the opportunity for them to fill clinic days with patients that are truly in need of an appointment that day versus monitoring others who can be coached to wellness at home.

    It’s about educating physicians, finding those champions and engaging them in the overall process and direction of our health system.

  • Reimbursement Regulations: You need an advocate who can speak for you, represent what you’re doing, and prove the value both at a state and federal level. That should be an ongoing process and on your calendar monthly: identifying and calling your state or federal representative.
  • Rising Technology Costs: This is a booming area; vendors can’t get their products out fast enough. When you set up a budget for a program like this and look to initiate a pilot or expansion, you must look at all technology costs—not only for hardware but for software, upgrades and required support. Do you go through a third party vendor, and do you lease or purchase your equipment? When do you purchase the equipment? Just from our original pilot in late 2012 to today, we’ve seen some changes in technology. If your kits are organized to fit that original technology, how will that change 18 months later, and what will be the cost of adjusting the kits (for example, Styrofoam, boxes, etc.)?

    All of that will change. Look at those technology costs and related issues as you move forward and have a plan to how best recycle that kit.

    Remote Monitoring
    Luke Webster, MD, is vice president and chief medical information officer of CHRISTUS Health. Dr. Webster has over 20 years of clinical and health informatics experience. He specializes in health informatics and physician leadership, clinician adoption and change leadership, clinical transformation, evidence-based medicine, clinical analytics and process improvement.

    Source: Remote Patient Monitoring for Chronic Condition Management

Risk Stratification Targets the High-Risk, Curbs Utilization Across Continuum

February 19th, 2015 by Cheryl Miller

Preventive care and utilizing hospital and discharge information are critical for stratification, say a number of thought leaders from organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and often lead to improved clinical and financial outcomes. Here, some advice from these thought leaders.

Across the healthcare continuum, improved clinical and financial outcomes at organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and Ochsner Health System were preceded by rigorous risk stratification of populations served.

“Humana encourages preventive care, and we are trying to prevent the most costly interventions by making sure we address things before they become big problems,” notes Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. “It is successful so far. We have been able to reduce hospitalizations from what we expected by about 42 percent. We have been able to decrease our hospital readmission rate to 11 percent.”

Hospital admission and discharge information is critical for stratification, adds Annette Watson, RN-BC, CCM, MBA, senior vice president of community transformation for Taconic Professional Resources. “Depending on the model in a primary care practice (PCP), if a physician is not the admitting physician—if the admission is from a specialist, hospitalist, or through the ER—it cannot be assumed the PCP has the admission and discharge information. People may think physicians know about their patients being in the hospital, but that is not always the case.”

“Our first step in launching Monarch’s Pioneer ACO program was to develop a population disease profile in risk stratification analysis,” contributes Colin LeClair, executive director of accountable care at Monarch HealthCare. “With the help of Optum Actuarial Solutions, we identified the eight most prevalent and costly conditions in our population. We then identified the largest cohort of high-risk patients best suited for Monarch’s care management programs. Ultimately we isolated the top 6 percent of high-risk patients with a diagnosis of diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or renal disease and found that of those patients, 6 percent account for 43 percent of total medical cost across the entire population. That analysis resulted in us targeting about 1,200 high-risk patients who have a similar constellation of issues.”

“You want to look at your high utilizers of care, because they’re using a great deal of care,” concludes Elizabeth Miller, RN, MSN, vice president of care management at White Memorial Medical Center, part of Adventist Health. “There’s potential for decreasing procedures, tests, ED visits, hospitalizations.”

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Hospital-Readmissions_p_4786.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.

BCBSM Physician Incentives Target 5 Root Causes of High-Cost Healthcare

February 17th, 2015 by Cheryl Miller

Designed to target underlying reasons for high-cost healthcare, Blue Cross Blue Shield of Michigan's (BCBSM) Physician Group Incentive Program (PGIP) rewards and incentivizes providers to enhance the delivery of care. To address poorly aligned incentives, for example, they developed tiered fees based on performance measured at the population level, not just at the individual physician level or patient’s level, says Donna Saxton, BCBSM's field team manager of BCBSM's value partnerships program.

How has the program evolved? The several root causes of high-cost healthcare within our system were readily apparent: poorly aligned incentives, a lack of population focus, very fragmented healthcare delivery, a lack of focus on process excellence or process improvement and a weak primary care foundation. As we’ve developed our Physician Group Incentive Program (PGIP) initiative, we were strategic and deliberate in how we were going to address the root causes of our high-cost system, keeping in mind the tenets and the philosophy of the PGIP program.

To address poorly aligned incentives, we developed tiered fees based on performance measured at the population level, not just at the individual physician level or patient’s level.

Tiered performance fees also addresses the lack of population focus and places emphasis on all patients and payor registries.

The one thing that really makes our PGIP program unique is that we are payor-agnostic. The incentive dollars we have distributed through the life of the program readily help and incentivize other payors in the state, because if these capabilities are implemented, they ultimately serve all the patients in our state. We’re very proud of that because we feel that that is part of the servant leadership we need to do for patients and members in our state.

To attack the fragmented healthcare delivery, we've organized our systems of care, aligning our incentives for primary care physicians, hospitals and specialists.

We also have collaborative quality initiatives, which help sharpen our physicians, specialists and care delivery people on the science of process improvement.

Our PCMH initiative is our pinnacle initiative, which we believe has strengthened our primary care foundation across the state.

generating medical home savings
Donna Saxton, field team manager of Blue Cross Blue Shield of Michigan’s (BCBSM) value partnerships program, currently oversees the team of representatives that support the statewide collaborative relationships with 44 physician organizations (PO) and 39 organized systems of care (OSCs) that participate in the BCBSM Physician Group Incentive Program (PGIP).

Source: Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures

Registries Identify High-Risk Patients, Support Evidence-Based Protocols

January 6th, 2015 by Cheryl Miller

Obtaining a clear snapshot of a patient population is the first step in managing health outcomes in an accountable care organization (ACO), says Gregory Spencer, MD, FACP, chief medical officer with Crystal Run Healthcare. Registries are a major part of that, and at Crystal Run Healthcare, care managers use them to identify high-risk patients, implement evidence-based protocols, and coordinate care inside and outside the office.

We have used care managers for about seven years. Groups of nurses use our registries to identify high-risk patients and implement evidence-based protocols. We have used an EHR, and we use e-mail and Blackberries ® extensively within our practice so that when we have a new development, we can get the word out quickly to mobilize people or alert them that certain things are happening. Registries are a major part of this: getting your list of people with a high-risk condition.

Our care managers are nurses that pull the list of patients from the registry using evidence-based guidelines. They contact them, make sure they get certain things done that they need to have done, and smooth those efforts. They do care planning and then communicate with the patients outside of the office. We are also embedding a care manager at a few of our sites to try and catch patients while they are in the office as well.

The template we use is pretty basic. It keeps track of the patient’s last test, and includes certain results so that if the patient has a question or is due for some lab work, the care manager can quickly order it. If it’s not protocol-driven, they can send it to the physician for review or potentially do it themselves if we are able to cover it with a protocol. This is one way we use registries of patients who require referral tracking.

Again, workflow is the Achilles heel of some brilliant quality efforts. You don’t want to destroy your workflow and patient flow. Not to say that you can’t redesign your workflow if it is important, but this process can end in tears. Sometimes if the change is not well thought out, it has negative effects on workflow.

Source: Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care

http://hin.3dcartstores.com/Population-Health-Management-Tools-for-ACOs-Technologies-and-Tactics-to-Support-Accountable-Care_p_4204.html

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care examines the building blocks of population health management that drive improvements in healthcare quality and efficiency in ACOs — while positioning healthcare organizations for core measure improvement and increased reimbursement. In this 40-page resource, Dr. Gregory Spencer, chief medical officer of Crystal Run Healthcare, demystifies registry use and shares patient registry best practices.