Archive for the ‘Reducing Readmissions’ Category

Infographic: Transitional Care Management

March 13th, 2017 by Melanie Matthews

Transitional Care ManagementMedicare's billing codes for Transitional Care Management (TCM) highlight the importance of timely post-discharge contact with patients by provider offices, and timely face-to-face follow up and evaluation by TCM providers. Incorporating automated patient communications can facilitate efficient and effective handoffs, and support a consistent track of care to help providers earn TCM reimbursements and avoid hospital readmission penalties, according to a new infographic by West Healthcare.

The infographic looks at the financial impact of reducing readmission penalties and examines how automated patient communications can improve care transitions.

A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home VisitsSun Health, an Arizona non-profit organization, launched its Sun Health Care Transitions program in November 2011. Modeled after the Coleman Care Transitions Intervention® and adapted to meet the needs of its community, the program has been credited with keeping readmission rates well below the national average.

Sun Health's program was part of the Center for Medicare and Medicaid Services' National Demonstration Program, Community-Based Care Transitions Program, which ended in January. Not only did Sun Health lead the CMS demonstration project with the lowest readmission rates, Sun Health also widened the gap between their expected 30-day readmission rate (56 percent lower than expected) and their expected 90-day readmission rate (60 percent less than expected).

During A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 23, 2017 webinar at 1:30 p.m. Eastern, Jennifer Drago, FACHE, executive vice president, population health, Sun Health, will share the key features of the care transitions program, along with the critical, unique elements that lead to its success.

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3 Priority Populations for Home Visits and 10 More House Calls Benchmarks

February 14th, 2017 by Patricia Donovan

More than half of home visits include screening for social determinants of health.

More than half of home visits include screening for social determinants of health.

Which patients should healthcare providers visit at home? A new survey on home visits identified three key populations that should receive home-based care management: the frail elderly and homebound (69 percent); the medically complex (69 percent); and individuals recently discharged from the hospital (68 percent).

In stratifying patients for these home visits, 62 percent rely on care manager referrals.

These were just two findings from the 2017 Home Visits survey conducted by the Healthcare Intelligence Network. Nearly three quarters of the survey's 107 respondents visit targeted patients at home, an intervention that can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit.

Who's conducting these home visits? In more than half of responding programs, a registered nurse handles the visit, although on rare occasions, patients may open their door to a primary care physician (4 percent), pharmacist (4 percent) or community paramedic (3 percent).

Once inside the home, the visit is first and foremost about patient and caregiver education, say 81 percent of respondents, with an emphasis on medication reconciliation (80 percent). Fifty-nine percent also screen at-home patients for social and economic determinants of health, factors that can have a huge impact on an individual's health status.

Patient engagement, including obtaining consent for home visits, tied with funding and reimbursement issues tied as the top challenges associated with in-home patient visits.

How to know if home visits are working? The most telling success indicator is a reduction in 30-day hospital readmission rates, say 83 percent of survey respondents, followed by a drop in hospital and ER utilization (64 percent). Seventy percent of survey respondents reported either a drop in readmissions or in ER visits.

Here are a few more metrics derived from HIN's 2017 Home Visits survey:

  • Eighty-five percent of respondents believe that the use of in-home technology enhances home visit outcomes.
  • Fifteen percent report home visits ROI of between 2:1 and 3:1.
  • Eighty percent have seen clients’ self-management skills improve as a result of home visits.

Download an executive summary of results from HIN's 2017 Home Visits Survey.

2016 Healthcare Headlines: MACRA Monopolizes News Until Election Shake-Up

December 26th, 2016 by Patricia Donovan
top 2016 news stories

The unexpected election of Donald J. Trump to the U.S. presidency threatened some healthcare initiatives from the Obama administration, including the Affordable Care Act.

There was only one thing capable of distracting the healthcare industry in 2016 from MACRA's imminent rollout: the election of Donald J. Trump to the presidency of the United States.

Nevertheless, the majority of the last twelve months was spent on healthcare business as usual—the business of transitioning to value-based models of care delivery and reimbursement.

Here are the headlines that dominated the news feeds of healthcare executives in 2016:

New CMS 'Accountable Health Communities' Model Aims to Improve Patients' Health by Addressing Social Needs

January 2016: In a first-ever CMS Innovation Center pilot project to test improving patients’ health by addressing their social needs, the HHS appropriated $157 million in funding to bridge clinical care with social services.

The new pilot will test whether screening beneficiaries for health-related social needs and associated referrals to and navigation of community-based services will improve quality and affordability in Medicare and Medicaid. Many of these social issues, such as housing instability, hunger, and interpersonal violence, affect individuals’ health, yet they may not be detected or addressed during typical healthcare-related visits.

Medicare Shares 6 Core Principles for 21 New 'Next Generation ACOs'

January 2016: The Centers for Medicare & Medicaid Services (CMS) made waves when it launched a new accountable care organization (ACO) model called the Next Generation ACO Model (NGACO Model). The twenty-one ACOs participating in the NGACO Model in 2016 have significant experience coordinating care for populations of patients through initiatives, including, but not limited to, the Medicare Shared Savings Program and the Pioneer ACO Model.

Providers Slow to Adopt Population Health, Value-Based Models of Care: Study

February 2016: Most healthcare providers continue to lag in implementing population health management despite broad agreement it will be important for future market success, according to a national study by healthcare strategy consultancy Numerof & Associates. The study synthesized survey responses from more than 300 executives and in-depth interviews with over 100 key decision-makers across U.S. healthcare delivery organizations. It provided the first in-depth, national look at the pace of transition from fee-for-service to models based on fixed payments linked to outcomes.

Horizon BCBSNJ 'Episodes of Care' Program Pays $3 Million in Shared Savings to Specialty Medical Practice

February 2016: Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced that it paid out approximately $3 million to 51 specialty medical practices as part of shared savings generated through the company’s innovative Episodes of Care (EOC) Program. The doctors, in five different specialty areas, earned the payments by achieving quality, cost efficiency and patient satisfaction goals in 2014 while treating more than 8,000 Horizon BCBSNJ members. The EOC model, also known as bundled payments, is one in which specialists manage the full spectrum of care related to a specific procedure, disease diagnosis or health event—such as a joint replacement or pregnancy.

Bundled Payments Improve Care for Medicare Joint Replacement Patients: NYU Langone Study

March 2016: Implementing bundled payments for total joint replacements resulted in year-over-year improvements in quality of care and patient outcomes while reducing overall costs, according to a new three-year study from NYU Langone Medical Center. The three-year pilot at the medical center reported reductions in patient length-of-stay and readmission rates.

CMS to Test New SNF Payment Model to Curb Readmissions, Foster Multidisciplinary Care

March 2016: The Centers for Medicare & Medicaid Services (CMS) today announced it would test whether a new payment model for nursing facilities and practitioners will further reduce avoidable hospitalizations, lower combined Medicare and Medicaid spending, and improve the quality of care received by nursing facility residents. This next phase of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents seeks to reduce avoidable hospitalizations among beneficiaries eligible for Medicare and/or Medicaid by providing new payments to practitioners for engagement in multidisciplinary care planning activities.

Proposed MACRA Rule Would Streamline Medicare Value-Based Payment Models

May 2016: In issuing a proposal to align and modernize how Medicare payments are tied to the cost and quality of patient care for hundreds of thousands of doctors and other clinicians, the Department of Health & Human Services took the first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Are You MACRA-Ready? Physician Groups Prep Members for Medicare Payment Modernization

May 2016: As they digested the HHS's momentous proposal to modernize how Medicare provider payments are tied to the cost and quality of patient care, physician organizations began assembling arsenals of educational tools to de-mystify MACRA. The federal government's first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was detailed in an April 2016 announcement.

CMS Releases MACRA Final Rule; Creates Two Pathways for Clinician Value-Based Payments

October 2016: The Department of Health & Human Services (HHS) finalized a landmark new payment system for Medicare clinicians that will continue the administration’s progress in reforming how the healthcare system pays for care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the flawed Sustainable Growth Rate (SGR), will equip clinicians with the tools and flexibility to provide high-quality, patient-centered care.

ACA Afterlife: Unwinding Obamacare Under the Trump Administration

November 2016: If U.S. President-elect Donald J. Trump delivers on his campaign promises, the 'repeal and replacement' of the Affordable Care Act (ACA) should be an early priority for the nation's chief executive-in-waiting. That prospect sent shock waves through the healthcare industry, as evidenced by a snapshot of post-election responses to the Healthcare Trends in 2017 survey sponsored by the Healthcare Intelligence Network.

Trump Taps Orthopedic Surgeon, Medicaid Architect to Helm U.S. Healthcare Posts, Determine ACA Fate

November 2016: Calling his nominees "the dream team that will transform our healthcare system for the benefit of all Americans," President-elect Donald J. Trump announced his plan to nominate Chairman of the House Budget Committee Congressman Tom Price, M.D. (GA-06) as secretary of the U.S. Department of Health and Human Services (HHS) and Seema Verma as administrator of the Centers for Medicare and Medicaid Services (CMS).

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Guest Post: Care Transitions Are Susceptible To Breakdowns; Technology-Enabled Patient Outreach Offers Clarity and Improved Outcomes

November 15th, 2016 by Chuck Hayes, vice president of product management for TeleVox Solutions, West Corporation

Technology-Enabled Patient Touchpoints Post-Discharge

A surprisingly simple way to improve care transitions is to reach out to patients within a few days of hopsital discharge automatically with the help of technology.

Transitional care's inherently complex nature makes it susceptible to breakdowns. During care transitions there are many moving parts to coordinate, patients are vulnerable, and healthcare failures are more likely to occur. For these reasons, transitional care is a growing area of concern for hospital administrators and other healthcare leaders.

Errors that happen at pivotal points in care, like during a hospital discharge or transfer from one facility to another, can have serious consequences. Fortunately, strengthening communication and engaging patients can effectively solve many of the problems that transpire during care transitions.

When patients' needs go unmet after being discharged from the hospital, the risk of those individuals being readmitted is high. Around 20 percent of Medicare patients discharged from the hospital return within a month. CMS has taken several steps to try to improve transition care and minimize breakdowns that lead to hospital readmissions. Under the government's Hospital Readmissions Reduction Plan (HRRP), hospitals can be assigned penalties for unintentional and avoidable readmissions related to conditions like heart attacks, heart failure, pneumonia, COPD, and elective hip or knee replacement surgeries.

Between October 2016 and September 2017, Medicare will withhold more than $500 million in payments from hospitals that incurred penalties based on readmission rates. These penalties affect about half of the hospitals in the United States.

Not only are payment penalties problematic, but because readmissions rates are published on Medicare's Hospital Compare website, public opinion is also worrisome for hospitals with a high number of readmissions.

A surprisingly simple way to prevent patients from returning to the hospital is to reach out to them within a few days of discharge. Outreach can be done automatically with the help of technology. For example, with little effort, hospitals can send automated messages prompting patients to complete a touchtone survey. A survey that asks patients whether they are experiencing pain–and whether or not they have been taking prescribed medications–provides good insight about the likelihood of them returning to the hospital. It also allows hospitals to respond to issues sooner rather than later.

Medical teams know that patients are particularly vulnerable during the 30 days following a hospital discharge. Leveraging technology-enabled engagement communications multiple times, in multiple ways throughout that month-long window is a good strategy for improving post-discharge transitions. Whether that involves reminding a patient about a follow-up appointment, asking them to submit a reading from a home monitoring device, verifying that they are tolerating their medication, or communicating about something else, it is important to have plans in place to initiate an intervention if necessary.

For example, if a patient indicates that they are experiencing side effects or symptoms that warrant examination by a doctor, a hospital team member should escalate the situation and help coordinate an appointment for the patient. Recognizing problems is one component of improving care transitions, responding to them is another.

Imagine a patient has recently been released from the hospital after having a heart attack. The patient was given three new prescriptions for medications to take. He may have questions about when and how to take the medications or whether they can be taken in combination with a previous prescription. Hospital staff can use technology-enabled communications to coordinate with the patient's primary care doctor and pharmacy to ensure the patient has all the information they need to safely and correctly follow medication instructions. The hospital can also survey the patient to find out if he is having difficulty with medication or other discharge instructions, and learn what services or interventions might be beneficial. Following that, a care manager can provide phone support to answer questions.

Fewer than half of patients say they're confident that they understand the instructions of how to care for themselves after discharge. Without some sort of additional support, what will happen to those patients? In the past, hospitals may have felt that patient experiences outside the walls of their facility were not their concern. But that has changed.

Care transitions are exactly that–transitions. They are changes, but not end points. Hospitals should foster a culture that recognizes and supports the idea that care does not end at discharge. It continues, just in a different way. When patients physically leave a hospital, the manner in which care is delivered needs to progress. Rather than delivering care in person, healthcare organizations can support patients via outreach communications. The degree to which that happens impacts how well (or poorly) transitions go for patients.

Improving care transitions is not as daunting as it might seem, particularly for medical teams that use technology-enabled communications to support and engage patients. To ensure patients have the knowledge and resources they need, and that they are acting in ways that will keep them out of the hospital, medical teams must focus on optimizing communications beyond the clinical setting.

About the Author: Chuck Hayes is an advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. He leads product and solution strategy for West Corporation’s TeleVox Solutions, focusing on working with healthcare organizations of all sizes to better understand how they can leverage technology to solve organizational challenges and goals, improve patient experience, increase engagement and reduce the cost of care. Hayes currently serves as Vice President of Product Management for TeleVox Solutions at West Corporation (www.west.com), where the healthcare mission is to help organizations harness communications to expand the boundaries of where, when, and how healthcare is delivered.

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.

UPMC: INTERACT Tools Boost Provider Communication in RAVEN Project to Reduce Long-Term Care Hospitalizations

September 6th, 2016 by Patricia Donovan
UPMC reduces long-term care hospitalizations

Even custodial or housekeeping staff can use the INTERACT Stop and Watch tool to record subtle changes in a patient.

The RAVEN (Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents) project by the University of Pittsburgh Medical Center (UPMC), aimed at improving quality of care for people residing in long-term care (LTC) facilities by reducing avoidable hospitalizations, is set to enter phase two in October 2016. Here, April Kane, UPMC's RAVEN project co-director, describes a pair of key resources that have enhanced communication between providers, particularly those at the eighteen nursing homes collaborating with UPMC on the RAVEN project.

Currently INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement project and has been funded through Medicare. It is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities (SNFs). The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. These tools are free online.

INTERACT is used in multiple settings, but in our long-term care setting, we've been primarily encouraging the use of two INTERACT tools. There are a wealth of others. First is the Stop and Watch tool. This is a very easy early detection tool that would be used by members of your nursing home staff, such as nurses aides, custodial or housekeeping staff, and other workers who have a lot of one-on-one engagement with residents.

Using this tool, they may notice subtle changes, such as a patient who isn't as well engaged, who has been eating or drinking a little less, or is not as communicative as they had been before. It's a very easy one-page tool. Sometimes it's a card where they can circle if they're seeing something different, for example, "The resident seems a little different," or "They ate less."

The goal would be to take that tool to either the LPN or the RN in charge of the unit they're working on and say, "You know, I was with Mrs. Smith today. This is what I've been seeing that's a little different with her." That nurse should take that tool, validate its usage and then from there, go in and assess the patient.

If appropriate, they should utilize a second INTERACT tool, SBAR (Situation, Background, Assessment, Recommendation), to provide a more thorough assessment of what is going on and determine if this is a true changing condition. The SBAR allows the nurse to provide feedback to physicians in the very structured format physicians are used to reviewing. This allows them to place all the vitals and information in one place.

When they do make that call to the physician, they're well prepared to update them with what is going on with a particular resident. The physician then feels comfortable in deciding whether to provide further treatment on site or if appropriate, to transfer out to the hospital, depending on that resident's need.

Click here for an interview with April Kane on the value of UPMC's onsite enhanced care coordinators in the RAVEN project.

Care Transitions Playbook Sets Transfer Rules for Post-Acute Network Members

July 28th, 2016 by Patricia Donovan

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

A primary tool for Saint Vincent’s Health Partners Post-Acute Network is a playbook documenting more than 140 transitions for patients traveling from one care setting to another, including the elements of each transition and ways network members should hold each other accountable during the move. Here, Colleen Swedberg, MSN, RN, CNL, director of care coordination and integration for St. Vincent’s Health Partners, explains the playbook's data collection process and information storage and describes a typical care transition entry.

The playbook is made up of several sections, including one with current expectations, based on the Michigan Quality Improvement Consortium, which we can review online. From an evidence-based point of view, they’ve listed the evidence for many common conditions patients are seen for in medical management. This is kept up to date. This is an electronic document stored on our Web site that can only be accessed by individuals subscribed to the network. We’ve also put this on flash drives for various partners.

A second section contains actual metrics for any network contracts. The metrics appear in such a way that the highest standard is included. For example, physician providers, as long as they provide the highest level of care in the metric, can be sure they’re meeting all the metrics. Those metrics are based on HEDIS® standards.

The third section is the transition section, laid out in two to three pages. For example, a patient moves from the hospital inpatient setting to a skilled nursing facility, such as Jewish Senior Services. For that transition, the playbook documents all the necessary tools for that patient: a personal health record, a medication list, whatever is needed. Also included is any communication with the primary care physician, if that provider has been identified. Finally, this section identifies the responsibility of the sending setting—in this case, the hospital inpatient staff. What do they need to organize and make sure they’ve done before the patient leaves and starts that transition, and what is the responsibility of the receiving organization?

That framework is the same for every transition: the content and tools change according to the particular transition. A final section of the playbook details all of the tools used for care transitions. For example, in our network, we’re just now working on the use of reviews for acute care transfers, which is an INTERACT (Interventions to Reduce Acute Care Transfers) tool. In fact, many settings, including all of our SNFs, as it turns out historically, have used that tool. This tool is in the playbook, along with the reference and expectation of when that tool would be used.

Source: Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands

http://hin.3dcartstores.com/Post-Acute-Care-Trends-Cross-Setting-Collaborations-to-Align-Clinical-Standards-and-Provider-Demands_p_5149.html

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient's journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

Infographic: The Impact of Medication Reconciliation on Readmission Rates

July 18th, 2016 by Melanie Matthews

Medication reconciliation programs, in which pharmacists review patients' medication regimens and provide adherence counseling during the patient's transition from hospital to home, reduced ths risk of hospital readmission by 50 percent and helped avoid unnecessary healthcare costs, according to a new study from the CVS Health Research Institute.

A new infographic by CVS highlights the survey findings, including details on the impact of medication non-adherence on readmission rates and how a pharmacist intervention reduced readmission risks.

Medication Management: Using Clinical Pharmacists To Complete Comprehensive Drug Therapy Management Post Discharge in High-Risk PatientsA clinical pharmacist-driven medication management effort at Novant Health identifies patients at high-risk for readmissions or ED visits related to adverse drug events. Using a combination of medication reconciliation, pharmacotherapy review, and patient education, Novant Health's clinical pharmacists are working to reduce preventable readmissions by optimizing medication regimens and removing barriers to adherence among these high-risk patients.

During Medication Management: Using Clinical Pharmacists To Complete Comprehensive Drug Therapy Management Post Discharge in High-Risk Patients a 45-minute webinar on February 3rd, now available for replay, Rebecca Bean, director, population health pharmacy, Novant Health, shares her organization’s medication management approach and why a clinical pharmacist is key to the program’s success.

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Guest Post: 6 Ways Predictive Analytics Will Move Healthcare Forward in 2016

June 28th, 2016 by Anand Shroff, co-founder and chief technology and product officer, Health Fidelity

change this text

Identifying at-risk patient populations is one way to use predictive analytics to generate rapid returns.

In non-healthcare sectors like retail and manufacturing, 'predictive analytics' was arguably the top buzz phrase of 2015. Respected industry analyst Gartner even included predictive analytics in its 'Top 10 Strategic Technology Trends' roundup. Predictive analytics have become increasingly important in the healthcare industry, too, as the volume of electronic data grows.

But healthcare organizations have grappled with how to access, analyze and apply their data. Many lack the advanced automated capabilities needed to extract meaning from complex, unstructured data sets from multiple sources. However, it’s crucial to find a way, since the stakes are incredibly high: A McKinsey & Company study estimated that the industry could extract $300 billion in value annually from big data and drive overall healthcare expenditures down by 8 percent.

The key to extracting maximum value from healthcare data sets is to use predictive analytics and cloud-based technologies. By analyzing current and historical data and using the findings to predict future events and trends, healthcare enterprises such as accountable care organizations (ACOs) and others can address the cost-quality equation that is so essential to successful operations in an outcomes-based environment.

The pay-for-performance ecosystem ACOs and other healthcare organizations operate in today demands new strategies to handle bundled payments and population health management challenges, and predictive analytics are tailor-made to produce the insights they need. Using predictive analytics to assess current data sheds new light on the following key metrics:

  • The relationships between cost, quality and patient outcomes;
  • Clinical best practices that drive optimal patient outcomes; and
  • Individual and population-level health risks.
  • By submitting current metrics to predictive analytics, healthcare organizations will gain incredibly valuable insights into how various factors intersect to affect outcomes and which issues they need to address first to drive improvements and value. As they respond to changes in payment models in 2016 and beyond, healthcare organizations will also use predictive analytics to refine their strategies by:

    • Gaining insights into risk factors and how to optimize risk management;
    • Identifying the practices, performers and results that affect organizational performance; and
    • Assessing the impact of ACO reimbursement and bundled payment strategies.
    • Taken together, these are the six ways predictive analytics will move healthcare forward in 2016. By leveraging the power of predictive analytics, healthcare organizations will be able to clearly identify the factors that drive clinical quality and operational expenses. And by applying this information, they can predict and manage clinical and financial performance with greater accuracy. Moreover, they’ll have the opportunity to drive continuous improvement in practices and processes, which will minimize costs while maximizing care quality going forward.

      Healthcare organizations that want to put predictive analytics to work for their operations should consider a two-part strategy that focuses on simple, high-value initiatives first. They’ll need to create an infrastructure that allows them to secure quick wins and then address more complex projects—for example, focusing on revenue improvement by using predictive analytics to proactively manage risk can pay tangible, substantial dividends in the short term.

      Identifying at-risk patient populations in terms of the 30-day readmission window is another way to use predictive analytics to generate rapid returns. Once healthcare organizations have the right processes and practices in place, they can branch out into more complex initiatives like analyzing value-based payment models such as the ACO, episode-based care and patient-centered medical homes. The ability to use discrete and unstructured clinical, financial and operational data to improve performance is the key to success.

      Organizations that embrace predictive analytics in 2016 and beyond will have a key competitive advantage: They will have finally unlocked the value of their data. Predictive analytics have transformed many business sectors in 2015, and 2016 is shaping up to be the breakthrough year for predictive analytics in healthcare, driving better value and outcomes. That’s good news for healthcare organizations and patients alike.

      Anand Shroff

      Anand Shroff, co-founder and chief technology and product officer of Health Fidelity.


      About the Author: Anand Shroff is a co-founder and chief technology and product officer of Health Fidelity. He is responsible for the company’s product strategy and execution and marketing initiatives. He has championed the cause of enterprise performance improvement by promoting electronic capture, exchange and analysis of healthcare data. Prior to founding Health Fidelity, Anand was vice president of EHR and HIE products at Optum. Anand has an MBA from the Haas School of Business at the University of California, Berkeley and an MS in Computer Science from the University of California, Santa Barbara. Anand has an undergraduate degree in Computer Engineering from the University of Mumbai. Connect with Anand on LinkedIn and on Twitter.

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

Infographic: How EMS Can Help Reduce Gaps in Care

May 18th, 2016 by Melanie Matthews

Emergency management services (EMS) can fill gaps in the care continuum with 24/7 medical resources that improve the patient care experience, improve population health, and reduces costs, according to the National Association of Emergency Medical Technicians (NAEMT). EMS is uniquely positioned to support healthcare transformation by assessing and navigating patients to the right care, in the right place, at the right time.

NAEMT created an infographic to explain the EMS role in healthcare transformation and how EMS can expand its services to fulfill this new role.

Yale New Haven Health System (YNHHS) takes an on-site, embedded face-to-face approach to coordinating care for its highest-risk, highest-cost patients—whether identified within its own employee population, inside a patient-centered medical home (PCMH), or among the geriatric homebound. The Connecticut-based health system believes this vision of care management is the most direct path to success in a value-based healthcare industry.

In 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.

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Horizon Episodes of Care Program Prototype for Value-Based Specialty Care and Reimbursement

April 21st, 2016 by Patricia Donovan

Horizon BCBS-NJ's Episodes of Care program engages specialists across a suite of nine episodes.

Imagine a value-based healthcare payment model in which the sole financial hazard to specialist providers is the risk of amassing additional revenue.

Further, envision a scenario in which these specialists are invited to design their payment program, from the model's intent to key quality metrics.

Those are some highlights of Horizon Blue Cross Blue Shield of New Jersey's Episodes of Care (EOC) program, a value-based model designed to focus specialists on the provision of quality- and value-based care across nine separate episodes, from joint replacement to hysterectomy to oncology.

Hailed as a national leader in advancing the episodes model as a prototype for value-based specialty care, Horizon is careful to distinguish its EOC program from a bundled payment initiative, for two key reasons.

"First, our EOC program is a quality-based program; it's not only about the payment or payment structure," explained Lili Brillstein, director of the Horizon Episodes of Care program during a recent webinar, Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship.

Secondly, bundled payments typically refer to a prospective model in which a bundled amount of money is paid to a provider or group of providers in advance of services being delivered, while Horizon's retrospective model pays providers after services have been provided.

The upside-only nature of Horizon's retrospective model contributes to the program's collaborative nature, Ms. Brillstein added. "If the metrics are met, savings are shared. If the metrics are not met, we’re not punishing our partners."

There is other evidence of collaboration and of Horizon's desire to see the providers succeed in the EOC program. One example is the payor's use of case mix-adjusted budgets at the practice level rather than the prevalent member-specific risk-adjusted budgets. "This budgeting allows Horizon to create an opportunity for providers to move the needle [on a metric], and benefit from that. The opportunity for cost savings and shared savings also is dramatically improved."

Another case in point is Horizon's invitation to prospective providers to talk through the episode's construct, intent and design prior to its launch.

Horizon's engagement of providers in the EOC program has "changed the spirit of the relationships between the payor and the provider," Ms. Brillstein noted. "It’s like nothing I’ve ever seen before. Our provider partners have become our ambassadors for the program."

Select EOC results presented during the webinar indicated that outcomes are better for EOC partners—in the area of reduced readmissions, for example—than they are for physicians not in the EOC program.

Horizon expects to launch at least three more episodes in 2016, including a Crohn’s Disease episode that will take into account behavioral health services for those members. While the payor fully expects to move to a prospective model, it believes its current EOC model is preparing them for that eventuality, softening the transition from fee for service to prospective payments.

"[That transition] doesn’t just happen. You don’t sign the paper, and suddenly know what to do. It is an evolutionary transformative process," concluded Ms. Brillstein.

Click here to listen to an interview with Lili Brillstein: Horizon BCBSNJ Episodes of Care: No-Risk Retrospective Model Paves Way for Value-Based Migration