Archive for the ‘Elder Care’ Category

Infographic: PACE by the Numbers

July 5th, 2019 by Melanie Matthews

PACE® (Programs of All-Inclusive Care for the Elderly) is growing both in terms of service area and enrollment, according to a new infographic by the National PACE Association.

The infographic examines PACE enrollment growth, demographics for participants, the top five chronic conditions among participants and program results.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM RevenueSince the January 2015 rollout by CMS of new chronic care management (CCM) codes, many physician practices have been slow to engage in CCM.

Arcturus Healthcare, however, rapidly grasped the potential of CCM to improve patient outcomes while generating care coordination revenue, estimating it could earn up to $100,000 monthly for qualified patients treated in its four physician practices—or $1 million a year.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM Revenue traces the incorporation of CCM into Arcturus Healthcare’s existing care management efforts for high-risk patients, as well as the bonus that resulted from CCM code adoption: increased engagement and improved relationships with CCM patients.

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Food for Thought: Nutrition Programs Reduce Hospital Visits and Readmissions by Vulnerable Populations

August 18th, 2017 by Patricia Donovan

Malnutrition is a social determinant of health that negatively impacts health outcomes.

It’s a difficult statistic to digest: one in three people enter the hospital malnourished or at risk of malnutrition, a state that impacts their recovery and increases their risk of health complications and rehospitalizations.

Two studies this week highlight the clinical benefits of addressing patients’ nutrition needs before and during hospital stays as well as savings that can result from identification of social determinants of health (SDOH) like access to nutrition that drive 85 percent of health outcomes.

In the first, a study of elderly Maryland residents by Benefits Data Trust, a national nonprofit based in Philadelphia, found that when it comes to low-income seniors, access to quality food via food stamps can also save money by reducing the number and duration of hospital visits and nursing home admissions.

In the second, research published in American Health & Drug Benefits journal and supported by Abbott found that when Advocate Health Care implemented a nutrition care program at four of its Chicago area hospitals, it showed more than $4.8 million in cost savings due to shorter hospital stays and lower readmission rates.

The Benefits Data Trust research found that participation by low-income seniors in the federal Supplemental Nutrition Assistance Program (SNAP) cut their odds of hospital admissions by 14 percent. The food stamps also reduced the need for ER visits by 10 percent, and cut their likelihood of going into a nursing home by nearly one quarter.

Finally, SNAP participation also led to an 8 to 10 percent drop in the number of days a patient who was admitted remained in one of these facilities.

As a result, hospitals and health care systems such as Advocate Health Care are looking at the value of nutrition to improve care and help patients get back to living a healthier life.

Starting in 2014, Advocate Health Care, the largest health system in Illinois and one of the largest accountable care organizations (ACO) in the country, implemented two models of a nutrition care program for patients at risk of malnutrition. The nutrition-focused quality improvement program, which targeted malnourished hospitalized patients, consisted of screening patients with a validated screening tool at admission, rapidly administering oral nutritional supplements, and educating patients on supplement adherence.

The leader in population health found that by doing so, it reduced 30-day readmission rates by 27 percent and the average hospital stay by nearly two days.

More recently, to evaluate the cost-savings of the Advocate approach, researchers used a novel, web-based budget impact model to assess the potential cost savings from the avoided readmissions and reduced time in hospital. Compared to the hospitals’ previous readmission rates and patients’ average length of stay, researchers found that optimizing nutrition care in the four hospitals resulted in roughly $3,800 cost savings per patient treated for malnutrition.

Given the healthcare industry’s appetite for value- and quality-based programs, SDOH screenings and the fortification of nutrition programs in both community and inpatient settings appear to be just what the doctor ordered. However, while a 2017 study on Social Determinants of Health identified widespread adoption of SDOH screenings by providers, it also documented a scarcity of supportive community services for SDOH-positive individuals.

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

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

wearables for seniors

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

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

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

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

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

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

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

John Valiton, CEO, Reemo Health

John Valiton, CEO, Reemo Health

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

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

Infographic: Protecting Patients From Falls

March 29th, 2017 by Melanie Matthews

In upstate New York, one in four adults ages 65 or older fell at least once in the last year, according to a new infographic by Univera Healthcare.

The infographic examines the impact of those falls on this population and on emergency room utilization, fall risk factors and fall prevention strategies.

Visiting targeted patients at home, especially high utilizers and those with chronic comorbid conditions, can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit. Increasingly, home visits have helped to reduce unplanned hospitalizations or emergency department visits by these patients.

2017 Healthcare Benchmarks: Home Visits examines the latest trends in home visits for medical purposes, from populations visited to top health tasks performed in the home to results and ROI from home interventions.

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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.

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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.

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