Archive for the ‘Medication Management’ Category

5 Features of the Patient-Centered Medical Home

October 23rd, 2014 by Cheryl Miller

Patient-centered medical homes (PCMHs) are not about pigeon-holing certain diseases or illnesses, says Terry McGeeney, MD, MBA, director at BDC Advisors, but about delivering acute and chronic care prevention and wellness. Dr. McGeeney reiterated the five essential features of the medical home as the groundwork for a medical neighborhood.

Given many of the initiatives of the Centers for Medicare and Medicaid Services (CMS), coupled with the Triple Aim, many have gotten bogged down and probably overly focused on the name: patient-centered medical home (PCMH). What’s important are the features or attributes of the PCMH: first, its patient-centeredness, a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients and ensures patients have the education and support they need.

Secondly, in a PCMH, the care needs to be comprehensive. It’s a team of care providers who are wholly accountable for a patient’s physical and mental healthcare needs, including prevention and wellness, acute care, and chronic care.

Third, you will hear discussions about the PCMH being about a certain disease or illness. Please note that it’s acute and chronic care prevention and wellness. Pigeon-holing conditions, while important, is more of a chronic quality improvement initiative and not PCMH.

Fourth, under the PCMH, care needs to be coordinated. Care is organized across all elements of the broader healthcare system, including specialists, hospital, home healthcare, community service and support. There’s a lot of debate now about what we call ‘post-acute care’ or ‘transitions in care.’ Jonathan Blum, principal deputy administrator of CMS, recently spoke on the importance of post-acute care. This is what coordinated care particularly is all about.

Care has to be accessible. Patients are able to access services with shorter waiting times, after-hours care with access to EHRs, etc., and there has to be a commitment to quality and safety. Clinicians and staff need to enhance quality improvement with the use of health IT and other tools that are available to them.

We also need to be very careful that quality care is not equated with lower cost of care. Sometimes those two have a tendency to get muddled.

Source: Blueprint for a Medical Neighborhood: Building Care Coordination Between Specialists and PCPs

http://hin.3dcartstores.com/Blueprint-for-a-Medical-Neighborhood-Building-Care-Coordination-Between-Specialists-and-PCPs_p_4967.html

Blueprint for a Medical Neighborhood: Building Care Coordination Between Specialists and PCPs provides a framework in which to evaluate the patient-centered medical neighborhood (PCM-N) model. Pictured here is Terry McGeeney, MD, MBA, director of BDC Advisors, who navigates the landscape of the medical neighborhood, from the value-based payment realities of healthcare today to identifying and engaging specialists in a medical home neighborhood.

Home Visits 101: Empower the Patient, and Don’t Forget the Gloves

September 2nd, 2014 by Patricia Donovan

It's hard to plan a home visit for a recently discharged patient if you don't know they've been in the hospital. Obtaining data on hospitalized patients is one of the challenges of administering a home visits program, notes Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care (SCC), a part of Stanford Hospital and Clinics.

Some of the challenges I’ve experienced with our home visits program is first of all, knowing when our patients are actually in the hospital. It’s easy to know when they’re at SCC; I get an electronic communications or an EMR. However, if patients go outside our system, I may not know. Sometimes that discharge summary is not available when I’m ready to go see the patient the day after. Holidays and weekends always increase that 48- to 72-hour window and I really do try to get in there the following day if possible.

For patients that don’t see primary care doctors within our clinic, it can sometimes be a challenge getting hold of their primary care doctor outside of SCC, and then explaining my role and why I need them.

On the back of our patient ID card, we emphasize to our patients to please contact us if they’re even considering going to the emergency department so that perhaps we can avoid a hospital admission or a readmission. If they are being seen in the hospital, we want them to call us as soon as they’re there, as soon as they’re able to, or to have their family member call so we can make sure that we’re involved in that transition.

Another lesson learned is definitely to empower the patient. Again, as a nurse I try to do as much for the patient as I can. But I have to keep in mind that when I’m in the home, my goal is to make sure will be able to identify the red flags and symptoms that indicate things are not going well, and that they’ll be able to contact the doctor’s office with their needs. I make sure that both handoffs are very clear; I never want to leave a patient wondering, ‘Oh I had this nurse and she came into my home and then she called me every few days and then all of a sudden she was gone.’

I need to make sure that I have good communication with that next transition.

And then last, I always carry a set of gloves, because you never know what you’ll walk into. I was not a home health nurse before I did these types of home visits, so I was ill prepared on one of my first visits to a patient with a dialysis catheter that was oozing blood. My nursing instinct caused me to run in there and try to clean things up.

Now I carry a good stock of gloves and supplies, because you just never know.

value-based reimbursement
Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care (SCC), a part of Stanford Hospital and Clinics.

Source: Home Visits for High-Risk Patients: Tools, Timing and Outcomes

Trained Military Medics Ease Transitions for John C. Lincoln’s Newly Discharged Patients

August 26th, 2014 by Patricia Donovan

A large part of the success of the John C. Lincoln Network accountable care organization (ACO) can be attributed to its Transition Coach Program, which uses trained military medics as care transition coaches, explains Heather Jelonek, the organization's CEO for ACOs.

We applied for a CMS Innovation grant in spring 2012. Our hypothesis was that we could take military healthcare professionals, medics and army corpsmen; these individuals are incredibly well trained. Army medics can do appendectomies in the field; they’re providing basic primary care services. However, when they’re discharged from the military, they have no equivalent licensure.

We decided to begin a program where we hired individuals we referred to as having ‘blood on their boots.’ Tom Jargon was our first transition coach; he started with us about 90 days after his last tour in Afghanistan ended. But what the program really does is bring these young men and women into our health system. They get six weeks of training, they meet with a cardiologist, they are introduced around the hospital staff, and they get to know how to use the EPIC® electronic health record to its most effective benefit.

These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients and develop a rapport, but they also start preparing the patients for discharge. They are doing basic things like making sure the patient has a social support system in place and transportation to their primary care or specialists’ visits. They also try to determine the patients' financial resources.

Once that patient is discharged from the hospital, our transition coaches follow them for a minimum of 30 days. They’re going into the patient’s home looking for fall risks. They’re helping the patient set up their home so that they’re a little bit safer. They’re doing a general review of cabinets: does the patient in fact have food in the refrigerator? Do they have pet food available if they have pets? Sometimes we find patients are feeding their pets rather than feeding themselves. So through our relationship with PetSmart®, we’ve been able to collect donations of animal food; we deliver those to our patients’ homes so they can afford food for themselves.

If on the other hand they’re finding evidence that the patient has pet food in the home but no food for themselves, we connect those patients with our Desert Mission Food Bank.

Transition coaches help patients learn to monitor their blood pressure. They explain their medication. They go through basic nutrition and education services. We bring in a registered dietician to work with patients who have dietary issues.

Source: Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care

Beyond the EMR Population Health Analytics


Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care
Reviews the concentrated data dig undertaken by John C. Lincoln to prepare for participation in the CMS Medicare Shared Savings Program (MSSP).

Infographic: Medicated to Death

May 16th, 2014 by Jackie Lyons

Approximately one in five Americans take five or more prescriptions, which can lead to risks such as addiction or drug-resistant infections, according to a new infographic from Top RN to BSN.

This infographic details the statistics behind the use of medication in the United States, as well as the causes and risks of overmedication.

Want to know more about medication and prescription drugs trends? 2013 Healthcare Benchmarks: Improving Medication Adherence provides actionable information from more than 100 healthcare organizations on efforts to improve medication adherence and compliance in their populations.

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: The Growing Industry, Effects of mHealth

April 11th, 2014 by Jackie Lyons

mHealth is currently a $1.3 billion industry that is expected to reach $20 billion by 2018, according to a new infographic from Mobile Future and Infield Health.

This infographic shows savings attributed to remote patient monitoring and medication adherence resulting from mHealth. It also assesses how mobile tools are transforming healthcare as more Americans, including healthcare providers, adopt mobile devices and wireless connectivity, and more.

Learn more about mHealth in 2013 Healthcare Benchmarks: Mobile Health, which delivers a snapshot of mHealth trends, including current and planned mHealth initiatives, types and purpose of mHealth interventions, targeted populations and health conditions, and challenges, impact and results from mHealth efforts. This 50-page resource provides selected metrics on the use of mHealth for medication adherence, health coaching and population health management programs.

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: U.S. Prescription Drug Costs

April 9th, 2014 by Jackie Lyons

American consumers pay 50 to 100 percent more for prescription drugs than any other country, with the average American paying $983 per year, according to a new infographic from Clarity Way.

This infographic outlines the cost of specific prescription drugs in comparison to other countries and the cost of drug research and development. It also identifies the benefits of access to prescription drugs, such as savings, prevention of death and hospital visits and more.

Drug Benefit Trends and Strategies: 2013 includes insight and expert analysis — from the publishers of Drug Benefit News and Specialty Pharmacy News — to help you understand what pharmacy benefit management trends are on the horizon in regards to: market share, formulary structures, PBM contracting, transparency, copays and Rx drug costs and utilization.


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: Technology Poised to Change Future of Nursing

April 4th, 2014 by Jackie Lyons

Healthcare reform is not the only change that will affect the nursing profession, evolving technology is likely to alter the future of nursing as well.

Among emerging healthcare technologies is barcode medication administration, which allows medications to be scanned before being administered. This enables nurses to check that the medication is correct, for the right patient and in the right dosage, according to a new infographic from Norwich University Online.

This infographic outlines other technologies that will change the nursing industry in years ahead, as well as how healthcare reform and education will affect the nursing profession.

Looking for other ways to increase medication adherence? You may also be interested in 2013 Healthcare Benchmarks: Improving Medication Adherence. This 56-page resource provides actionable information from more than 100 healthcare organizations on efforts to improve medication adherence and compliance in their populations.

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: Timeline of the Patient Experience

March 24th, 2014 by Jackie Lyons

From the first encounter on a benefits enrollment website to hospital discharge, the healthcare industry is looking to improve care quality and patient satisfaction.

However, 83 percent of Americans do not follow treatment plans given by their doctor as prescribed, according to a new infographic from Codebaby. This infographic chronicles the average experience of Americans, from making an appointment to follow-up treatment and everywhere in between.

Looking to enhance the patient experience and better coordinate care? You may also be interested in this webinar replay: Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results. Improving care coordination improves the overall patient experience and satisfaction. During this webinar, Gail Miller, the vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, shared details of their telephonic care management program and how these remote monitoring pilots will enhance their care coordination efforts.

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.

3 Reasons Home Visits Critical During Care Transitions

February 20th, 2014 by Cheryl Miller

As far back as 2010, home visits were a vital component of the Durham Community Health Network (DCHN), a primary care case management program for Medicaid recipients who live in Durham County, NC, explains Jessica Simo, program manager with Durham Community Health Network (DCHN) for the Duke Division of Community Health. Conducted in three-month increments, and designed initially to better address Medicaid recipients' needs and link them to their medical homes, the face-to-face visits helped establish a level of trust between case manager and patient, eventually leading patients to better outcomes, including improving medication reconciliation.

Why are home visits so important? Number one, it is very challenging to observe problems that individual patients may have with adhering to their medication regimens if providers can’t see the medicines in the bottle in the patient’s home. You need to be available to count the medicines and ascertain definitively that they are not missing. Trying to do medication reconciliation over the phone is nowhere near as effective as being in a patient’s home.

Another reason home visits are more effective is that you can physically see what activities of daily living (ADL) or instrumental activities of daily living (IADL) deficits the patient may be experiencing in their natural environment. This is something you can’t directly observe within the confines of an exam room.

The engagement of family or other support persons is also important. Home visits are an excellent way to see somebody in their natural environment, find out who the support people are for the patient, have a comfortable discussion in their home about an individual plan of care and get the people who can assist with that on board.

For all of the previous reasons, home visits were critical to the DCHN pilot. It’s especially important in a medically complex patient population where there are frequent transitions, whether they be from the acute care setting, from any emergency department (ED) visit or back into the home from an assisted living facility.

Excerpted from 2013 Healthcare Benchmarks: Home Visits.

3 Nurse Navigator Tools to Enhance Care Management

January 29th, 2014 by Jessica Fornarotto

Where does the nurse navigator spend their day? Certainly on transitions of care. Bon Secours Health System nurse navigators use a trio of tools to identify patients' obstacles to care and connect them to needed resources, explains Robert Fortini, vice president and chief clinical officer of Bon Secours Health System.

One tool that our nurse navigators use that's built into our EMR is the hospital discharge registry from Laburnum Medical Center, one of our largest family practice sites with about nine physicians. This tool is used to identify which patients the navigators need to work with, and it's where the navigators begin and end their day. This registry provides a list of all the patients who have been discharged from one of our hospitals in the last 24 hours, and each patient is listed by the physician. The navigators have to reach out to each of these patients and make telephonic touch within 24 to 48 hours of discharge. Medication reconciliation is extremely important at this time and can be very challenging. When a patient goes into a hospital, often their medications get scrambled, and they come out confused and taking the wrong prescriptions. Nurse navigators spend a lot of time on medication reconciliation at this point.

The Navigators also conduct 'red flag' rehearsals with this tool, so that the patient knows the signs and symptoms of a worsening condition and what to do for it. We also schedule the patient with a follow-up appointment, either with a specialist who managed the individual in the hospital or with their primary care physician. We try to do it as close to the time of discharge as possible, within five to seven days, or more frequently if the risk of readmission is higher.

Second, nurse navigators also use a documentation tool to help manage the care of heart failure patients. This tool allows the navigator to stage the degree of heart failure using a hyperlink called the 'Yale tool.' The Yale tool allows us to establish what stage of heart failure the patient is in: class one, two, three, or four. Then, a set of algorithms is launched based on these stages' failure; we manage the patient according to those algorithms. For example, if a patient falls into a class four category, we might bring them in that same day, or the next day, for an appointment rather than wait five or seven days because they're at more risk. We might also make daily phone calls or network in-home health, as well as make sure that the patient has scales for weight management and an assessment of heart failure status. All of those interventions will be driven by the patient's class of heart failure.

The last tool we use is a workflow for ejection fractions. The patient's ejection fraction will define specific interventions that the navigator will follow.

Excerpted from: Profiting from Population Health Management: Applying Analytics in Accountable Care.