Connected care includes AMITA Health front line staff, administrators, physicians, hospital executives and community partners.
Does a health system
really need four types of care managers?
When AMITA Health set out to craft an ambulatory care coordination team for its highest-risk Medicare beneficiaries, it realized it didn’t.
As part of its thirteen-point plan to revamp care management across its continuum, the newly minted Medicare Shared Savings Program (MSSP) accountable care organization (ACO) reexamined the roles of its navigators, case managers, patient-centered home care managers and ACO care managers, ultimately abandoning its siloed approach in favor of a more human-centric model of care.
“We really needed a better way to care for our patients across the continuum,” explained Susan Wickey, vice president, quality and care management at AMITA Health, during Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care Management Strategy, an August 2016 webinar now available for replay. “We had to identify and remove those silos, and break down those barriers.”
AMITA Health’s decision to remake care management was a response to its MSSP program goal of fulfilling the Triple Aim: improving population health and experience of care while fostering appropriate utilization and cost. The initiative in no way devalued care managers’ contributions. “Our care coordinators across the continuum serve as our first responders when high risk patients need intervention,” said Ms. Wickey.
In the process of improving efficiencies, the nine-hospital system discovered that often, one could be more effective than four.
With help from Phillips Healthcare Consulting Division, AMITA inventoried its care management resources, then created a single centralized care management hub. Communication would occur via a single universal transfer form for each patient, for whom a single care plan would be developed. This power of one echoed throughout the transformation as AMITA restructured processes and programs.
AMITA rolled out the program initially with one unit of patients; today, all nine of AMITA Health’s hospitals operate with some component of this enterprise-wide redesign.
“We wanted to be a health system where our patients were transitioned but never really discharged from our healthcare system,” explained Ms. Wickey’s co-presenter, Dr. Luke Hansen, vice president and chief medical officer, population health for AMITA Health. “We never discharge a patient from our system; rather we transition our patients to the most appropriate setting.”
“This collaborative vision of connected care includes all of the front line staff, key administrators, physicians, hospital executives, along with AMITA’s community partners,” added Ms. Wickey.
In assessing its MSSP experience, Dr. Hansen said access to Medicare claims data enabled AMITA Health to track utilization, a first for the organization. Trends toward lower all-cause readmissions, lower admissions for ambulatory-sensitive conditions and emergency department visits were recorded, he said. And while he can’t definitely credit the MSSP for his organization’s improved quality scores in recent years, he takes pride in AMITA’s achievements of strengthening quality while holding costs relatively stable.
However, improvements have leveled off since 2013, its first MSSP performance year, which frustrates the population health CMO. “As those of you participating in MSSP know, year-over-year improvement is what you need to do to succeed.”
“We live that tension between our old models of care delivery, which were very successful for our organization, and new models, which we will have to adopt in a timely way to be successful in the future,” concluded Dr. Hansen.
Click here for an audio interview with Dr. Hansen.
The hyper-connected patient provides a number of opportunities for healthcare organizations to manage and prevent chronic diseases, according to a new infographic by EMC2.
Encouraged by early success in coaching 23 patients to wellness at home via remote monitoring, CHRISTUS Health expanded its remote patient monitoring (RPM) enrollment to 170 high-risk, high-cost patients. At that scaling-up juncture, the challenge for CHRISTUS shifted to balancing its mission of keeping patients healthy and in their homes with maintaining revenue streams sufficient to keep its doors open in a largely fee-for-service environment. 
