Archive for the ‘Health Coaching’ Category

Patient Engagement Prerequisite: School Staff in Patient Activation, Health Literacy

October 19th, 2017 by Patricia Donovan

YNHHS embedded care coordinationEven after multiple years of patient engagement education, awareness training and related programming for its clinicians, PinnacleHealth Systems knew those efforts needed to continue if they were to move forward with new interventions. Here, Kathryn Shradley, director of population health, PinnacleHealth System, describes two key focus areas for clinician education.

We wanted to level-set on the definitions of patient activation and health literacy and what these terms meant to the organization and to the teams within. In full transparency, I want to be very clear: I believe initiatives for health literacy, patient engagement, patient education and population health will be on our task list for as long as I’m employed, and that’s okay.

We spent a lot of time educating front-line clinicians on health literacy, understanding who was using the Patient Activation Measure® (PAM®) and tools and attempting to broaden the language used around the health system. One of our initial goals was simply to have the words ‘health literacy’ be recognized and understood throughout the system. This is certainly still something we work on daily as a core piece of all of our engagement strategies. I’m happy to say that we have made progress.

One of the ways we obtained buy-in for our patient engagement strategy was to talk about the financial bottom line of low levels of patient activation and low levels of patient health literacy. We demonstrated to our executive teams, directors and managers that no matter where they were building an initiative and what they were building, if they didn’t include an engagement strategy in their product or service line, they were likely to experience difficulty—a difficulty that could otherwise be mitigated if we addressed some of these issues in their programs.

Source: Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians

patient engagement

Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians describes PinnacleHealth’s two-pronged strategy for prioritizing patient engagement among its clinicians and patient population, tactics that elevated key quality and clinical metrics in the process.

SNF Visits to High-Risk Patients Break Down Barriers to Care Transitions

September 21st, 2017 by Patricia Donovan

For patients recently discharged from the hospital, a SNF visit covers the same ground as a home visit: medications, health status, preparing for physician conversations and care planning.

The care transitions intervention developed by the Council on Aging (COA) of Southwestern Ohio for high-risk patients starts off in the hospital with a visit by an embedded coach, and includes a home visit.

Additionally, to reduce the likelihood of a readmission, patients discharged to a skilled nursing facility (SNF) also can expect a COA field coach to stop by within 10 days of SNF admission. Here, Danielle Amrine, transitional care business manager for the COA of Southwestern Ohio, describes the typical SNF visit and her organization’s innovative solution for staffing these visits.

We conduct the home visit within 24 to 72 hours. We go over medication management, the personal health record (PHR), and follow-up with specialists and red flags. At the SNF, we do the same things with those patients, but in regards to the nursing facility: specifically, do you know what medications you’re taking? Do you know how to find out that information, especially for family members and caregivers? Do you know the status of your loved one’s care at this point? Do you know the right person to speak to about any concerns or issues?

We also ask the patients to define their goals for their SNF stay. What are your therapy goals? What discharge planning do you need? We set our SNF visit within 10 calendar days, because normally within three days, they’ve just gotten there. They’re not settled. There haven’t been any care conferences yet. We set the visit at 10 calendar days to make sure that everything is on track, to see if this person is going to stay at the SNF long-term. Our goal is to have them transition out. We provide them with all of the support, resources and program information to help them transition from the nursing facility back to independent living.

For our nursing facility visits, we also utilize the LACE readmissions tool (an index based on Length of stay, Acute admission through the emergency department (ED), Comorbidities and Emergency department visits in the past six months) to see if that person would need a visit post-discharge.

For our CMS contract, we are paid for only one visit. Generally we’re only paid for the visit we complete in the nursing home, but through our intern pilot, our interns do that second visit to the home once the patient is discharged from the nursing home. We don’t pay for our interns, and we don’t get paid for the visit. We thought that was a perfect match to impact these patients who may have a hard time transitioning from the nursing facility to home.

Source: Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

home visits

In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) of Southwestern Ohio, describes her organization’s home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

PinnacleHealth Engagement Coaches Score Points with High-Risk Patients, Win Over Clinicians

September 7th, 2017 by Patricia Donovan

PinnacleHealth’s targeted outreach, 24/7 nurse advice line and clinician coaching have helped to bring chronic disease high utilizers back to care.

A dual engagement strategy by PinnacleHealth System that recruits both patients and providers is scoring significant gains in CAHPS® scores, clinical indicators in high risk patients, and the provision of health-literate care.

Kathryn Shradley, director of population health for PinnacleHealth System, outlined her organization’s patient engagement playbook during A Two-Pronged Patient Engagement Strategy: Closing Gaps in Care and Coaching Clinicians, an August 2017 webcast now available from the Healthcare Intelligence Network training suite.

The winning framework? Focused outreach and health coaching for high-risk, high utilizers that break down barriers to care, and a patient engagement coach to advise PinnacleHealth clinicians on the art of activating patients in self-management.

PinnacleHealth’s engagement approach, aligned with its population health strategies and based on the Health Literate Care Model, began in its ambulatory and primary care arenas. Before any coaching began, the health system schooled its staff on the value of health literacy. “Moving to a climate of patient engagement is nothing short of a culture change for many of our clinicians,” said Ms. Shradley.

To foster leadership buy-in, PinnacleHealth also strove to demonstrate bottom-line benefits of patient engagement, including lowered costs and staff turnover and increased standing in the community.

Then, having combed its registry to identify about 1,900 chronic disease patients most in need of engagement, the health system hired a health maintenance outreach coordinator who built outreach and coaching pilots designed to break down barriers to care. At the end of the six-month pilot, higher engagement and lower A1C levels were noted in more than half of these patients. For the 23 percent that remained disengaged, the outreach coordinator dug a little deeper, uncovering additional social health determinants like transportation they could address with more intensive coaching and even home visits.

At the same time, a new 24/7 nurse advice line staffed with PinnacleHealth employees continued that coaching support when the health coach was not available.

Complementing this patient outreach is a patient engagement coach, a public health-minded non-clinician that guides PinnacleHealth providers in the use of tools like motivational interviewing and teach-back during patient visits to kindle engagement.

“The engagement coach does a great job of standing at the elbow with our providers in a visit, outside of a visit, surrounding a visit, to talk about what life looks like from the patient side of view.”

Providers and staff receive one to two direct coaching sessions each year, with additional coaching available as needed.

With other elements of its patient engagement approach yet to be implemented, PinnacleHealth has observed encouraging improvements in HCAHPS scores for at least one practice that received coaching over seven months. It has also learned that by educating nurses on health-literate care interventions, it could increase HCAHPS communication scores.

Listen to an interview with Kathryn Shradley: PinnacleHealth’s Patient Engagement Coach for Clinicians: Supportive Peer at Provider’s Elbow.

Infographic: How to Make Fitness Resolutions that Stick in the New Year

December 30th, 2016 by Melanie Matthews

The failure rate for New Year’s resolutions is truly shocking. Every year some 64 percent of people will resolve to change for the better. Eating healthy food, losing excess pounds or getting fit are the most common goals, according to a new infographic by Fitness Review.

The infographic examines the key factors which can increase the success rate of these goals.

Infographic: How to Make Fitness Resolutions that Stick in the New Year

Increasing demand for quality-based, pay-for-value healthcare has elevated the health coach’s contribution to chronic care management and population health. From supporting ‘rising risk’ populations telephonically to conducting home visits for recently discharged high-risk, high-cost individuals, health coaching offers an essential care management touch point.

2016 Healthcare Benchmarks: Health Coaching is the fifth comprehensive analysis of the health coaching arena by the Healthcare Intelligence Network, capturing key metrics such as populations, health conditions and health risk levels targeted by health coaching programs; risk stratification criteria; prevalence of embedded coaching within care sites; coaching tools and incentives as well as program outcomes and ROI from more than 100 healthcare organizations.

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.

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.

HINfographic: Health Coaching: A Win-Win Game Plan for Behavior Change

November 28th, 2016 by Melanie Matthews

From supporting ‘rising risk’ populations telephonically to visiting recently discharged high-risk, high-cost individuals at home, health coaches aim to score all-important health behavior change. Seventy percent of respondents to the 2016 Health Coaching survey by the Healthcare Intelligence Network have launched health coaching ventures.

A new infographic by HIN examines the primary duties of health coaches, the trend toward co-location of health coaches and incentives for health coach participation.

2016 Healthcare Benchmarks: Health Coaching2016 Healthcare Benchmarks: Health Coaching is the fifth comprehensive analysis of the health coaching arena by the Healthcare Intelligence Network, capturing key metrics such as populations, health conditions and health risk levels targeted by health coaching programs; risk stratification criteria; prevalence of embedded coaching within care sites; coaching tools and incentives as well as program outcomes and ROI from more than 100 healthcare organizations.

2016 Healthcare Benchmarks: Health Coaching drills down to explore health coaching case loads, experience, certification, performance measurement (individual and program) and more key metrics and is supported with more than 50 graphs and tables. Click here for more information.

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.

Infographic: Achieving Wellness Goals

September 2nd, 2016 by Melanie Matthews

Choosing the right tools and components for employer-sponsored wellness programs can make the difference in terms of generating healthy behavior change in employees, according to a new infographic by CompPsych.

The infographic examines what motivates employees to achieve wellness goals and compares results from health trackers versus coaches.

Increasing demand for quality-based, pay-for-value healthcare has elevated the health coach’s contribution to chronic care management and population health. From supporting ‘rising risk’ populations telephonically to conducting home visits for recently discharged high-risk, high-cost individuals, health coaching offers an essential care management touch point.

2016 Healthcare Benchmarks: Health Coaching is the fifth comprehensive analysis of the health coaching arena by the Healthcare Intelligence Network, capturing key metrics such as populations, health conditions and health risk levels targeted by health coaching programs; risk stratification criteria; prevalence of embedded coaching within care sites; coaching tools and incentives as well as program outcomes and ROI from more than 100 healthcare organizations.

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.

Health Coaching Success Metrics and 8 More Behavior Change Benchmarks

July 7th, 2016 by Patricia Donovan

Satisfied clients and participants on track for goal attainment are two hallmarks of a can't-lose coaching initiative.

Satisfied clients and participants on track for goal attainment are two hallmarks of a can’t-lose coaching initiative.

What are the hallmarks of a winning health coaching strategy? The answer depends on what’s being measured: the effectiveness of the individual coach, the participant’s progress, or overall program success.

That’s the feedback from 111 healthcare organizations responding to the 2016 Health Coaching Survey by the Healthcare Intelligence Network.

If you’re looking to measure the health coach’s success, then client satisfaction is the best indicator, say 27 percent of these respondents.

On the other hand, for a gauge of an individual’s progress, look to the participant’s goal attainment, report 78 percent.

This same metric—goal achievement—is also the best indicator of program success as a whole, agree 64 percent.

The May 2016 survey documented a number of other health coaching benchmarks, including the following:

  • Motivational interviewing is a coach’s top tactic to effect behavior change, say 83 percent.
  • All-important ‘face time’ with coaches is plentiful: 47 percent embed or co-locate health coaches at points of care, with most onsite coaching occurring in primary care offices (50 percent) or at employer work sites (50 percent).
  • Nine percent even embed health coaches in hospital emergency rooms.
  • While a majority focuses on coaching high-risk individuals with multiple chronic illnesses, 51 percent now extend eligibility for health coaching to individuals stratified as ‘rising risk.’
  • Nearly half of respondents—48 percent—offer health coaching to patients and health plan members with behavioral health diagnoses.
  • Reflecting the surge in telehealth, 12 percent of respondents offer video health coaching sessions to clients.

Download an executive summary of the 2016 Health Coaching survey.

Yale New Haven’s High-Risk Care Management Commences with Its Employees

January 14th, 2016 by Patricia Donovan

A care management pilot by YNHHS for employees and their dependents with diabetes was a template for future embedded care management efforts.

Disenchanted with vendors it engaged to provide care management for its workforce, Yale New Haven Health System (YNHHS) launched an initial care management pilot for its high-risk employee populations. The pilot went on to become a very robust program and served as a training ground for two more embedded on-site care management initiatives. Here, Amanda Skinner, YNHHS’s executive director for clinical integration and population health, provides details from on-site face-to-face care management for YNHHS employees and their dependents.

We have an RN care coordinator based on each of the four main hospital campuses of our health system: one in Greenwich, one in Bridgeport and two in New Haven. All of the RN care coordinators in this program are trained in motivational interviewing. The intent is for them to work with our high-risk, high-cost employees who have chronic diseases, and with their adult dependents that also fall into that population.

The care coordinators work with these employees across the entire system to help them access the care they need, identify their goals of care, get under the surface a little to determine barriers to their being as healthy as they can be, and manage them over time. We did create some incentives for employee participation in this program, including waived co-pays on a number of medications (for example, any oral anti-diabetics).

When we initially launched the program, we limited it to employees and dependents that had diabetes, because that was the population for which we had very robust data. We also knew that diabetes was generally a condition that lent itself well to the benefit of care coordination; that there were a lot of gaps in care. When we looked at our data, we saw that ED utilization was very high for this population; that their past trend was rising, that utilization of their primary care provider was actually below what you would expect. This meant that they were under-utilizing primary care, over-utilizing hospital services, and were not particularly compliant with care.

With that population, we saw a lot of opportunity that a care management program could help address. In general, diabetes is a condition that lends itself to accepting a helping hand, to help people understand their condition and address the medical and social issues so they can manage that condition more effectively.

The program has been tremendously successful. We expanded it this year to include wellness coaches based at all of our delivery networks’ main campuses as well. These coaches work with a lower risk population and are available to any health system employee that wants to work with a coach to set care goals and then meet with the coach monthly or quarterly to track improvements against those goals. This expansion is because we’ve seen such positive results from this program.

Source: 3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients across the Continuum examines YNHHS’s three models of embedded care coordination that deliver value while managing care across time, across people, and across the entire continuum of care. In this 30-page resource, Amanda Skinner, executive director for clinical integration and population health at Yale New Haven Health System, and Dr. Vivian Argento, executive director for geriatric and palliative care services at Bridgeport Hospital, present a trio of on-site care models crafted by YNHHS to manage three distinct populations.

New Population Health Management Strategy for ‘Emergent-Risk:’ Arrest Trajectory of Compounding Conditions, Cost

June 11th, 2015 by Adam Kaufman, PhD, President & CEO, Canary Health

Adam Kaufman, PhD, president and CEO, Canary Health


For many years, healthcare organizations have invested in two approaches to population health management: First, wellness management for healthy populations who want to prevent illness, and second, disease/case management for the very sick who must adhere to physicians’ prescribed medical care.

Now, organizations are filling the gap between the healthy and very sick by investing in the ’emergent-risk’ population—adults with one or more pre-chronic or early-stage chronic conditions. Population goal: arrest the trajectory of compounding chronic conditions that compound declines in quality of life and compound increases in cost of care.

Consumer Engagement with Digital Health Self-Management

For many years, the natural worsening of chronic illness has been the focus of academic institutions, a few digital health innovators, and pioneering health plans. As a result of these efforts, a new class of digital health programs is now proven to arrest the trajectory of chronic illness. It started when Stanford’s Patient Education Research Center discovered that self-efficacy (a person’s belief in his or her own ability to achieve goals) had the strongest correlation to improved health outcomes. With this discovery, the concept of health self-management was born. Thus began the drive to engage and impact consumers.

Over the years, healthcare organizations across the United States began offering Stanford’s in-person workshops with notable improvements in health and with measurable reductions in cost of care. According to Stanford research, participants reduced pain, fatigue, depression, and A1C—and reduced ER visits and days in the hospital for up to one year.1 While results were impressive, the programs had one drawback for managers of population health: due to the cost and complexity of in-person delivery, the programs were hard to scale.

As web-based technologies advanced, the research community began to search for ways to harness digital innovation to scale evidence-based programs. In 2006, researchers at the University of Pittsburgh tested the first digital self-management program aimed at diabetes prevention. This digital translation2 of the NIH’s Diabetes Prevention Program3 (DPP) delivered outcomes that mirrored those achieved with the DPP’s in-person, self-management intervention—but at a fraction of the cost.

Data-Driven Insight: The Compounding Effect

As health plans began to adopt digital health self-management, data revealed deeper insights into individuals with prechronic and early-stage chronic conditions. Data from years of Canary Health research with a pioneering health plan shows that chronically ill patients add, on average, a new chronic condition every two to three years. These compounding conditions drive compounding increases in the cost of care—specifically in the areas of pharmacy, medical equipment, and outpatient care.

And without intervention, according to Advisory Board, each year 15 to 20 percent transition to the high-risk population of very sick individuals who require high-cost medical care. This trajectory of chronic illness translates into an additional $1,000-$3,500 in expenses per person, per year. With 80 million adults in this population, that’s an additional $80-$280 billion in costs each year to the U.S. healthcare system. If healthcare leaders don’t prevent this compounding effect, both health plans and providers will hit a financial tipping point where the cost of care puts both margins and mission at risk.

Proven Outcomes: Arresting the Trajectory of Chronic Illness

As health plans began to measure the ROI of digital interventions, a deeper look at results revealed the broader and longer-term impact4 of digital health self-management programs. For emergent-risk populations, the interventions accomplished the following:

  • Halted the progression of individuals’ preconditions to diabetes, heart disease and other conditions;
  • Slowed the progression of existing conditions, and;
  • Prevented compounding conditions and compounding costs of care.

On the heels of this research, the goal became “trajectory impact” at a population level: programs for the emergent-risk population are now designed to arrest the trajectory of compounding conditions and compounding costs of care. With digital technology’s ability to scale, entire emergent-risk populations can be targeted immediately for outreach and intervention.

And with the lower cost structure of digital technology, health self-management interventions can generate a return beginning one year after the intervention and continuing over the lifetime of each individual.

Citations:
1 Lorig K, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999; 37(1):5-14. View the abstract at http://www.ncbi.nlm.nih.gov/pubmed/10413387.

2 The digital translation of the DPP was described in the journal article from McTigue, et al. Using the Internet to Translate and Evidenced Based Lifestyle Intervention into Practice Telemedicine and e-Health Vol 15#9 November 2009. Read more at http://www.ncbi.nlm.nih.gov/pubmed/19919191.

3 The Diabetes Prevention Program (DPP), a major, multicenter clinical research study, discovered that modest weight loss through dietary changes and increased physical activity sharply delayed the onset of type 2 diabetes among pre-diabetic patients. The study showed that taking metformin also reduced risk, although less dramatically. Read more at http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram.

4 A two-year, controlled matched study by Canary Health for GEHA, a self-insured, not-for-profit association providing health and dental plans to federal employees and retirees and their families through the Federal Employees Health Benefits Plan. For a briefing on case study results, contact akaufman.canaryhealth.com

About the Author: Adam Kaufman is a health economist and the president and CEO of Canary Health. He speaks to audiences nationwide on the accelerating trend of chronic illness and the financial tipping point that threatens the margins and mission of American healthcare organizations and advises healthcare senior management teams on making strategic investments in their emergent-risk populations. Prior to serving Canary Health as President and CEO, Adam served as general manager of dLife’s Healthcare Solutions division. Kaufman has served as adjunct assistant professor in the economics department at the University of Southern California, and he is the author of a data analytics patent that predicts consumer engagement.

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