Archive for the ‘Wellness/Prevention’ Category

Population Health Tactics to Boost an ACO’s Medicare Annual Wellness Visit Rates

February 9th, 2018 by Patricia Donovan

One of the most important revenue opportunities for primary care physicians, and for population health nurses under their direct supervision, is the Medicare Annual Wellness Visit (AWV), advises Tim Gronninger, senior vice president of development and strategy, Caravan Health. The AWV offers an opportunity to check a number of Medicare quality boxes, including preventive check-ins, vaccinations and health screenings, to help make sure that a beneficiary’s medical needs are being met.

Here, Gronninger suggests ways that physician practices can improve all-important AWV rates.

Much of increasing annual wellness visit rates is about how to manage expectations of the practice and of the patient. You’ll be chasing your tail a lot if you are looking at your data and saying, “Well, these 1,000 patients haven’t had an annual wellness visit. I’m going to make a thousand phone calls, and then I’m going to make a thousand follow-up phone calls to try to schedule them all.”

It is very important for a practice to create a process where you have the time, the space and the plan, so that when a patient comes in the door for an Evaluation and Management (E&M) visit, the patient is handed off seamlessly to a nurse coordinator to complete an annual wellness visit at the same time. Obviously, different patients will require different handling. But we have found a very high acceptance rate from that approach among patients of clients that we work with.

It’s something that many patients take for granted, that their clinician knows this about them already. However, many times, the physician in practice doesn’t know whether the patient is up to date on their mammograms or other types of screenings.

Editor’s Note: Caravan Health’s ACOs saved more than $26 million in the Medicare Shared Savings Program (MSSP) and achieved higher than average quality scores and quality reporting scores in 2016.

Source: Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success

ACO population health

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

Guest Post: Patient Engagement Technology Tool for Preventing Hospital Readmissions in Chronic Patients

January 23rd, 2018 by Allison Hart, Vice President of Marketing, TeleVox Solutions at West

While almost all chronic care patients say they need help managing their disease, less than one-third receive regular check-ins from healthcare providers.

During the past decade, the Centers for Medicare and Medicaid Services have increased the pressure on hospitals to prevent readmissions. In response to that pressure, many hospitals made changes that have led to declines in readmission rates. However, even with more measures in place to prevent readmissions than ever before, the risk of being readmitted to the hospital is still high for patients with chronic illnesses.

Studies have shown that the risk of adverse health effects increases with each hospitalization. Unfortunately, it can be difficult to keep chronic patients from readmitting once they have been hospitalized. Because of this, it is important that healthcare teams prioritize chronic disease management, and work to engage and support chronic patients. One tool that can help with this is the patient engagement technology many healthcare teams already have in place.

Survey responses indicate that chronic patients welcome efforts from their healthcare team that are aimed at managing disease and preventing hospital admissions and readmissions. A West survey found that 91 percent of chronic patients say they need help managing their disease, and at least 70 percent would like more resources or clarity on how to manage their condition. Additionally, 75 percent of chronic patients want their healthcare provider to touch base with them regularly so they can be alerted of potential issues.

Although patients with chronic conditions have expressed that they desire more assistance from their healthcare providers, they are not necessarily receiving it. For example, more than half (54 percent) of patients feel a weekly or twice-weekly check-in from their provider would be valuable, yet only 30 percent of patients report receiving regular check-ins. This shows that, in some cases, providers could be doing much more to offer ongoing chronic disease management support.

Providers seem to be underestimating patients’ interest in chronic care and their desire to receive support. Patients have suggested that they not only want assistance with managing chronic conditions, they would also be willing to pay for that extra support. Many providers are unaware that their patients feel this way. When asked if their patients would agree to pay 10 dollars per month for additional chronic care support, just over half (53 percent) of providers answered “yes.” However, two-thirds of patients say they would be willing to pay a nominal amount for chronic care support. The eye-opening response from patients confirms that chronic disease management is in demand—more so than providers realize. It also suggests that some providers may need to do more to offer ongoing chronic disease management support.

Chronic Care Management Enrollment

One way healthcare teams can better serve chronic patients and potentially prevent readmissions is by enrolling patients in chronic disease management programs. Chronic care programs, like Medicare’s Chronic Care Management program, require a lot of communication on the part of the healthcare team. Automating some of the communication and outreach makes it easier for providers to offer ongoing chronic care support. Healthcare teams can use their patient engagement technology to:

  • Send patients messages to invite them to enroll in a chronic care program. Using information from electronic health records, healthcare teams can identify patients that are eligible for chronic care management programs. (Patients must have two or more chronic conditions to enroll in Medicare’s Chronic Care Management program.) Then, they can use their patient engagement technology to send patients automated messages with information about the benefits of participating in a chronic care program, and instructions or links for patients to enroll or get further information.
  • Schedule disease-specific preventive screenings and tests. The Chronic Care Management program mandates that patients receive recommended preventive services. Care managers can schedule and send patients automated text messages, emails or voice messages to notify them when they are due for preventive screenings and tests. Patients with diabetes, for example, would automatically receive messages when they are due for an A1C test, foot exam or eye exam.
  • Send medication reminders and messages. Providers are required to manage and reconcile medications for patients enrolled in the Chronic Care Management program. Providers can assign medication reminders and send automated messages to ensure patients know how and when to take their medication, and that they don’t forget to take it.

Communication that engages chronic patients and aids them in disease management can result in better health outcomes and fewer readmissions. Engagement communications can be easily automated, meaning outreach does not require excessive time or resources. Hospitals and healthcare providers have incentives to reduce readmissions, and in many cases, they have the technology in place to make chronic disease management efficient and effective.

About the Author: Allison Hart is a regularly published advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. She leads thought leadership efforts for West’s TeleVox Solutions, promoting the idea that engaging with patients between healthcare appointments in meaningful ways will encourage and inspire them to follow and embrace treatment plans – and that activating these positive behaviors ultimately leads to better outcomes for both healthcare organizations and patients. Hart currently serves as Vice President of Marketing for TeleVox Solutions at West, 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.

From Last Place, Bronx Communities Now Prize Culture of Health

December 7th, 2017 by Patricia Donovan

Barely eight years ago, the Bronx landed at the very bottom of the first county health rankings issued by the Robert Wood Johnson Foundation (RWJF) —the least healthy of 62 New York counties, to be exact.

It didn’t help that as a borough, the Bronx topped a few other lists compiled by New York officials, including the highest prevalence of obesity and diabetes and the top consumers of sugary drinks.

Rather than discourage this diverse borough, however, these rankings galvanized residents and a number of Bronx organizations, including the Bronx Institute of Health, to partner and examine facets of community life to see where health might be improved. Under the hash tag and rallying cry of #Not62, the coalition’s reach has extended into Bronx schools, housing and even local food stores known as bodegas as it attempts to reimagine and enhance community health.

During Innovative Community-Clinical Partnerships: Reducing Racial and Ethnic Health Disparities through Community Transformation, a November 2017 webcast now available for rebroadcast, Charmaine Ruddock, project director, Bronx Health REACH, charted the path to some of the innovative community health partnerships forged by her organization.

Formed in 1999 with a grant from the Centers for Disease Control and Prevention (CDC), Bronx Health REACH (shorthand for “racial and ethnic approaches to community health”) is charged with eliminating racial and ethnic disparities in health outcomes, particularly those related to diabetes and heart disease, in Bronx populations. Since its inception, Bronx Health REACH has grown from five to more than 70 community-based organizations, schools, healthcare providers, faith-based institutions, housing, social service agencies and others.

“Those founding partners were particularly concerned that Bronx Health REACH not be seen as a program per se, but as a catalyst for creating a movement around health and well-being in the community,” explained Ms. Ruddock.

From early focus groups, Bronx Health REACH determined that community members not only felt disrespected by the healthcare system, but also powerless to advocate on their own behalf for better services. Those findings helped to shape the Bronx Health REACH mission and subsequent efforts.

Outreach began at the organizational level, such as examining the way a local church provided meals at church events. The coalition brainstormed ways to prepare those meals in a healthier manner, supplementing the church’s work with nutrition training that quickly spread throughout the faith community. From there, the program applied that approach to the food offered during school meals and via vending machines, and eventually within the local food retail environment, which consists principally of bodegas.

Today, the scope of Bronx Health REACH is broad, encompassing street safety, physical activity and overall wellness, among other areas. Its early work with bodegas has grown from demonstrations and tastings of healthy foods to the formation of a Bronx bodega work group and a new Healthy Bodegas marketing initiative. It has engaged farmers’ markets in its objective of increasing healthier food options. To that end, healthcare providers now issue “prescriptions” for fruits and vegetables that are accompanied by ten-dollar coupons.

The transformation is visible in the community, Ms. Ruddock notes. Today, some previously padlocked playgrounds are open; murals by visiting artists that adorn the walls of local housing are left alone for all to enjoy.

However, a great deal of work remains. “We have given ourselves as a goal that by 2020, we will establish a multi-sector infrastructure working with housing groups, economic development groups, and others as the first step in addressing many of the health-related factors and issues,” explained Ms. Ruddock.

But for now, the enthusiasm and contributions of Bronx residents have not gone unrewarded. In 2015, just five years after receiving its disappointing health ranking, the Bronx was one of eight recipients of the RWJF’s Culture of Health prize. The prize is awarded to communities that work to ensure residents have the opportunity to live longer, healthier and more productive lives.

Listen to Charmaine Ruddock explain how early findings from focus groups helped to shape Bronx Health REACH initiatives.

Infographic: New Hypertension Guidelines

November 24th, 2017 by Melanie Matthews

New blood pressure guidelines have been released by the American Heart Association. People with readings of 130 as the top number or 80 as the bottom one now are considered to have high blood pressure, according to these new guidelines.

An infographic by the American Heart Association details the guidelines.

Since the January 2015 rollout by CMS of new chronic care management (CCM) codes, many physician practices have been slow to engage in CCM. Arcturus Healthcare, however, rapidly grasped the potential of CCM to improve patient outcomes while generating care coordination revenue, estimating it could earn up to $100,000 monthly for qualified patients treated in its four physician practices—or $1 million a year.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM Revenue traces the incorporation of CCM into Arcturus Healthcare’s existing care management efforts for high-risk patients, as well as the bonus that resulted from CCM code adoption: increased engagement and improved relationships with CCM patients.

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Infographic: How to Make Fitness Resolutions that Stick in the New Year

December 30th, 2016 by Melanie Matthews

The failure rate for New Year’s resolutions is truly shocking. Every year some 64 percent of people will resolve to change for the better. Eating healthy food, losing excess pounds or getting fit are the most common goals, according to a new infographic by Fitness Review.

The infographic examines the key factors which can increase the success rate of these goals.

Infographic: How to Make Fitness Resolutions that Stick in the New Year

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.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today. Have an infographic you’d like featured on our site? Click here for submission guidelines.

HINfographic: Health Coaching: A Win-Win Game Plan for Behavior Change

November 28th, 2016 by Melanie Matthews

From supporting ‘rising risk’ populations telephonically to visiting recently discharged high-risk, high-cost individuals at home, health coaches aim to score all-important health behavior change. Seventy percent of respondents to the 2016 Health Coaching survey by the Healthcare Intelligence Network have launched health coaching ventures.

A new infographic by HIN examines the primary duties of health coaches, the trend toward co-location of health coaches and incentives for health coach participation.

2016 Healthcare Benchmarks: Health Coaching2016 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.

2016 Healthcare Benchmarks: Health Coaching drills down to explore health coaching case loads, experience, certification, performance measurement (individual and program) and more key metrics and is supported with more than 50 graphs and tables. Click here for more information.

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Have an infographic you’d like featured on our site? Click here for submission guidelines.

MACRAeconomics: Chronic Care Management Is the Future of Medicare Reimbursement

November 3rd, 2016 by Patricia Donovan

The newly finalized 2017 Physician Fee Schedule expands Chronic Care Management codes to complex patients with multiple chronic illnesses.

Managing a Medicare population, particularly when the majority has two or more chronic illnesses, can be daunting. But in the current realm of healthcare reimbursement, the care of these beneficiaries is rife with opportunity.

“Depending on the manner in which you’re managing your Medicare Part B demographic, you have an opportunity to generate from 100 to 120 percent of the Medicare fee schedule under MACRA,” noted Barry Allison, chief information officer, the Center for Primary Care, during Physician Chronic Care Management Reimbursement: Setting MACRA’s MIPS Path for 2017.

During this October 2016 webinar now available for replay, Allison described how early adoption of Medicare’s Chronic Care Management (CCM) Reimbursement program enhanced the Center’s MACRA-readiness under the Merit-based Incentive Payment System (MIPS) path. By identifying the more than three-quarters of its 24,000 active Medicare beneficiaries that met CMS’s CCM requirements, the Center had a ready pool of patients on which to overlay CMS’s care coordination best practices and begin earning crucial CCM revenue.

“CMS recognizes that care management is a critical component of primary care. It contributes to better health and care for individuals, as well as reduced spending,” said Allison, who estimates his 40-provider organization is the largest chronic care management initiative in the Southeast.

Using the value-based modifier data available within CMS’s Quality Use and Resource Report (QRUR), The Center for Primary Care further identified its percentage of high-risk Medicare patients for more focused care management.

Accessing and reviewing QRUR reports, available from the CMS Enterprise Identity Management (EIDM) desk, is an essential prerequisite to MACRA participation, advised Allison, who also detailed the type of reports and data available from the QRUR. “Procure that data as soon as possible, because you can learn a lot about what CMS will be looking for in the future, and how the value-based modifier will actually become a part of that MACRA multi-pronged approach.”

While his organization’s CCM program utilized ENLI software to identify ‘hot-spotter’ data elements such as unfilled prescriptions or ER visits for specific conditions, physician practices that lack this technology still have many tools at their disposal—even appointment scheduling software—to identify high-risk patients.

“Open up consistent lines of dialogue and engage your providers. Sit down with them and say, ‘You know your patients better than anyone else. Tell us who to reach out to.'” With or without CCM software, practices should “document, document, document” the amount of time devoted to CCM, as well as how that time benefited patients.

Long-term planning rather than a reactive view will better position physician practices for success under MACRA’s Quality Payment Program, Allison concluded. The Center is already estimating how it will fare under Medicare’s newly finalized 2017 Physician Fee Schedule (PFS). Next year’s PFS significantly updates CCM, offering new codes for complex chronic care management and for extra care management furnished by a physician or practitioner following the initiating visit for patients with multiple chronic conditions.

“For us, CCM is not really focused on the near term revenue as much as it is about the long term action-reaction we can have in the patient’s life, and how our physicians are paid over the next three years.”

Click here for an interview with Barry Allison on the MACRA Prerequisite of Procuring QRUR Performance Data to Maximize MIPS Success.

Infographic: Achieving Wellness Goals

September 2nd, 2016 by Melanie Matthews

Choosing the right tools and components for employer-sponsored wellness programs can make the difference in terms of generating healthy behavior change in employees, according to a new infographic by CompPsych.

The infographic examines what motivates employees to achieve wellness goals and compares results from health trackers versus coaches.

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.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Health Coaching Success Metrics and 8 More Behavior Change Benchmarks

July 7th, 2016 by Patricia Donovan

Satisfied clients and participants on track for goal attainment are two hallmarks of a can't-lose coaching initiative.

Satisfied clients and participants on track for goal attainment are two hallmarks of a can’t-lose coaching initiative.

What are the hallmarks of a winning health coaching strategy? The answer depends on what’s being measured: the effectiveness of the individual coach, the participant’s progress, or overall program success.

That’s the feedback from 111 healthcare organizations responding to the 2016 Health Coaching Survey by the Healthcare Intelligence Network.

If you’re looking to measure the health coach’s success, then client satisfaction is the best indicator, say 27 percent of these respondents.

On the other hand, for a gauge of an individual’s progress, look to the participant’s goal attainment, report 78 percent.

This same metric—goal achievement—is also the best indicator of program success as a whole, agree 64 percent.

The May 2016 survey documented a number of other health coaching benchmarks, including the following:

  • Motivational interviewing is a coach’s top tactic to effect behavior change, say 83 percent.
  • All-important ‘face time’ with coaches is plentiful: 47 percent embed or co-locate health coaches at points of care, with most onsite coaching occurring in primary care offices (50 percent) or at employer work sites (50 percent).
  • Nine percent even embed health coaches in hospital emergency rooms.
  • While a majority focuses on coaching high-risk individuals with multiple chronic illnesses, 51 percent now extend eligibility for health coaching to individuals stratified as ‘rising risk.’
  • Nearly half of respondents—48 percent—offer health coaching to patients and health plan members with behavioral health diagnoses.
  • Reflecting the surge in telehealth, 12 percent of respondents offer video health coaching sessions to clients.

Download an executive summary of the 2016 Health Coaching survey.

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.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.