Archive for the ‘Telephonic Case Management’ Category

Intermountain Healthcare Determined to Diminish Patient Disengagement Divide

November 5th, 2015 by Patricia Donovan

One in three healthcare consumers are disengaged from self-care, prevention and health IT, explained Intermountain Healthcare's Tammy Richards, corporate director of patient and clinical engagement.

Dismayed by national dips in patient engagement, satisfaction and health literacy, among other industry currents, Intermountain Healthcare convened a patient engagement steering committee composed of its highest level leaders.

What emerged was a strategic six-point patient engagement framework that not only has transformed patient care by the Salt Lake City-based organization but also has fostered a climate of shared accountability throughout the not-for-profit health system.

In a dramatic example of the framework's potential, Tammy Richards, corporate director of patient and clinical engagement at Intermountain Healthcare, described how one Intermountain ER nurse, using newly acquired engagement skills, emotionally and personally connected with Harold, an alcoholic, disenfranchised frequent ER utilizer who previously had only reacted in an angry, abusive fashion.

"We changed, and Harold changed, and this is really what patient engagement is about: genuinely connecting with individuals, understanding their story and then providing them with the tools, electronic or personal, to heal or hopefully stay healthy," Ms. Richards said during A Patient Engagement Framework: Intermountain Healthcare's Approach for a Value-Based System, an October 2015 webinar now available for replay.

In presenting the six key program tenets, Ms. Richards underscored how her organization's multilayered approach supports the mission of Intermountain Healthcare: Helping people live the healthiest lives possible.

Intermountain was particularly disturbed by Deloitte's finding that one in three healthcare consumers are disengaged, Ms. Richard explained. "[The disengaged] are reporting less desire for care, less commitment to preventive action, less interest in technology and other solutions, and they are less financially prepared," she said.

That critical data point ignited Intermountain's efforts to reengage and engage its consumers, she added.

She shared highlights from the six-point engagement framework, including the following:

  • Incorporation of patient and family perspectives into the planning, delivery and evaluation of healthcare;
  • Designation of a staff member as the system's health literacy coordinator;
  • Application of meaningful technology that spans the engagement framework;
  • Formation of workgroups and work streams dedicated to health literacy, engagement technology and patient experience that report to the steering committee; and
  • Better-timed offering of care decision aids to patients.

Although technology is often touted as the answer to patient engagement, Ms. Richards cautioned against the employment of too many tools to engage patients. "Historically, we’ve created chaos with systems and programs that have no interoperability. This is certainly an issue from an industry perspective; it’s also an issue within a hospital or within a system."

With its engagement framework in place, Intermountain will continue to explore new methods of creating a seamless, integrated care experience for its patients, so that it may better serve its Harolds, its chronically ill, and even its pediatric populations, Ms. Richards concluded.

"We know that we’re going to fulfill our mission and it will be a constant journey. We know that our mission of helping people live the healthiest lives possible is within our grasp."

Click here for an interview with Tammy Richards.

5 Trends in Chronic Care Management by Physician Practices

March 17th, 2015 by Cheryl Miller

One hundred percent of physician practices rely on face-to-face and telephonic visits to administer chronic care management (CCM) services, according to respondents to the Healthcare Intelligence Network's 10 Questions On Chronic Care Management survey administered in January 2015.

A total of 119 healthcare organizations described tactics employed, 17 percent of which were identified as physician practices. A sampling of this sector's results follows.

  • Less than half of physician practices (46 percent) admitted to having a chronic care management program in place. But they overwhelmingly agree (100 percent) that CMS’s CCM initiative will drive similar reimbursement initiatives by private payors.
  • This sector’s criteria for admission to existing chronic care management programs is on par with other sectors except for asthma; just 17 percent of physician practices use this as an admitting factor versus 49 percent of all respondents.
  • Not surprisingly, this sector assigns major responsibility for CCM to the primary care physician, versus 29 of all respondents. This sector also relies on healthcare case managers (40 percent versus 29 of all respondents) and advanced practice nurses (APNs) (20 percent versus 8 percent overall) to assist with CCM.
  • This sector relies most heavily on face-to-face visits for CCM services (100 percent versus 71 percent for all respondents) and telephonically (100 percent versus 87 percent of all respondents).
  • Among the biggest challenges for this sector is reimbursement (33 percent versus 20 percent overall) and documentation (17 percent versus 2 percent overall). Unlike other sectors, patient engagement is not a major challenge (17 percent versus 33 percent overall).

Source: 2015 Healthcare Benchmarks: Chronic Care Management

http://hin.3dcartstores.com/2015-Healthcare-Benchmarks-Chronic-Care-Management_p_5003.html

2015 Healthcare Benchmarks: Chronic Care Management captures tools, practices and lessons learned by the healthcare industry related to the management of chronic disease. This 40-page report, based on responses from 119 healthcare companies to HIN's industry survey on chronic care management, assembles a wealth of metrics on eligibility requirements, reimbursement trends, promising protocols, challenges and ROI.

10 Healthcare Trends Measured in 2014: Medical Neighborhoods, Data Analytics Flourish

January 13th, 2015 by Patricia Donovan

2014's HINtelligence Reports captured trends in healthcare delivery, technology and utilization management.


Each year, the Healthcare Intelligence Network's series of HINtelligence Reports pinpoint trends shaping the industry, from cutting-edge care collaborations to remote patient management connections to tactics to reduce avoidable utilization.

HINtelligence Report benchmarks are derived from data provided by more than one thousand healthcare companies.

Here are 10 highlights from 2014 HINtelligence Reports that support Triple Aim goals of improving population health and the patient experience while reducing the per capita cost of healthcare.

Share your reactions with us on Twitter @H_I_N.

  • Readmissions: More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, said respondents to the fourth annual Reducing Hospital Readmissions Survey.
  • Palliative Care: While the majority of respondents (68 percent) administer palliative care on an inpatient basis, more than half (54 percent) say care is conducted on home visits and just under a third offer palliative care at extended care facilities.
  • Patient-Centered Medical Home: Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransformMed℠ as “a strong foundation of transformed primary care practices aligned with health systems and specialists to insure that care is maximally coordinated and managed.
  • Remote Patient Monitoring: More than half of 2014 respondents—54 percent—have instituted remote monitoring programs, the survey found, which was most often employed for patients or health plan members with multiple chronic conditions (83 percent). Other targets of a remote monitoring strategy included frequent utilizers of hospitals and ERs (62 percent) and the recently discharged (52 percent).
  • Telephonic Case Management: More than 84 percent of respondents utilize telephonic case managers. „One-fifth of telephonic case managers work within the office of a primary care practice.
  • Population Health Management: The last two years reflects a dramatic surge in the use of data analytics tools barely on population health management's radar in 2012: the use of health risk assessments (HRAs), registries and biometric screenings more than tripled in the last 24 months, while electronic health record (EHR) applications for population health increased five-fold for the same period.
  • Emergency Room Utilization: Among populations generating the majority of avoidable ED visits, dual eligibles jumped nearly 10 percent in the last four years, from 2 to 11 percent, while other populations—high utilizers, Medicare and Medicaid—remained roughly the same. „„Chronic disease replaced pain management as the most frequently presented problem in the ER, at 54 percent.
  • Stratification of High-Risk, High-Cost Patients: The „LACE readmission risk tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Embedded Case Management: Fifty-seven percent of respondents embed or co-locate case managers in primary care practices, where their chief duties are care and transition management, reducing hospital readmissions and patient education and coaching.
  • 2015 Healthcare Forecast: Almost 92 percent of 2015 respondents said the impact of value-based healthcare on their business has been positive, with more than one quarter identifying healthcare’s value-based shift as the trend most likely to impact them in the year to come.

Make your healthcare voice count in 2015 by answering 10 Questions on Chronic Care Management by January 31, 2015. You'll receive a complimentary HINtelligence Report summarizing survey results.

Remote Diabetes Monitoring: Magic is in the Phone Call, Not the Technology

January 8th, 2015 by Patricia Donovan

Using a blend of telehealth, access to electronic medical records, electronic communication with providers and direct communication with patients, nurse care managers with the New York City Health and Hospitals Corporation's (NYCHHC) House Calls Telehealth Program significantly improved patient clinical outcomes and impacted healthcare costs for enrollees with diabetes. Here, Susan Lehrer, RN, BSN, CDE, associate executive director of the telehealth office for NYCHHC, shares some lessons learned from the eight-year-old program.

We can achieve really significant clinical and financial outcomes with available simple technology. I want to say 'simple' because this is not rocket science. It’s a glucometer that transmits over a modem, a blood pressure cuff that transmits the information of blood pressure via Bluetooth® to us that we see on a Web site within seconds.

That information is the first step, but providing the case management and communication back to providers is where the magic happens. Conducting effective patient interactions utilizing motivational interviewing can be done over the phone. We were all disbelievers in the beginning. “How can I do the same thing that I did face-to-face over the phone?” we asked ourselves.

You can’t do the same thing, but over time, you can achieve the same outcomes, as long as you have providers seeing the patients and patients keeping their appointments.

Technology enables us to give the feedback at the moment that the patient needs it. If somebody’s blood sugar is 58, and they don’t feel very well, calling them at that moment, which we do every day, prevents them from overcorrecting. Eventually, they learn how to treat their hypoglycemia. Giving that immediate feedback to a patient is where the dramatic clinical outcomes occur. Patients can learn self-management with very targeted interventions and support.

To recap, it’s not about the technology, because the data comes to us every day, but it’s the magic that happens in the phone call back to the patient.

remote diabetes management
Susan Lehrer RN, BSN, CDE is the Associate Executive Director for the House Calls Telehealth program for the New York City Health and Hospitals Corporation. Ms. Lehrer joined HHC in 2006 to design and implement the Telehealth program to provide expert care management for Diabetics with poor control.

Source: Diabetic Telehealth Monitoring: The Impact of Real-Time Data on High-Risk Patients (webinar available for replay)

12 Core Competencies for the Hybrid Embedded RN Care Manager

December 30th, 2014 by Cheryl Miller

Core competencies for a registered nurse (RN) are different than those for an RN care manager, says Mary M. Morin, RN, NEA-BC, RN-BC, vice president, nurse executive with Sentara Medical Group. When Sentara officially converted to a hybrid embedded case management model, RN care managers' job descriptions had to be rewritten; to be successful in this new model, they didn't necessarily have to have care management experience; instead, having a strong clinical background and experience doing patient assessments were more important.

To get RN care management away from the embedded telephonic model, we had to rewrite the job descriptions, and if you’re going to rewrite job descriptions, have a new position. This is different work.

We found out people will hear it, but until they go through it, until they feel it, they’re all for it until it actually happens. If I were to do this again, I would make everybody reapply for their job because this requires a certain type of individual. These people need to be able to engage patients for a long-term relationship. They have to know how to work with hospital-based caregivers, home health, life care and not just within our own healthcare system.

We established core competencies. Core competencies for an RN care manager are different than those for an RN. We have an ambulatory-based RN. We were looking for people that didn’t necessarily have previous care management experience, but who had experience doing patient assessments. They also had to have a strong clinical background.

Following are 10 more core competencies for the hybrid embedded RN care manager:

  • Job descriptions: BSN requirement
  • Maintain patient lists by populations
  • Accept assignments
  • Meet expectations
  • Send patient letter from primary care physician (PCP)
  • Engage patients
  • Send contact letter, brochure
  • Standardize work flow
  • Use SMG, Optima (Health Plan), and clinically integrated network (CIN) electronic medical record (EMR)
  • Hold meetings with home health and inpatient care coordinators
  • Complete education/training
  • Achieve specialty certification

value-based reimbursement
Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Source: Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination

Top Risk Stratification Tools for Telephonic Case Management

December 18th, 2014 by Patricia Donovan

The case management assessment is the top tool for stratifying candidates for telephonic case management contact, according to market data from HIN’s 2014 survey on Telephonic Case Management.

Sixty-one percent of respondents use a case management assessment to identify high-risk, high-cost individuals who would benefit from telephonic follow-up and care coordination.

Other risk stratification tools reported by survey respondents include the following:

  • Provider referral: 60 percent

  • Claims utilization data: 55 percent

  • Hospital census and discharge reports: 48 percent

  • Predictive modeling: 39 percent

  • Self- or family referrals: 37 percent

In other market data, more than 84 percent of respondents utilize telephonic case managers, with more than half—54 percent—making contact with patients from virtual home offices.

The complex comorbid are the primary targets of telephonic case managers (TCMs), the survey found, but the newly discharged, those in acute stages of chronic illness, frequent utilizers and high-risk, high-cost patients also receive their fair share of telephonic attention from these case managers.

Source: Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics

http://hin.3dcartstores.com/Stratifying-High-Risk-High-Cost-Patients-Benchmarks-Predictive-Algorithms-and-Data-Analytics_p_4934.html

Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics presents a range of risk stratification practices to determine candidates for health coaching, case management, home visits, remote monitoring and other initiatives designed to engage individuals with chronic illness, improve health outcomes and reduce healthcare spend.

Each program discussion is supplemented by market data on risk stratification approaches for that care coordination intervention.

Telephonic Case Management Targets High-Risk, High-Cost Conditions

July 17th, 2014 by Cheryl Miller

While the complex comorbid are the primary targets of telephonic case managers, the newly discharged, those in acute stages of chronic illness, frequent utilizers and high-risk, high-cost patients also receive their fair share of attention from telephonic case managers, according to new market data from the Telephonic Case Management survey conducted in May 2014 by the Healthcare Intelligence Network.

To expand the scope of care coordination, telephonic case management is evolving as a cost-effective and efficient means of monitoring and engaging individuals with chronic illness or a weak circle of care, according to an inaugural survey on Telephonic Case Management by the Healthcare Intelligence Network (HIN).

More than 84 percent of respondents utilize telephonic case managers, according to this new market data, with more than half — 54 percent — making contact with patients from virtual home offices. And while the telephone is an essential tool of the trade, these case managers also draw on motivational interviewing and robust data from electronic health records (EHRs) and case management software to help them manage their populations.

The complex comorbid are the primary targets of telephonic case managers, the survey found, but the newly discharged, those in an acute stage of chronic illness, frequent utilizers and high-risk, high-cost patients also receive their fair share of telephonic attention from these case managers.

While charged primarily with the management of chronic illness and transitions in care, most telephonic case managers also find themselves in the role of patient educator and health coach, say 75 percent of respondents.

  • „„The case management assessment is the primary method of identifying candidates for telephonic contact, report 61 percent of respondents.
  • „„One-fifth of telephonic case managers work within a primary care practice.
  • „„Engagement of members in telephonic case management is the primary challenge of the program, say 43 percent of respondents.
  • „„Workloads of telephonic case managers fall into the 50-99 case range, say 30 percent of respondents.

Excerpted from 2014 Healthcare Benchmarks: Telephonic Case Management.