Posts Tagged ‘Bon Secours’

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

February 4th, 2016 by Patricia Donovan

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


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

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

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

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

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

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

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

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

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

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

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

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

Bon Secours Blueprint for Advanced Medical Home: From Mortar to Measurement

October 7th, 2014 by Patricia Donovan

The building of Bon Secours Health System’s Advanced Medical Home1 began with a walk-through—an assessment of bricks and mortar, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System.

In Phase 1 of our Advanced Medical Home project, my team goes into a practice and does a basic workflow discovery—an assessment of bricks and mortar. Oftentimes, the physical plant is not effectively used.

Our objective in a primary care practice is to give each physician at least three or four exam rooms whenever possible. We will do that in a number of different ways, even if it means putting up walls or moving charts out now that we are electronic, or eliminating sample medication closets. We will do whatever it takes to achieve those three rooms per physician.

Next, we review the staff that is providing clinical support. We have developed competency assessment tools for patient service representative (PSR) staff, medical assistant (MA) staff, several different levels of licensed practical nurse (LPN) and our registered nurse (RN) navigator, which is the embedded case manager.

Third, we do an analysis of the physician’s panel size and risk acuity levels and form teams. Team formation is a difficult thing to do because you not only have to assess skills, licensures, panel size and patient acuity, but you also have to take personalities into consideration as well. That is the single most difficult obstacle to being effective.

Fourth, we introduce equipment and training on that equipment so the staff has tools they can use. We do wave testing point of care again, the objective being to eliminate that patient behavioral component and capture an actionable result on the spot before they leave the office. Their hypoglycemic agent or their Coumadin® dose could be titrated accordingly.

Fifth, we do optimization training with the use of our electronic medical record (EMR). We make sure everyone knows how to navigate and is comfortable with the documentation we require. We also use a coding training for the physician’s staff.

Finally, we have a set of metrics to establish baseline so we measure performance.

1. The Advanced Medical home is a model developed by the American College of Physicians involving the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, and other strategies to manage a patient population.

embedded case management

Robert Fortini, PNP, is vice president and chief clinical officer for Bon Secours Medical Group in Richmond, Virginia. He is responsible for facilitating provider adoption of EMR, coordinating clinical transformation to a patient-centered medical home care delivery model, and facilitating participation in available pay for performance initiatives as well as physician advocacy and affairs.

Source: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination

Severity Index Drives Patients’ Touch Points with Nurse Navigators

August 12th, 2014 by Patricia Donovan

Beyond telephonic outreach, assessment and education, nurse navigators in Bon Secours Health System Advanced Medical Home also manage a case load for face-to-face patient work, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Here, he describes the process of assigning patients to nurse navigators.

Based on our learning experiences with the Geisinger system, it becomes difficult for an RN to handle more than about 150 patients, depending upon the complexity of the patient.

We also give back-line access, and the RNs all have beepers as well. They have the license to give that beeper number to the more complex patients—the frequent flyers who are going to need more attention. Or they can give that access to our colleagues on the managed care side who might be engaged in managing patients with a severe illness. To our case management team in the hospital, it just allows for more bandwidth and clearer communication across the spectrum of care delivery.

How does a patient get into a case load? It is by the physician’s decision. For example, Mr. Smith has seven different major active problems. He is on 18 different medications, he is 87 years old and he has a touch of Alzheimers. That individual needs hand-holding, so that would be the first way to give the patient case management. We also take referrals from the hospital and from our managed care colleagues. We are also using some predictive modeling tools provided to us by insurers to identify patients who need closer following.

How frequently a patient is touched, brought in for face-to-face care or called on the phone depends on the severity index. We use a tool my colleague designed that will calculate a relative readmission risk index based on several sets of criteria: number of medications, length of stay in the hospital, the acuity level of the patient in the hospital and whether or not they are in intensive care unit (ICU) initially, etc. How frequently they are touched depends on how high up the severity index they are.

Excerpted from: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination