Posts Tagged ‘clinical integration’

Infographic: Improving Patient Care through Clinical Integration

November 28th, 2018 by Melanie Matthews

Clinical integration plays a key role in the creation of meaningful connections and collaboration within the healthcare sector, according to a new infographic by Regis College.

The infographic examines the benefits of clinical integration and conditions that benefit from integrated 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, 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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8 Effective PCMH Tools to Protect the Medical Home Investment

March 19th, 2015 by Cheryl Miller

The patient-centered medical home (PCMH) model is one of the top five investments in 2015, according to Accenture’s recent analysis of government-sponsored State Health Innovation Plans. Researchers from Accenture found that states are investing in PCMHs in order to strengthen primary care integration with specialists and community health workers. Most will also integrate physical and behavioral care.

Embedding care coordinators in physician offices so they can work with case managers is one way to achieve this integration, according to respondents to the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN). We asked survey respondents what other tools they felt were most effective in implementing the medical home. Following are their responses:

  • Electronic communications that include actionable data and access to patients to initiate the change, and a focus on minimal hassle to physician office.
  • The NCQA PCMH tool.
  • Pre-visit planning and ‘huddles.’
  • Patient registries.
  • Monitoring. We fundamentally changed how we operate daily and monitor change. We incorporated our goal measures into the very fabric of what we do.
  • Using templates in electronic medical records (EMRs) for pre-visit planning and coordination of relevant visits.
  • Home care nurse management system.
  • Patient-centered scheduling.

Source: 2014 Healthcare Benchmarks: The Patient-Centered Medical Home

http://hin.3dcartstores.com/Remote-Monitoring-of-High-Risk-Patients-Telehealth-Protocols-for-Chronic-Care-Management_p_5008.html

2014 Healthcare Benchmarks: The Patient-Centered Medical Home is the Healthcare Intelligence Network’s in-depth analysis of medical home adoption, tools, technologies, challenges, benefits and outcomes. Based on HIN’s PCMH survey administered in February 2014, this resource takes the industry’s pulse on patient-centered activity. Now in its seventh year, it is designed to meet business and planning needs of physician practices, clinics, health plans, managed care organizations, hospitals and others by providing critical benchmarks in medical home implementation and results.

Risk Stratification Targets the High-Risk, Curbs Utilization Across Continuum

February 19th, 2015 by Cheryl Miller

Preventive care and utilizing hospital and discharge information are critical for stratification, say a number of thought leaders from organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and often lead to improved clinical and financial outcomes. Here, some advice from these thought leaders.

Across the healthcare continuum, improved clinical and financial outcomes at organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and Ochsner Health System were preceded by rigorous risk stratification of populations served.

“Humana encourages preventive care, and we are trying to prevent the most costly interventions by making sure we address things before they become big problems,” notes Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. “It is successful so far. We have been able to reduce hospitalizations from what we expected by about 42 percent. We have been able to decrease our hospital readmission rate to 11 percent.”

Hospital admission and discharge information is critical for stratification, adds Annette Watson, RN-BC, CCM, MBA, senior vice president of community transformation for Taconic Professional Resources. “Depending on the model in a primary care practice (PCP), if a physician is not the admitting physician—if the admission is from a specialist, hospitalist, or through the ER—it cannot be assumed the PCP has the admission and discharge information. People may think physicians know about their patients being in the hospital, but that is not always the case.”

“Our first step in launching Monarch’s Pioneer ACO program was to develop a population disease profile in risk stratification analysis,” contributes Colin LeClair, executive director of accountable care at Monarch HealthCare. “With the help of Optum Actuarial Solutions, we identified the eight most prevalent and costly conditions in our population. We then identified the largest cohort of high-risk patients best suited for Monarch’s care management programs. Ultimately we isolated the top 6 percent of high-risk patients with a diagnosis of diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or renal disease and found that of those patients, 6 percent account for 43 percent of total medical cost across the entire population. That analysis resulted in us targeting about 1,200 high-risk patients who have a similar constellation of issues.”

“You want to look at your high utilizers of care, because they’re using a great deal of care,” concludes Elizabeth Miller, RN, MSN, vice president of care management at White Memorial Medical Center, part of Adventist Health. “There’s potential for decreasing procedures, tests, ED visits, hospitalizations.”

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Hospital-Readmissions_p_4786.html

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement—data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry’s value-focused climate.

Medical Neighborhood Bridges Gap Between Health Systems and Physicians

February 18th, 2014 by Patricia Donovan

The medical neighborhood is one approach to defragmenting care coordination in the United States.


The need for better coordination within the U.S. healthcare system cannot be refuted, notes Terry McGeeney, MD, MBA, director of BDC Advisors, who introduces the trend toward medical neighborhoods.

We need to start talking about the solution to bridge the gap between health systems and physicians. We can do that as we talk about the medical neighborhood concept and the integrated network concept. I have come to realize that the medical neighborhood in many environments is a physician term that’s been embraced widely by both specialty organizations and primary care organizations.

A clinically integrated network (CIN) is a hospital term. These CINs have been around since the late nineties, when they were established by the Federal Trade Commission (FTC) and Federal Communication Commission (FCC). And you will often hear hospitals talking about clinical integration. The difference is that until the last couple of years, clinical integration has often been within the four walls of the hospital, where now it’s being expanded to broader networks around population management.

What are these medical neighborhoods that we are talking about and where are they? When you want to look for a medical neighborhood, look no further than your CIN for the foundation of that network. The challenge you often see is that the CIN or clinically integrated entity was set up as a legal entity and is not necessarily a high functioning medical neighborhood. It may have been set up by a law firm, or an accounting organization. It meets all the legal requirements, but it may not meet the requirements needed for improving quality of care in lowering cost.

But that existing CIN does create a foundation from which you can work. What you want to work and think about is transitioning your clinically integrated entity to a high functioning medical neighborhood. And to me that’s the real opportunity, but also a significant challenge.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

Infographic: Physician Alignment and Clinical Integration in Community Hospitals

January 14th, 2014 by Jackie Lyons

Approximately 95 percent of hospitals will consider physician employment in the future, according to an infographic by Kurt Salmon and the Community Hospital 100 Leadership & Strategy Conference.

This infographic provides an analysis of why economic alignment with physicians will be essential for community hospitals of all types in coming years. The analysis includes major differences in hospital approaches to physician alignment and the future evolution of clinical integration strategies.

Physician Alignment and Clinical Integration in Community Hospitals

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You may also be interested in this related resource: The New Hospital-Physician Enterprise: Meeting the Challenges of Value-Based Care.

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Guest Post: Accountable Care Reflects Paradigm Shift from Volume to Value

March 29th, 2013 by Ally C. Evans
Ally C. Evans

Ally C. Evans is an industrial engineer specializing in process and system improvement in healthcare.

In this second in a three-post series on “Accountable Care: The Power of Partnerships,” guest blogger Ally C. Evans, healthcare consultant with Freed Associates, argues that the U.S. volume-based, fragmented healthcare system has to change.

So, volume is a bad thing? Try telling that to a hospital CFO and you’ll quickly realize it’s a hard pill to swallow. The United States’ volume-based, fragmented healthcare system has to change. To that effect, health reform legislation is driving us toward a substantial overhaul of the healthcare delivery system, part of which includes the advent of accountable care, a concept that demands a deliberate rethinking of the way we deliver, coordinate and manage healthcare.

The term ‘Accountable Care Organization’ (ACO) was coined in 2006 by Elliot Fisher of the Dartmouth Institute for Health Policy and Clinical Practice. His idea resonated with policy-makers and lead to the inclusion of ACO provisions in section 3022 of the Affordable Care Act, enacted in March 2010 with final rule in October 2011, under the Shared Savings Program umbrella.

Although the formal introduction of ACOs started with the Medicare-specific Shared Savings Program, the ACO construct provided a new focus for the private sector, which rapidly began experimenting with similar frameworks to constrain costs for commercially insured patients. Through this evolution, ACO has become one of the hottest acronyms in healthcare and most likely has a slightly different definition depending on whom you ask.

In a nutshell, ACOs are formalized, collaborative partnerships between various organizations that agree to be financially accountable for the quality and cost of care for a specific population of patients. This population of patients is typically designated by payor type.

ACOs focus on three core principles:

  1. Provider-led organizations with a strong base of primary care are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients;
  2. Payments are linked to quality improvements that also reduce overall costs;
  3. Reliable and progressively more sophisticated performance measurements are employed to support improvement and provide confidence that savings are achieved through advances in care.

ACOs have various structures, with most including some combination of physicians, other providers such as hospitals and post-acute services, and payors. Together they are responsible — and receive incentives — for enhancing processes and services across the full continuum of care. The ultimate goal is to change the cost-growth trajectory.

The philosophy of shifting from volume to value-driven care remains consistent across all ACO approaches, due to the shared-savings or shared-risk agreements that are integral to the model. These agreements align high performance (e.g., good outcomes) with financial rewards to encourage providers to maximize efficient utilization of healthcare resources, while providing the most appropriate care for the patient.

Smart ACOs will capitalize on the concept of 'sharing' beyond the financial rewards of success.

High-performing ACO providers will receive a designated percentage share of the cost savings based on performance relative to target thresholds. Smart ACOs will capitalize on this concept of ‘sharing’ beyond the financial rewards of success. ACOs that master the art of clinical and system integration will undoubtedly be able to see greater results more rapidly by leveraging sophisticated processes, systems, technologies and teams to coordinate optimal-quality care both vertically and horizontally within the continuum (See figure above.)

Integrated health systems, or ‘real’ ACOs (i.e. those where the provider partners have pre-existing affiliations) are at a clear advantage here, but what about the ‘virtual’ ACOs (i.e. those comprised of independent providers embarking on new partnerships)? These ACOs need more work on the front end relative to investments of time, energy, and money to design and deploy robust governance systems and infrastructures. This infrastructure is essential to allow for real-time and efficient sharing of patient-health information, information technology resources, decision-making, human resources, research and innovation development and data across all ACO partners.

ACOs that do not invest in this foundational work may struggle later on to implement solutions that rely on integration, and to monitor the impact of those solutions due to poor data systems. As with all projects, the costs incurred trying to fix implementation-gone-wrong will far outweigh any up-front costs involved with detailed set-up.

It’s worth noting that ACO partners may be part of multiple ACOs simultaneously, each focused on a unique population of patients and different participating partners. Some organizations are embarking on both commercial and Medicare-sponsored ACOs; others have multiple commercial ACOs in progress. Although this approach expands potential bandwidth by reaching a larger population of patients, it is likely to dilute their ability to maximize their ‘sharing’ potential within each ACO. Also, as ACO models continue to adapt, particularly in the private sector, each ACO may prescribe different metrics, goals, and therefore, solutions, to ensure success. Clear delineation of priorities across and within ACOs, and alignment of core tactics and timeframes with organization-wide strategy, will be core components of success.

Read Part 1: Why Accountable Care Organizations?

In the final post in the series, Ms. Evans will propose ACOs as a panacea.

Ally C. Evans is an industrial engineer specializing in process and system improvement in healthcare. Most recently, Ally has driven various initiatives in the Accountable Care arena, focusing on the design and implementation of ACO strategy and tactical interventions. She is a consultant with Freed Associates, a California-based healthcare consulting firm. Their work is to provide sustainable solutions that enable healthcare organization to improve patient care services reduce costs and increase operational efficiency.

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.

Healthcare Delivery Advice for 2013: Shore Up Payment Before Shifting Model

October 23rd, 2012 by Patricia Donovan

Eying a move to an ACO or the patient-centered medical home model in 2013? First, adjust the payment structure to support it, advises Steven Valentine, president of the Camden Group. Shifting to one of the popular post-reform healthcare delivery models before changing the payment system is courting financial disaster, Valentine warned during HIN’s ninth annual Healthcare Trends & Forecasts strategic planning session.

Valentine charted anticipated trends for healthcare providers in 2013, while Hank Osowski and Dennis Eder, both managing directors for Strategic Health Group, covered business opportunities for health plans during the 60-minute webinar.

All of the analysts agreed that the outcome of next month’s presidential election would have little impact on healthcare reform.

“Regardless of who gets elected president, many of the things I’m talking about — bundled payment, patient-centered medical home, co-management agreements, clinical integration, accountable care organizations — are all going happen due to the economics of healthcare.”

“The reform train has left the station,” agreed Eder. “Folks who are waiting around to see what happens in the election, or who waited around for the Supreme Court decision on the Affordable Care Act, are too late.”

The election results will “likely influence the pace of change to the healthcare system, but probably not the direction,” added Osowski. The continued acquisitions and consolidations evident in the industry are proof in the market’s belief in the longevity of reform-based initiatives, he said.

Common ground across the industry continuum includes potential from collaborations — hospital-physician co-management service agreements on the provider side, and strategic partnerships in population health management on the payor side. Partnership opportunities are more plentiful now than at any time in recent healthcare history, noted Eder. “I was involved in the original integrated health world in the mid-1980’s when systems were buying both hospitals and physician organizations and starting health plans. The sincerity and the desire to work as true partners are unlike any time I’ve seen before.”

The speakers identified the strategic focus for each sector, with Valentine indicating that the key investment for providers should be on growing their population — getting as large a defined population base at the bottom of the pyramid as possible, which encompasses the access points and primary care, he said.

For payors, the industry’s increasingly population-centric, value over volume sensibility offers many opportunities in coordinated care, particularly for Medicaid-Medicare dual eligibles, said Osowski. “Duals comprise about 18 percent of the state Medicaid population, and yet they account for almost a little more than a third of the total spend on Medicaid,” he said.

Duals are a complex population with unique health concerns, requiring a strong behavioral health component. “Duals tend to be very costly because they’re typically non-compliant patients and don’t really follow what is being asked of them in terms of their healthcare,” said Valentine.

“The dual population is not just frail elders; the dual population is 40 percent people under 65,” added Eder. And the vast majority of the people under 65 are disabled because of behavioral health-related issues. So for organizations considering getting into the dual market, if you’ve just done frail elderly programs and you think you’re going to be working with that same cohort of members, it’s going to be a painful learning.”

In other trends, the industry should expect delays in implementation of health insurance exchanges (HIEs), which face significant funding hurdles, said Osowski.

Healthcare may also see the reemergence of narrow networks, in which health plan members or employers benefit from lower costs when staying within their own health systems. Individuals will still have the choice of going outside the system, but face much higher copays.

“We’re leaving choice in place, but we are getting much better at directing back to a smaller, more narrow network that will help to steer volume back to the providers, and reduce the total cost of care and the out of pocket cost for the employee,” concluded Valentine.

Listen to an interview with Dennis Eder, Hank Osowski and Steven Valentine.

Q&A: How Clinical Integration Creates Framework for Value-Based Payment Contract

August 8th, 2012 by Jessica Fornarotto

Advocate Physician Partners is proud of its infrastructure of success in shared savings, built on a foundation of clinical integration.

“To describe how valuable our clinical integration program is at Advocate Physician Partners, two areas need to be highlighted,” says Dr. Carrie Nelson, medical director for special projects with Advocate Physician Partners (APP).

Dr. Carrie Nelson, Medical Director for Special Projects


Prior to her presentation on Bending the Cost Curve with a Commercial Value-Based Payment Contract: A Case Study from Advocate Physician Partners, Dr. Nelson discussed in depth APP’s clinical integration program that helped to set the framework for their value-based payment contract with Blue Cross Blue Shield of Illinois (BCBSIL). This payor-provider agreement has reduced inpatient admissions and ER visits, and has bent the cost curve after its first year of implementation. APP’s clinical integration program is described in detail in
Case Study in Clinical Integration: The Advocate Physician Partners Experience.

HIN: How has APP’s clinical integration of more than 4,000 physicians and 10 hospitals over the last few years helped to lay the groundwork for your value-based payment contract?

(Dr. Carrie Nelson): We feel very fortunate that we have a strong clinical integration program in place. It has created a strong foundation for the work that we’re doing with shared savings. There are two major areas that demonstrate how valuable that foundation has been to us.

First, it is a culture of delivering that value that we have established here over the last eight years or so since we’ve been deeply involved in this clinical integration program. That has been a tremendous spirit to build upon with movement toward shared savings and value-based contracting. Physicians in our network have a strong understanding of the importance of delivering that value and achieving quality metrics and not just a fee-for-service volume-based approach to care.

The second would be the framework that it has laid for us in how we can continue to incentivize the physicians to achieve the goals associated with shared savings. We have been able to build a number of our key priorities into the clinical integration program, such as decreasing ER utilization, length of stay, and admissions for ambulatory care-sensitive conditions. Many of those things have rolled into our clinical integration program and have helped physicians to be energized to help achieve these shared goals.

We feel very fortunate that we had this program in place in many cases before it was truly rewarded. It has also provided this cultural basis and framework for building upon the successes that we’ve already seen. The last thing to remember is this: all that needs to be accomplished in shared savings can be overwhelming. Clinical integration and the measurements that we’ve been involved in for many years are some of those things.

It’s nice to be able to focus on some alternative areas to show our infrastructure of success in shared savings, instead of having to focus explicitly on just the measures that are brought along.

Joint Contracting Key Component of Clinical Integration Program

June 20th, 2012 by Cheryl Miller

Joint contracting is the ‘glue’ that keeps the Advocate Physician Partners (APP) clinical integration program together, explains Mark Shields, MD, MBA, APP senior medical director and vice president of medical management for Advocate Health Care.

To put together our clinical integration (CI) program, we have negotiated with all of the carriers in our marketplace. There are 10 clinically integrated contracts with our 10 lead carriers. The funding of the CI programs is based on a percentage of allowable physician billings. That is how we create the cash flow for our pay for performance (PFP) program and key infrastructure. The key component of CI is that our quality, patient safety and cost-effectiveness measures are the same across all of the health plans. Our program covers both risk contracts and FFS contracts. Therefore, both health maintenance organization (HMO) and preferred provider organization (PPO) contracts are covered.

We negotiate both base and incentive compensation for physicians. The key component to drive outcome is that the same measures and thresholds of performance are common across all of these contracts. That allows the providers to overcome what has been referred to as a “Tower of Babel” in the past. Even when different insurance companies had similar measures in their PFP programs, the thresholds and methods to collect and report the data were different. It became so confusing for providers that they were not able to focus on performance improvement. They threw up their hands and said, “Well, let the chips fall where they may.”

By having the common set of measures across all of the payors, we are able to develop tools and common reporting systems to drive change. This is our definition of CI: physicians across specialties working together with hospitals to drive quality, patient safety and cost-effectiveness. Joint contracting is a critical component of CI; it is the key glue to keep the program together. Joint contracting has been a key issue that has engaged APP in discussions with regulators, particularly the Federal Trade Commission (FTC). They have given us approval to continue with this CI program, and that is important for others who are thinking about doing this kind of program. It passes not only market acceptance, but also regulatory acceptance.