Archive for the ‘Patient Registry’ Category

How Bon Secours Gets Paid for Providing Value-Based Healthcare

February 13th, 2015 by Patricia Donovan

ACO

Bon Secours 'Good Health' ACO is one of the largest in CMS's Medicare Shared Savings Program (MSSP).

Bon Secours Medical Group isn't waiting for CMS to fully transition Medicare to pay-for-performance reimbursement models to get paid for providing value-based healthcare.

Instead, the 600-provider medical group has aligned itself closely with healthcare payment reform, applying a broad mix of patient-centered team-based care, technology and retooled care delivery systems to maximize quality and clinical outcomes and reduce spend associated with its managed patients.

Highlights of Bon Secours' patient-centered approach were presented by Jennifer Seiden, administrative director, population health, and Lu Bowman, population health market program manager, during the recent webinar, Positioning for Value-Based Reimbursement: Workforce Development for Transitional Care, Chronic Care Management, now available for on-demand replay.

"The HHS's historic announcement [of Medicare's value-based payment timeline] was a clear signal to the industry and to the market that we better align ourselves and set ourselves up for it," noted Ms. Seiden.

As far back as 2009, the prescient medical group had several pay-for-performance programs in place; in 2015, Bon Secours Good Health accountable care organization (ACO) is one of the largest participants in CMS's Medicare Shared Savings Program (MSSP).

Today, most Bon Secours tactics emanate from the principles of the patient-centered medical home (PCMH), she said, with a focus on taking a population-wide view and closely managing "below-the-waterline" patients, guiding them to the most appropriate care settings and following up on them post-discharge.

The multidisciplinary care team is so essential to this patient-centered approach Bon Secours has constructed a business case to justify the team, she added, using a "Back to Basics" ROI equation developed by Robert Fortini, vice president and chief clinical officer.

Lauding Fortini's efforts, Seiden explained the motivation behind his formula. "We had to develop a return on investment equation for the care team, because if you're an independent practice or even if you're employed, you've got to justify the expense of that additional overhead. That labor is not cheap."

Results, revenue and key metrics like the number of post-discharge office visits and readmissions are tracked via electronic dashboards and rolled into the ROI equation.

Other strategies, including integration of behavioral health, embedding of case managers (nurse navigators) and EMTs, the use of ambulatory registries to stratify high-risk patients and a foray into retail healthcare contribute to Bon Secours' impressive results, like a readmission rate of 2.08 percent for patients heavily monitored and managed by nurse navigators.

Ms. Bowman then described Bon Secours' cohesive Care Management Services, which are divided into chronic care management services and complex chronic care management services. Nurse navigators are already working with Medicare's new Chronic Care Management codes, another stepping stone in the federal payor's volume-to-value transition.

"Nurse navigators are already providing chronic care management to patients. It was the natural next step for us to utilize these care management codes. The education for our team was focused on meeting the criteria, documentation and making sure the patient is always aware of and included in the care plan, which is so important to patient-centered care," concluded Ms. Bowman.

Listen to comments from Jennifer Seiden.

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

January 6th, 2015 by Cheryl Miller

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

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

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

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

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

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

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

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

Infographic: 7 Reasons to Engage With Patients Before Their Appointments

February 26th, 2014 by Jackie Lyons

The need to engage patients by preparing them before their appointments is rapidly growing. Positives include efficiency and increased patient satisfaction due to less manual data entry and shorter patient wait times among other benefits, according to a new infographic from Leading Reach.

This infographic provides the top seven reasons to engage with patients before their appointments and 10 examples of information that can be sent to patients before their appointment to ensure satisfaction.

You may also be interested in this related resource: Healthcare Innovation in Action: 19 Transformative Trends. Need more ways to increase patient satisfaction? This 40-page resource examines a set of pioneering efforts supporting the industry's seismic shift from a volume-based culture to one rewarding value and patient-centeredness.


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9 Things to Know About Patient and Disease Registries

February 19th, 2014 by Jessica Fornarotto

In the environment of accountable and value-based healthcare, registries are a straightforward tool for creating realistic views of clinical practices, patient outcomes, safety and comparative effectiveness and for supporting evidence-based medicine development and decision-making.

The Healthcare Intelligence Network's most recent analysis of registries and their impact on healthcare quality, efficiency and cost, reveals that the management of chronic disease is a key driver in the use of registries.

E-survey responses provided by 105 healthcare organizations also found that one-third of existing registries are a component of an electronic health record (EHR); the top reason for not having implemented a registry is because respondents already use an alternative, such as an EHR.

Other survey highlights include:

  • A disease- or condition-specific registry is the most popular type of registry, say 17 percent of respondents.
  • Diabetes is the condition most frequently targeted by respondents’ registries (78 percent), followed by CHF and asthma (both reported at 59 percent).
  • The most popular reason for using a registry is to measure quality and performance on key health outcomes, followed by disease management and the identification of high-risk patients.
  • Almost two-thirds of respondents who are not using registries at this time say they will launch a registry within the next 12 months.
  • A third of respondents include 20 percent or more of their population in registries.
  • Chart audits are the most common sources from which registries draw data, say half of respondents.
  • Engaging staff in registry use is the greatest challenge of implementing a patient registry, according to 29 percent of respondents.

Excerpted from: 38 Disease Management Metrics: Population Health Benchmarks to Drive Accountable Care