Posts Tagged ‘Care Coordination’

10 Critical Care Coordination Model Elements for Medicaid Managed Care Members

May 17th, 2018 by Melanie Matthews

There are 10 critical elements of the care coordination model for Independent Health Care Plan (iCare) Medicaid managed care members, according to Lisa Holden, vice president of accountable care, iCare.

The first element and touchpoint for Medicaid managed care members is their care coordinator. “Every single one of our incoming SSI Medicaid members is assigned to a care coordinator,” Holden told participants in the May 2018 webinar, Medicaid Member Engagement: A Telephonic Care Coordination Relationship-Building Strategy, now available for replay. “That person is responsible for everything to do with that member’s coordination of care.”

Care coordinators are assigned to every Medicaid member and are responsible for engaging and coordinating member’s care needs.

“We want our care coordinators to make an initial phone call as early as a couple of days after the member is enrolled in our plan,” she said. “If the member is interested in having a conversation, we offer to conduct a health risk assessment. But if the timing isn’t right, then we offer to schedule another appointment. There’s no pressure except that we want them to feel engaged by us.”

Once completed, the health risk assessment forms the basis of an interdisciplinary individualized care plan created by the care coordinator with the member.

The care coordinator, who is a social worker by background, has access to a nurse, who is available for medically complex members, said Holden.

iCare also relies on health coaches. Health coaches are now teaming up with a care coordinator as much as, if not more than, the nurses are historically, Holden said.

“Our health coaches are literally assigned to work in the community to become very familiar with the resources that are available,” she added. “They are becoming steeped in the communities in which they serve. Each one is assigned to a neighborhood, and we’ve asked them, ‘Get to know the police. Get to know the fire. Get to know the food organizations and food pantries. Get to know the housing specialists in your area.'”

The health coaches also help the care coordinators locate difficult-to-contact members by being in the community as a boots on the ground force. They’re also focused on assessing and addressing social determinants of health.

“We really believe that health coaches are going to be the key to our success in this year and in years to come,” Holden explained.

In addition to the care coordinators, health coaches and nurses, the care coordination team includes two specialized positions…a trauma-informed intervention specialist and a mental health and substance abuse intervention specialist. “We brought those two specialties into this program for our Medicaid members because we know that there’s a high instance of behavioral health conditions, which usually has another diagnosis of alcohol and drug use, not always, but quite often. We wanted to have the team ready to engage the member,” said Holden.

Once the member is engaged, iCare’s care coordination team begins to identify unmet needs, she explained. “We want to know, ‘Is their life going well? Do they have appropriate medical care? Are they in a relationship with a primary care provider that they feel is co-respectful? Are they getting their answers to their questions?'”

To begin talking about medical needs, the care coordination team has to establish trust, said Holden. “We have to talk with the member in an honest way that reflects our respect for them and also engages them in order for them to tell us how they really feel.”

iCare uses the Patient Activation Measure tool to help identify where the member is in a spectrum of four different levels of activation. iCare then tailors its member engagement approach to build a trusting relationship and provide member education by recognizing where they are in their activation level.

Following up on preventive measures are key for the iCare care coordination model. Care coordinators reach out to members for care plan updates. The care plan has to be alive and very member-centric, said Holden. The health risk assessment is repeated each year and the care plan is updated based on those results.

iCare is also focusing on social determinants of health with the recognition that they impact a members’ health more than clinical care. Clinical care attributes to only about 20 percent of somebody’s health outcomes; the rest of that 80 percent is made up of by health behaviors, social and economic factors, and physical environment. “If we don’t get underneath those issues, we can ask for things to improve, but we’re going to see minimal success,” Holden added.

During the webinar, Holden also shared: how the care coordinators helps Medicaid members overcome barriers to care; seven rising risk/acuity identification tools; readmission prevention initiatives for high-risk patients; three programs aimed at reducing high emergency department utilization; and details on a Follow-to-Home program for members who are homeless. Holden also shared: details on language to use…and not to use…when engaging members; advice on the best time to connect with members by phone, such as time of day, specific days of the months; the role of the specialist interventionist compared to the care coordinator; and the background of iCare’s care coordinators and health coaches.

Click here to view the webinar today or order a DVD or CD of the conference proceedings.

Infographic: Seven Essentials Steps to Effective Care Coordination

April 30th, 2018 by Melanie Matthews

Understanding and removing barriers to health and coordination is the key to successful care coordination, according to a new infographic by Optum.

The infographic examines seven essentials steps to removing these barriers.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-LifeWhen acknowledging its position as a top-ranking Medicare Shared Savings Program (MSSP), Memorial Hermann is quick to credit its own physicians—who in 2007 lobbied for a clinically integrated network that formed the foundation of the current Memorial Hermann accountable care organization (ACO). Now, eight years later, collaboration and integration continue to be the engines driving the ACO’s cost savings, reduced utilization and healthy patient engagement rates associated with Memorial Hermann ACO’s highest-risk population.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life details Memorial Hermann’s carefully executed journey to quality and the culmination of the ACO’s community-based care management program.

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Healthcare Hotwire: Care Coordination

November 2nd, 2017 by Melanie Matthews

Care coordination organizes patient care activities and information for safer and more effective care.

Care coordination involves deliberately organizing patient care activities and sharing information among all vested participants to achieve safer and more effective care, per the Agency for Healthcare Research and Quality (AHRQ).

These patient care activities span all care settings, including the patient’s home, according to the Healthcare Intelligence Network’s Benchmark Survey on Care Coordination.

Initiatives aimed at coordinating care for high-risk patients are reporting healthcare cost savings, reductions in expensive sites of care and improvements in quality, outcomes and patient satisfaction.

In the new edition of Healthcare Hotwire, you’ll get details on enhanced care coordination Medicare savings, reducing emergency department utilization through care coordination and the impact of care coordination efforts on patient and provider satisfaction.

HIN’s newly launched Healthcare Hotwire tracks trending topics in the industry for strategic planning. Subscribe today.

HINfographic: Care Coordination Trends: Oversight of Complex Comorbid Spans Continuum

May 17th, 2017 by Melanie Matthews

Care coordinators organize patient care activities and share information among vested participants to achieve safer and more effective care, per the Agency for Healthcare Research and Quality (AHRQ). And for 86 percent of respondents to the 2016 Care Coordination survey by the Healthcare Intelligence Network, care coordination takes place across all care settings, including the patient’s home.

A new infographic by HIN examines patient care coordination touchpoints, patients by diagnoses prioritized for care coordination and care coordination touchpoint frequency and reimbursement models.

2016 Healthcare Benchmarks: Care CoordinationCare coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care, as defined by the Agency for Healthcare Research and Quality (AHRQ).

2016 Healthcare Benchmarks: Care Coordination examines care coordination settings, strategies, targeted populations, supporting technologies, results and ROI, based on responses from 114 healthcare organizations to the September 2016 Care Coordination survey by the Healthcare Intelligence Network.

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HINfographic: Care Plans Put Healthcare Team on Same Page

April 13th, 2016 by Melanie Matthews

Though supporting technologies may vary, most healthcare organizations develop detailed, evidence-based, sharable care plans that follow high-risk patients through clinical episodes and transitions of care, with the goal of enhancing care quality and engagement and reducing spend, according to the 2015 Care Plans survey by the Healthcare Intelligence Network.

A new infographic by HIN examines how care plans are distributed and stored, how long patients’ care plans are tracked and the frequency of care plan tracking.

2016 Healthcare Benchmarks: Care PlansDetailed evidence-based care plans that follow high-risk patients through clinical episodes and transitions of care help these patients and their providers assess the level of care needed, evaluate services available and empower patients with goals of care, a strategy that impacts quality, outcomes and patient experience and engagement.

2016 Healthcare Benchmarks: Care Plans examines care plan utilization strategies and successes from more than 75 healthcare organizations responding to the November 2015 Care Plan survey by the Healthcare Intelligence Network. Click here for more information.

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Infographic: Hospitals Coordinate Care to Serve Patients

February 3rd, 2016 by Melanie Matthews

Hospitals are working together and with physicians and other community caregivers to provide patients with convenient, high quality and affordable care, according to a new infographic by the American Hospital Association.

The infographic looks at hospitals’ effort to coordinate care.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-LifeWhen acknowledging its position as a top-ranking Medicare Shared Savings Program (MSSP), Memorial Hermann is quick to credit its own physicians—who in 2007 lobbied for a clinically integrated network that formed the foundation of the current Memorial Hermann accountable care organization (ACO). Now, eight years later, collaboration and integration continue to be the engines driving the ACO’s cost savings, reduced utilization and healthy patient engagement rates associated with Memorial Hermann ACO’s highest-risk population.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life details Memorial Hermann’s carefully executed journey to quality and the culmination of the ACO’s community-based care management program.

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Infographic: Collaboration for Better Care

October 7th, 2015 by Melanie Matthews

Technology can help break down communication barriers and extend more immediate care, according to a new infographic by CDW Healthcare.

The infographic showcases health IT components that support connected care.

Collaboration for Better Care

The rapid evolution of healthcare payment reform requires a sea change of both hospital and physician behavior. As healthcare providers are held more accountable for the quality and cost of care delivered, the physician-hospital organization (PHO) provides an efficient framework for collaboration and resource consolidation.

Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement describes the relevance of the PHO model to today’s healthcare market, offering strategies to leverage the physician-hospital organization for maximum clinical outcomes, competencies and value-based reimbursement.

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Infographic: Coordinated Care Models Needed for Cancer Care

September 28th, 2015 by Melanie Matthews

Coordinated Care Models Needed for Cancer Care

Overall satisfaction among cancer patients and caregivers with the care they received has improved significantly since the 2012, according to new data from the 2015 Cancer Experience: A National Study of Patients and Caregivers, reflected in a new infographic.

The survey results also mirror the ongoing national healthcare debate and reveal significant gaps between patients’ expectations and the quality of care they receive. While having access to advanced oncology therapies is important, survey respondents indicated that healthcare providers need to address their dissatisfaction with the lack of care coordination, confusion and frustration surrounding healthcare terminology (literacy), and the inability to obtain timely information from their care team.

The infographic drills down on these survey results and examines how healthcare providers can respond to these patient concerns.

Anthem's Cancer Care Quality Program: Pathways to Improve Care and Reduce CostsDespite enormous innovations in the field, average costs for oncology drugs are skyrocketing and thousands of people in the U.S. die from cancer each week. Some payers, including Anthem, Inc., have turned to the use of pathways in an effort to make sure patients get the most appropriate evidence-based care that is still cost-effective.

Anthem’s Cancer Care Quality Program: Pathways to Improve Care and Reduce Costs discusses the specifics of the insurer’s Cancer Care Quality Program, its expectations in terms of outcomes and cost control, lessons it has learned and changes already made in the initial plans.

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Infographic: Standardization, Collaboration Across Care Teams Improves Care Quality

August 3rd, 2015 by Melanie Matthews

Failures in care coordination can increase healthcare costs by between $25 and $25 billion annually, according to a new infographic by Elsevier.

The infographic examines the impact of poor care coordination on the patient experience and healthcare costs and how healthcare organizations can address this challenge.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team. Having demonstrated the team’s bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations chronicles AltaMed’s four-phase rollout of care coordination for dual eligibles—a population with higher hospitalization and utilization and care costs twice those of any other population served by AltaMed.

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Infographic: Population Health Communication Breakdown

July 6th, 2015 by Melanie Matthews

There’s a fundamental problem standing in the way of improving population health — doctors and nurses still struggle to get in touch with each other to coordinate care, according to a new infographic by PerfectServe.

The infographic examines the problems clinicians face when trying to coordinate care and how technology is not adequately being used to coordinate care.

2014 Healthcare Benchmarks: Population Health ManagementPopulation health management, with its focus on stratifying and managing care of high-risk, high-utilization sectors, is the area of healthcare most ripe with opportunity, according to 2014 HIN market data. Population health metrics drive quality and reimbursement returns in the current value-based healthcare environment.

2014 Healthcare Benchmarks: Population Health Management delivers an in-depth analysis of population health management (PHM) trends at 129 healthcare organizations, including prevalence of PHM initiatives, program components, professionals on the PHM team, incentives, challenges and ROI.

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