Archive for the ‘Patient-Centered Medical Home’ Category

AMITA Health Connected Care Management: Patients Transitioned But Never Really Discharged

August 23rd, 2016 by Patricia Donovan

Connected care includes AMITA Health front line staff, administrators, physicians, hospital executives and community partners.

Does a health system really need four types of care managers?

When AMITA Health set out to craft an ambulatory care coordination team for its highest-risk Medicare beneficiaries, it realized it didn't.

As part of its thirteen-point plan to revamp care management across its continuum, the newly minted Medicare Shared Savings Program (MSSP) accountable care organization (ACO) reexamined the roles of its navigators, case managers, patient-centered home care managers and ACO care managers, ultimately abandoning its siloed approach in favor of a more human-centric model of care.

"We really needed a better way to care for our patients across the continuum," explained Susan Wickey, vice president, quality and care management at AMITA Health, during Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care Management Strategy, an August 2016 webinar now available for replay. "We had to identify and remove those silos, and break down those barriers."

AMITA Health's decision to remake care management was a response to its MSSP program goal of fulfilling the Triple Aim: improving population health and experience of care while fostering appropriate utilization and cost. The initiative in no way devalued care managers' contributions. "Our care coordinators across the continuum serve as our first responders when high risk patients need intervention," said Ms. Wickey.

In the process of improving efficiencies, the nine-hospital system discovered that often, one could be more effective than four.

With help from Phillips Healthcare Consulting Division, AMITA inventoried its care management resources, then created a single centralized care management hub. Communication would occur via a single universal transfer form for each patient, for whom a single care plan would be developed. This power of one echoed throughout the transformation as AMITA restructured processes and programs.

AMITA rolled out the program initially with one unit of patients; today, all nine of AMITA Health's hospitals operate with some component of this enterprise-wide redesign.

"We wanted to be a health system where our patients were transitioned but never really discharged from our healthcare system," explained Ms. Wickey's co-presenter, Dr. Luke Hansen, vice president and chief medical officer, population health for AMITA Health. "We never discharge a patient from our system; rather we transition our patients to the most appropriate setting."

"This collaborative vision of connected care includes all of the front line staff, key administrators, physicians, hospital executives, along with AMITA's community partners," added Ms. Wickey.

In assessing its MSSP experience, Dr. Hansen said access to Medicare claims data enabled AMITA Health to track utilization, a first for the organization. Trends toward lower all-cause readmissions, lower admissions for ambulatory-sensitive conditions and emergency department visits were recorded, he said. And while he can't definitely credit the MSSP for his organization's improved quality scores in recent years, he takes pride in AMITA's achievements of strengthening quality while holding costs relatively stable.

However, improvements have leveled off since 2013, its first MSSP performance year, which frustrates the population health CMO. "As those of you participating in MSSP know, year-over-year improvement is what you need to do to succeed."

"We live that tension between our old models of care delivery, which were very successful for our organization, and new models, which we will have to adopt in a timely way to be successful in the future," concluded Dr. Hansen.

Click here for an audio interview with Dr. Hansen.

MACRA Mantra for Physician Practices: “Chase the Quality, and the Dollars Will Follow”

July 19th, 2016 by Patricia Donovan

Physician practices should position themselves to be paid for volume now and value in the future, McKesson's Eric Levin advised webinar participants.

If provider discontent doesn't prompt a delay, the controversial MACRA legislation will become reality in just six months, shaking up traditional physician reporting and reimbursement as healthcare knows it.

And while the proposed MACRA rule is still in flux, the bones of the law aren't expected to change, notes Eric Levin, McKesson's director of strategic services. From this point forward, he says, care coordination will be the ticket to success in eventual MACRA value- and performance-based healthcare models.

"As clinical alignment and care coordination increase, if you are not participating in some type of value-based care program, most likely you're not being reimbursed or rewarded for that work," Levin told participants in The New Physician Quality Reporting: Positioning Your Practice for MACRA's Merit-Based Incentive Payment System, a July 2016 webinar now available for replay.

In outlining MACRA's intent, Levin chiefly focused on the Merit-Based Incentive Payment Systems (MIPS) rather than the second reimbursement path, alternative payment systems (APMs), since the majority—88 percent—of physicians is expected to qualify under MIPS rather than APMs.

Zeroing in on MIPS, Levin reviewed eligibility, performance categories and data submission options, among other points. He then detailed the plethora of current and planned technical assistance options from CMS—including eventual practice transformation networks to provide peer-level support to physicians—before offering practical ways physician practices can prepare now for MACRA.

His six immediate action steps for practices included dipping a toe into analytics and data aggregation. "Look at the data. Learn how to risk-stratify. See the gaps in care you currently have and where those can be filled in so you're not just measuring but actually improving quality," Levin advised. The CMS Quality and Resource Use Report is useful for estimating a practice's MIPS score, he added.

In offering six additional tactics to become MACRA-ready, Levin recommended physician practices acquaint themselves with national benchmarks as a primer in quality measurement.

And on Levin's accompanying five-point MACRA implementation checklist is a reminder to stay current on CMS's proposed and final MACRA rulings. Fostering relationships with technology vendors wouldn't hurt either, he added.

His final points covered additional MACRA implementation resources, including education from provider associations, as well as the benefits of Patient-Centered Medical Home recognition and engagement in CMS's Chronic Care Management initiative in MACRA preparation.

"These programs will really help you begin the value-based journey if you have not started."

Levin emphasized providers should not wait for the final rule. Rather, physician practices should "learn how to focus on quality outcomes and costs, helping focus on the patient as well as that patient-provider relationship. Look at how you can identify ways to increase inexpensive patient encounters."

Before concluding, Levin answered participants' questions on how MACRA and MIPS will impact specialty providers; lessons practices can take from participation in the Physician Quality Reporting System, Meaningful Use and other value-based initiatives to enhance MACRA success; recommendations for small and solo practices; and other key concerns.

Learn more about Levin's presentation.

Infographic: Proven Preventative Healthcare Practices

July 1st, 2016 by Melanie Matthews

Adopting simple, proven preventative practices could save Americans billions in healthcare costs per year and allow most to live longer lives. Nurses trained in basic screenings and counseling can have profound impacts, according to a new infographic by the University of San Francisco’s Online Master of Science in Nursing program.

The infographic highlights 20 proven preventative services and the impact on the number of lives saved and healthcare costs if more people had access to these services.

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.

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6 Population Health Strategies to Set Stage for Physician Reimbursement

May 12th, 2016 by Patricia Donovan

Robert Fortini, PNP

A team-based, top-of-license approach is key to population health success, says Robert Fortini, PNP, Bon Secours Medical Group chief clinical officer.

In the last six years, Bon Secours Medical Group (BSMG) has deployed a half-dozen population health strategies as groundwork for its Next Generation Healthcare offering. Here, Robert Fortini, PNP, BSMG chief clinical officer, identifies the tactics his organization leverages to effect health behavior change.

The specific population health strategies Bon Secours has deployed over the last six years start with the patient-centered medical home (PCMH) concept. I’m an avid believer in the concept of a team of professionals working together, along with that ‘top of license’ aspect, where it’s not just the sole domain of the independent ‘cowboy’ physician taking care of the patients. It’s pharmacists, nurses, social workers, and registered dietitians. It’s the entire team, with everyone having a vested responsibility for practicing to the top of his or her license.

Next, access is huge. It is ridiculous to think we can manage chronic disease in four 15-minute visits a year scheduled between 8 a.m. and 5 p.m. Monday through Friday, while closing at lunchtime. It’s absolutely ludicrous. We are blowing that up by opening weekends and evenings and using technology to expand access, which is critical to affecting that behavioral change.

Third, know your population. Identifying effectively those who are most at risk with advanced analytics to make your efforts more efficient is very important.

Next is managed care contracting—aggressively coming to the table with our payors to help guide the conversations and craft the contracts and benefit designs that are attainable and achievable. That has been a new experience for Bon Secours in the last five years in particular. We have a CMS-based Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) covering about 30,000 attributed lives. We also have a number of commercial ACO-type contractual relationships with our commercial payors.

Fifth on the list: aggressive growth for palliative and hospice. We have invested very significantly in management of advanced illness that occurs at the end of life. The Medicare numbers around that are staggering: 40 percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible. Investing in the resources necessary to manage that effectively has been our strategic initiative at Bon Secours. We have a very large, well-versed palliative program that provides inpatient, outpatient and even home-based palliative services. And our hospice agency, which I am responsible for in addition to our medical group, has quadrupled in size in the last two years alone.

Then, finally, we manage the white space with powered care coordination, which includes health promotion, chronic disease management, care transition management, and more.

Source: Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care Management Revenue and Results

Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care Management Revenue and Results details the ways in which Bon Secours Medical Group (BSMG) leverages a team-based care approach, expanded care access and technology to capitalize on four Medicare billing events: transitional care management, chronic care management, Medicare annual wellness visits and advance care planning.

CMS Postpones LOI Deadline to May 2, Readies for Next Wave of ‘Next Generation ACO’ Participants

March 10th, 2016 by Patricia Donovan

Update: On March 11, 2016, the Centers for Medicare and Medicaid Services (CMS) pushed back the deadline for letters of intent for 2017 Next Generation ACO participation to May 2, 2016.


April 1 is the deadline to submit a letter of intent to participate in the Next Generation ACO Model in 2017.

Letters of intent from healthcare organizations interested in applying to the Next Generation ACO Model for the January 1, 2017 start date must be submitted by April 1, 2016, according to an update from the Centers for Medicare and Medicaid Services.

The letter of intent (LOI) as well as more information about CMS's newest accountable care organization model, including dates and times for Application Open Door Forums, can be found on the Next Generation ACO Model web page.

Only organizations that submit an LOI will be able to complete an application. Even applicants that submitted an application previously but are not participating in the Next Generation ACO Model for 2016 must complete and submit an LOI if they wish to apply to participate in the Next Generation ACO Model beginning in 2017, CMS stated.

Subsequent to the organization's LOI, applications for 2017 Next Generation ACOs will be due in two parts:

  • The narrative portion is due May 25, 2016; and
  • The Participating Provider list is due June 3, 2016.

If an organization plans to submit more than one LOI, it should use a different email address for the primary contact listed on each LOI submission, CMS said in its Next Generation ACO LOI and application FAQs.

In 2016, there are currently 21 ACOs participating in the Next Generation ACO Model, an initiative for ACOs that are experienced in coordinating care for populations of patients. The Next Generation ACO model allows these provider groups to assume higher levels of financial risk and reward than are available under the current Pioneer and Shared Savings Program (MSSP) models. The goal of the Next Generation ACO model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.

2015 metrics from the Healthcare Intelligence Network (HIN) found that one-fifth of healthcare organizations expect to participate in CMS' new 'Next Generation' ACO Model in the future.

View an infographic on the Next Generation ACO model.

An April 5th webinar hosted by the Healthcare Intelligence Network will provide a value-based, risk contract roadmap to determine organizational readiness for participation in the Next Generation ACO Model in particular and in risk-based contracts in general. Click here for more details.

Bon Secours Next Generation Healthcare: Smart Tools Tell Care Transitions, Chronic Care Management Stories

February 4th, 2016 by Patricia Donovan

Next Generation Healthcare smart tools facilitate Bon Secours care plans for care transitions, chronic care management and Medicare wellness visits.

A key component of chronic care management is a comprehensive plan of care—the "refrigerator copy" patients can refer to, explains Robert Fortini, PNP, chief clinical officer for Bon Secours medical Group (BSMG).

Today, using smart tools built into its electronic medical record, Bon Secours nurse navigators document twelve-point care plans for the 50 patients they have enrolled via Medicare's year-old Chronic Care Management (CCM) codes—a number Fortini expects will double this month.

The CCM assessment tool also captures frequently forgotten issues such as depression, pain and sleep problems that can derail care, Fortini said in a recent webinar on Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning.

Bon Secours' seventy nurse navigators, embedded in physician practices, also tap these point-and-click smart tools to document transitions of care for patients recently discharged from the hospital. This Transition of Care smart note tracks 17 different aspects of patient care, including risk of readmission and medication reconciliation, and includes a placeholder for an advance medical directive.

Similar tools are in use for Medicare's three types of wellness visits, he added.

"I have been in this business a long time, and the documentation that navigators produce using these workflows is extraordinary," Fortini noted. "This is purposeful design. It tells a story and you have something actionable at the conclusion of reading it."

The smart tools are but one aspect of Bon Secours' Next Generation Healthcare initiative, which Fortini defined as "population health meets total access." Next Generation Healthcare fortifies the team-based medical home foundation Bon Secours introduced six years ago with expanded care access and technology, among other components the organization leverages to improve clinical outcomes and value-based reimbursement.

In the Next Generation Healthcare model, the primary care physician is the quarterback of care, with embedded nurse navigators doing the "heavy lifting" of enrolling at-risk patients into care management, building comprehensive care plans, and scheduling Medicare beneficiaries for annual wellness visits, Fortini explained.

Additionally, Bon Secours has broadened its care access menu to include employee clinics, fast care and urgent care sites, self-scheduling, and virtual visits for primary care. The organization expects to expand virtual visits to specialist consultations and behavioral health in the near future, and also envisions virtual case management visits, allowing nurse navigators to conduct real-time medication reconciliations with at-home patients.

To round out its Next Generation Healthcare continuum, Bon Secours is training a portion of nurse navigators as facilitators in a Virginia advance care planning initiative called "Honoring Choices," with the goal of formalizing the placement of advance directives in patients' records.

Investing in resources necessary to manage end-of-life effectively is a critical aspect of Bon Secours' strategic initiative, Fortini concluded. "Forty percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible."

Listen to an interview with Robert Fortini in which he describes how Bon Secours nurse navigators have won over solo practitioners.

Infographic: Community Health Centers Transform to Medical Homes

November 20th, 2015 by Melanie Matthews

Community health centers provide essential health services to all patients, even those uninsured or unable to pay. When these centers operate as patient-centered medical homes, they can care for patients more efficiently and effectively.

A new infographic by the Commonwealth Fund looks at some of the key characteristics of a patient-centered medical home and the growth of community health centers now operating as medical homes from 2009 to 2013.

Having established a firm foundation over two decades of patient-centered care, the medical home model is poised for a makeover, expanding to medical neighborhoods and opening the door to specialists' enhanced role in care coordination—while embracing value-based compensation models that reward quality over quantity.

Those are just two of the trends explored in 2014 Healthcare Benchmarks: The Patient-Centered Medical Home, the Healthcare Intelligence Network's in-depth analysis of medical home adoption, tools, technologies, challenges, benefits and outcomes.

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Guest Post: Winning the Healthcare Revolution with Technology for Care Coordination, Collaboration & Communication

September 8th, 2015 by Richard Purcell, intelliSanté president & CEO

Healthcare is in the middle of a revolution. Health systems continue to integrate and expand, acquiring private practices and hospitals. Insurance carriers still navigate the Affordable Care Act, and merge to build actuarial risk pools. Providers deal with changing payment models, transitioning from traditional fee-for-service to merit-based incentive payments, though the exact definition of pay-for-performance is not yet codified. And in the midst of these radical changes, doctors, hospitals, and health systems are implementing an array of electronic medical records (EMRs) to finally replace paper records.

Two things are clear with all of this upheaval in the medical world: providers are frustrated, and the patient is nowhere to be found.

Doctors, nurses, and healthcare administrators are all under financial and workload pressures; they are trying to comply with healthcare IT requirements for meaningful use, and everyone is uncertain about the future. Patients are exasperated with figuring out insurance plans and in-network versus out-of-network provider coverage; obtaining medical records from their doctors is a challenge; and they are left to their own devices to navigate the complexities of the healthcare system.

Technology is the answer for healthcare transformation, but the entire healthcare ecosystem is a decade behind the information technology boom that has transformed every other industry.

6 Barriers to Health IT Integration

Why has it been difficult to bring technology to healthcare? Based on two years of interviewing dozens of stakeholders across the healthcare continuum, we can point to several reasons:

  • HIPAA, short for the Health Insurance Portability and Accountability Act passed in 1996 that legislates data privacy and security provisions designed to safeguard medical information.;
  • Reimbursement: Only this year and last has CMS provided CPT codes for care coordination, Chronic Care Management 99490 and Transitional Care Management 99495 and 99496. Shared savings models provide inconsistent results and are still largely undefined;
  • Limited investment: Providers already have invested heavily in EMRs, spending money and time on workflow management, and are therefore reluctant to add new workflows and software unless integrated with their current EMR systems, which are not built for patient-centric care coordination;
  • Technology proficiency: Medical personnel, especially physicians, are not broadly trained in technology and software other than the specific EMR in the practice or hospital, and that training is lagging. Patients, especially senior citizens, have widely varying and often negligible technology access and knowledge;
  • Data overload: There is so much unintegrated data from internal EMR and billing systems, claims forms, labs, and metabolic measures from myriad devices that no person can comprehend. Doctors and patients need clinically meaningful reports, not just data.
  • Transformation: The medical system has been trained and operated as a treatment-focused, fee-for-service business; that is how healthcare professionals earn their living. Population health management and the primary care medical home (PCMH) models of healthcare require a realignment of the provider-patient relationship, transformation of business focus from in-office visits to out-of-the-office management, new staff and resource allocation—all without a defined financial model for future practice.

What's Needed for a Patient-Centric Collaboration?

So, how in the current tumultuous environment can we ever achieve the Triple Aim of better health and improved care delivery at lower costs? The answer is patient-centric collaboration—working together to achieve a common outcome. But in order to make collaborative care work, we need patients, nurses, and doctors to embrace technology for collaboration. To this end, a new role in healthcare, the care coordinator, is the lynchpin to connecting patients to the healthcare system. Plus, an array of new and emerging software platforms like GetRealHealth and C3HealthLink for population health management can foster the personal communication necessary to engage patients outside the office environment, with the system-driven performance to drive efficiency.

Fortunately, the care coordinator position is currently being championed in several areas. For example, in New Jersey, Horizon Blue Cross Blue Shield has promoted care coordination for many years by funding practices for on-site care coordinators. The PCMH movement embraces the care coordinator role and collaborative care, and The Patient Centered Primary Care Collaborative (PCPCC), a not-for-profit trade group, is dedicated to healthcare transformation through primary care.

Plus there is hope on the patient technology front. According to the Pew Research Center, 64 percent of Americans own a smartphone, and for those seniors who do own smartphones, 82 percent describe the phone as “freeing." Plus, broadband access is expanding through initiatives like the recently announced ConnectHome Pilot Program that will bring Internet access to underserved areas.

4 Ways Technology Will Optimize Healthcare Delivery

Through technology, we can optimize care delivery if we can provide care coordinators and patients with the tools they need to engage in health, and systems that provide interconnected data exchange through the patient’s health record, enabling the following:

  • Patients to engage in health practices that promote adherence to medication schedules, self-monitoring, and care planning, together with HIPAA-compliant communications tools that foster responsibility and collaboration with a care team;
  • Medical practices to manage patient populations inside and outside of the healthcare system to optimize care coordination (treatment, transition, communication, monitoring), while establishing workflows for the impending reimbursement changes to pay for performance;
  • Health systems to establish new care coordination and data sharing models using cloud-based, HIPAA-compliant data exchange and communications channels that integrate clinically relevant data;
  • Payors to evaluate and measure patient engagement in health and provider practices for care coordination and collaborative care in order to reimburse providers for performance.

The challenges in healthcare are many, but we can emerge from this healthcare revolution with a stronger healthcare system through collaboration: with patients taking responsibility, providers communicating and sharing data, health systems funding new delivery models, and payors enabling a sustainable financial model that provides benefits to all stakeholders.

Richard Purcell

About the Author: Richard Purcell is president and chief executive officer of intelliSanté. He has played a lead role in founding the company, molding the corporate vision, and leading the commercial launch of C3HealthLink. Purcell has extensive experience in drug development, clinical data management, and business operations in a regulated environment. Previously, he was president of ClinPro, Inc., a mid-sized clinical research organization. In addition, he participated in the start-up of the medical Web site Medscape through sales and business development initiatives. Rich holds a B.S. in Biochemical Sciences from Princeton University, and attended Rutgers Graduate School of Management majoring in marketing and finance. He is an executive member of the Patient Centered Primary Care Collaborative (PCPCC), a member of the Licensing Executives Society, and an active member of the New Jersey Technology Council and HIMSS. (rich@intelliSanté.com)

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.

3 Embedded Care Coordination Models Manage Diverse High-Risk, High-Cost Populations

June 30th, 2015 by Patricia Donovan

YNHHS embedded care coordination

YNHHS uses an embedded care coordination approach to manage its high-risk, high-cost medical home patients, geriatric homebound and health system employees.

When it comes to coordinating care for its highest-risk, highest-cost individuals—whether patients in a medical home, the geriatric homebound or its own employees—Yale New Haven Health System (YNHHS) believes an onsite, embedded face-to-face approach will best position it for success in a value-based healthcare industry.

The Connecticut-based health system shared its vision for managing patients across its continuum via three embedded care coordination models during a June 2015 webinar, Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, now available for replay.

In the first model, livingwellCARES, RN care coordinators at YNHHS's four health system campuses work with its high-risk, high-cost health system employees and their adult dependents with chronic disease.

"We help these employees access the care they need and identify their goals of care. We get under the surface a little bit to determine barriers to their being as healthy as they can be and manage them over time," explained Amanda Skinner, executive director, clinical integration and population health, adding that YNHHS offers employees incentives such as waived insurance co-pays for participation.

Launched three years ago, livingwellCARES was YNHHS's "on-the-job training for learning to manage care across the continuum," she continued. Starting with employees with diabetes, livingwellCARES expanded to care coordination of most chronic diseases. Having significantly impacted clinical metrics like A1Cs as well as hospital utilization and ED visits in the approximately 500 employees it manages, livingwellCARES is now transitioning to a more risk-based approach.

The second embedded care coordination model, a patient-centered medical home (PCMH), also launched three years ago. Focused on complex care management, the PCMH is heavily driven by data derived from its electronic health records and patient registries, Ms. Skinner continued.

Because five of eight PCMH care coordinators are embedded and cover multiple physician practices, YNHHS is exploring the use of televisits by care coordinators to manage patients in the practices served. Also important is schooling PCMH staff in the relatively new practice of "warm handovers" during critical transitions of care.

Nine challenges of the PCMH embedded model shared by Ms. Skinner include engaging patients and obtaining reimbursement for various pay for performance programs.

In the third model, outpatient geriatric care coordination, embedded high touch care coordinators manage frail elderly deemed homebound by Medicare standards—when it’s a severe and taxing effort to leave the home—and those in assisted living facilities, explained Dr. Vivian Argento, executive director of geriatric and palliative services at Bridgeport Hospital.

"There is a challenge not just with frailty but also with access—having these patients go into the physician offices—so that the care tends to get shifted into the hospital because it’s easier for those patients to get there," Dr. Argento explained.

Physicians and nurse practitioners provide care in the patient's home to break that utilization cycle, while embedded care coordinators constantly collaborate with the care team to risk-stratify and prioritize patients, resolve medication concerns, make referrals, manage care transitions, triage telephone calls—all tasks required to coordinate care for what Dr. Argento termed "a very sick Medicare population in in the last two to three years of life."

Well received by the geriatric patients, the program also has positively impacted healthcare utilization metrics: its annual hospital admission rate of 5.4-5.8 percent is significantly below Medicare's overall 28-30 percent hospitalization rate, and the program boasts a readmissions rate of 14 percent, versus Medicare's 20 percent national average, Dr. Argento added.

6 Ways Social Workers Can Bridge Healthcare Gaps in the Post-Reform Period

May 29th, 2015 by Chris Ingrao

Editor's Note: The following excerpt has been reprinted with permission from the Simmons School of Social Work.

With the Affordable Care Act's (ACA) increased emphasis on preventive care and community-based treatment, social workers have an opportunity to bridge the gap between physical and mental health, taking on the role of a care coordinator and working between patients and physicians.

The New York City Health and Hospitals Corporation defines care coordinators as "social workers who work with patients to create a plan that addresses mental health, physical, and social service needs." These services can include:

  • Community resource planning and coordination;
  • Connecting patients with specialists and other healthcare providers;
  • Advance directives;
  • Helping patients understand chronic conditions;
  • Crisis intervention;
  • Counseling for emotional adjustments and lifestyle changes: and
  • Assistance with legal issues, transportation, or applications for financial aid.

While the benefits of community-based treatment and preventive care are already widely recognized, the ACA further incentivizes hospitals and care providers, imposing sanctions when patients come back too soon after being released, increasing the value of community-based preventive care programs. One such program is a Health Home, a free program (not a physical location) that helps patients manage the care and services that they need. In a health home, beneficiaries are paired with care coordinators who help them better understand and manage their conditions outside of the hospital setting.

Social Workers’ Role in Healthcare Reform

The ACA specifically mentions social workers as key players in implementing healthcare reform, which means they will likely have an opportunity to shape policy by advising policymakers on the following aspects of reform:

  • Effect and influence of social and environmental factors: Healthcare issues are much larger than the individual, and social workers will recognize how policy should best account for these factors.
  • Appropriate timeline and perspective: Social workers interact with individuals of all ages and think in terms of a life span, as opposed to short-term goals.
  • Advocacy: Social workers concern themselves with matters that extend beyond their individual clients. Social equity surrounding the access of care is a paramount concern of social work professionals, and as a result, social workers can become healthcare advocates in their communities.
  • Comprehensive care planning: Effective care, and thus policy, must take into account families, communities, and service providers.
  • Access expansion: Social workers understand that between human services, clinics, hospitals, mental health facilities, the community, and the home, there are many places where access to care is denied or not aligned with other phases of treatment.
  • Social work education: Medical education typically focuses on identifying and treating disease and physical illness, while social work education focuses instead on prevention, community support, and case management.

In the future, there will be more social workers bringing their unique educational background to the healthcare system. Significant post-ACA expansions to healthcare services, particularly for low-income individuals, as well as an emphasis on community-based preventive care, will likely create more career opportunities for social workers in the United States.

With more people than ever obtaining healthcare coverage, there will be a high demand for social workers that can act as care coordinators to help recipients connect their benefits across their care providers, communities, and homes.

As the healthcare landscape continues to change, social workers will be key players in advising and implementing improvements.

Read this post in its entirety at the Simmons School for Social Work. The oldest school of social work in the country, Simmons School of Social Work (SSW) was founded in 1904 as a joint venture with Harvard University. Today, SSW offers a rigorous, clinical social work curriculum that prepares students for direct practice with individuals, groups, and families. This post was authored by Chris Ingrao, the community manager for SocialWork@Simmons, the online MSW offered through the Simmons School of Social Work.

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.