Posts Tagged ‘health literacy’

PinnacleHealth Engagement Coaches Score Points with High-Risk Patients, Win Over Clinicians

September 7th, 2017 by Patricia Donovan

PinnacleHealth’s targeted outreach, 24/7 nurse advice line and clinician coaching have helped to bring chronic disease high utilizers back to care.

A dual engagement strategy by PinnacleHealth System that recruits both patients and providers is scoring significant gains in CAHPS® scores, clinical indicators in high risk patients, and the provision of health-literate care.

Kathryn Shradley, director of population health for PinnacleHealth System, outlined her organization’s patient engagement playbook during A Two-Pronged Patient Engagement Strategy: Closing Gaps in Care and Coaching Clinicians, an August 2017 webcast now available from the Healthcare Intelligence Network training suite.

The winning framework? Focused outreach and health coaching for high-risk, high utilizers that break down barriers to care, and a patient engagement coach to advise PinnacleHealth clinicians on the art of activating patients in self-management.

PinnacleHealth’s engagement approach, aligned with its population health strategies and based on the Health Literate Care Model, began in its ambulatory and primary care arenas. Before any coaching began, the health system schooled its staff on the value of health literacy. “Moving to a climate of patient engagement is nothing short of a culture change for many of our clinicians,” said Ms. Shradley.

To foster leadership buy-in, PinnacleHealth also strove to demonstrate bottom-line benefits of patient engagement, including lowered costs and staff turnover and increased standing in the community.

Then, having combed its registry to identify about 1,900 chronic disease patients most in need of engagement, the health system hired a health maintenance outreach coordinator who built outreach and coaching pilots designed to break down barriers to care. At the end of the six-month pilot, higher engagement and lower A1C levels were noted in more than half of these patients. For the 23 percent that remained disengaged, the outreach coordinator dug a little deeper, uncovering additional social health determinants like transportation they could address with more intensive coaching and even home visits.

At the same time, a new 24/7 nurse advice line staffed with PinnacleHealth employees continued that coaching support when the health coach was not available.

Complementing this patient outreach is a patient engagement coach, a public health-minded non-clinician that guides PinnacleHealth providers in the use of tools like motivational interviewing and teach-back during patient visits to kindle engagement.

“The engagement coach does a great job of standing at the elbow with our providers in a visit, outside of a visit, surrounding a visit, to talk about what life looks like from the patient side of view.”

Providers and staff receive one to two direct coaching sessions each year, with additional coaching available as needed.

With other elements of its patient engagement approach yet to be implemented, PinnacleHealth has observed encouraging improvements in HCAHPS scores for at least one practice that received coaching over seven months. It has also learned that by educating nurses on health-literate care interventions, it could increase HCAHPS communication scores.

Listen to an interview with Kathryn Shradley: PinnacleHealth’s Patient Engagement Coach for Clinicians: Supportive Peer at Provider’s Elbow.

Infographic: Improving Health Literacy with Data

May 10th, 2017 by Melanie Matthews

Individuals are not solely responsible for increasing their health literacy, healthcare organizations are accountable too, according to a new infographic by Sagitec.

The infographic examines health literacy trends, implications, possibilities and solutions.

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health SystemIntermountain Healthcare’s strategic six-point patient engagement framework not only has transformed patient care delivered by the Salt Lake City-based organization but also has fostered an attitude of shared accountability throughout the not-for-profit health system.

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health System details Intermountain’s multilayered approach and how it supports its corporate mission: Helping people live the healthiest lives possible.

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Use Annual Wellness Visit to Screen for Social Determinants of Health in High-Risk Medicare Population

December 13th, 2016 by Patricia Donovan

The social determinant of social isolation carries the same health risk as smoking, and double that of obesity.

With about a third of health outcomes determined by human behavior choices, according to a Robert Wood Johnson Foundation study, improving population health should be as straightforward as fostering healthy behaviors in patients and health plan members.

But what’s unstated in that data point is that the remaining 70 percent of health outcomes are determined by social determinants of health—areas that involve an individual’s social and environmental condition as well as experiences that directly impact health and health status.

By addressing social determinants, healthcare organizations can dramatically impact patient outcomes as well as their own financial success under value-based care, advised Dr. Randall Williams, chief executive officer, Pharos Innovations, during Social Determinants and Population Health: Moving Beyond Clinical Data in a Value-Based Healthcare System, a December 2016 webinar now available for replay.

“The challenge is that few healthcare systems are currently equipped to identify individuals within their populations who have social determinant challenges,” said Dr. Williams, “And few are still are structured to coordinate both medical and nonmedical support needs.”

The Medicare annual wellness visit is an ideal opportunity to screen beneficiaries for social determinants—particularly rising and high-risk patients, who frequently face a higher percentage of social determinant challenges.

Primary social determinants include the individual’s access to healthcare, their socio- and economic conditions, and factors related to their living environment such as air or water quality, availability of food, and transportation.

Dr. Williams presented several patient scenarios illustrating key social determinants, including social isolation, in which individuals, particularly the elderly, are lonely, lack companionship and frequently suffer from depression. “Social isolation carries the same health risk as smoking and double that of obesity,” he said.

While technology is useful in reducing social isolation, studies by the Pew Research Center determined that segments of the population with the highest percentage of chronic illness tend to be least connected to the Internet or even to mobile technologies.

“Accountable care organizations (ACOs) and other organizations managing populations must continue to push technology-enhanced care models,” said Dr. Williams, “But they also have to understand and assess technology barriers and inequalities in their populations, especially among those with chronic conditions.”

In another patient scenario, loss of transportation severely hampered an eighty-year-old woman’s ability to complete physical rehabilitation following a knee replacement.

Dr. Williams then described multiple approaches for healthcare organizations to begin to address social determinants in population health, including patients’ cultural biases, which may make them more or less open to specific care options. This fundamental care redesign should include an environmental assessment to catalog available social and community resources, he said, providing several examples.

“This is not the kind of information you’re going to find in a traditional electronic health record or even care management platforms,” he concluded.

Intermountain Healthcare Determined to Diminish Patient Disengagement Divide

November 5th, 2015 by Patricia Donovan

One in three healthcare consumers are disengaged from self-care, prevention and health IT, explained Intermountain Healthcare's Tammy Richards, corporate director of patient and clinical engagement.

Dismayed by national dips in patient engagement, satisfaction and health literacy, among other industry currents, Intermountain Healthcare convened a patient engagement steering committee composed of its highest level leaders.

What emerged was a strategic six-point patient engagement framework that not only has transformed patient care by the Salt Lake City-based organization but also has fostered a climate of shared accountability throughout the not-for-profit health system.

In a dramatic example of the framework’s potential, Tammy Richards, corporate director of patient and clinical engagement at Intermountain Healthcare, described how one Intermountain ER nurse, using newly acquired engagement skills, emotionally and personally connected with Harold, an alcoholic, disenfranchised frequent ER utilizer who previously had only reacted in an angry, abusive fashion.

“We changed, and Harold changed, and this is really what patient engagement is about: genuinely connecting with individuals, understanding their story and then providing them with the tools, electronic or personal, to heal or hopefully stay healthy,” Ms. Richards said during A Patient Engagement Framework: Intermountain Healthcare’s Approach for a Value-Based System, an October 2015 webinar now available for replay.

In presenting the six key program tenets, Ms. Richards underscored how her organization’s multilayered approach supports the mission of Intermountain Healthcare: Helping people live the healthiest lives possible.

Intermountain was particularly disturbed by Deloitte’s finding that one in three healthcare consumers are disengaged, Ms. Richard explained. “[The disengaged] are reporting less desire for care, less commitment to preventive action, less interest in technology and other solutions, and they are less financially prepared,” she said.

That critical data point ignited Intermountain’s efforts to reengage and engage its consumers, she added.

She shared highlights from the six-point engagement framework, including the following:

  • Incorporation of patient and family perspectives into the planning, delivery and evaluation of healthcare;
  • Designation of a staff member as the system’s health literacy coordinator;
  • Application of meaningful technology that spans the engagement framework;
  • Formation of workgroups and work streams dedicated to health literacy, engagement technology and patient experience that report to the steering committee; and
  • Better-timed offering of care decision aids to patients.

Although technology is often touted as the answer to patient engagement, Ms. Richards cautioned against the employment of too many tools to engage patients. “Historically, we’ve created chaos with systems and programs that have no interoperability. This is certainly an issue from an industry perspective; it’s also an issue within a hospital or within a system.”

With its engagement framework in place, Intermountain will continue to explore new methods of creating a seamless, integrated care experience for its patients, so that it may better serve its Harolds, its chronically ill, and even its pediatric populations, Ms. Richards concluded.

“We know that we’re going to fulfill our mission and it will be a constant journey. We know that our mission of helping people live the healthiest lives possible is within our grasp.”

Click here for an interview with Tammy Richards.

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: Social Media’s Impact on Health Literacy

July 22nd, 2015 by Melanie Matthews

Healthcare costs attributed to wasteful spending are estimated to be $800 million each year, according to a new infographic by iTriage.

Half of that total can be attributed, directly or indirectly, to low health literacy, including missed prevention opportunities; preventable errors; and unnecessary services or patients going to the ER when less expensive yet appropriate care could be obtained at another facility.

The infographic examines the opportunities for social media to improve health literacy.

Advancing Health Literacy: A Framework for Understanding and ActionAdvancing Health Literacy: A Framework for Understanding and Action addresses the crisis in health literacy in the United States and around the world. This book thoroughly examines the critical role of literacy in public health and outlines a practical, effective model that bridges the gap between health education, health promotion, and health communication.

Step by step, the authors outline the theory and practice of health literacy from a public health perspective. This comprehensive resource includes the history of health literacy, theoretical foundations of health and language literacy, the role of the media, a series of case studies on important topics including prenatal care, anthrax, HIV/AIDS, genomics, and diabetes.

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Infographic: Health Literacy

May 6th, 2015 by Melanie Matthews


One in two adults can’t use a BMI chart to find a healthy weight, understand a vaccination chart and/or read a prescription label, according to an infographic by GSW on health literacy.

The infographic details examples of low health literacy and the impact it has on patients and the healthcare system.

Advancing Health Literacy: A Framework for Understanding and ActionAdvancing Health Literacy: A Framework for Understanding and Action addresses the crisis in health literacy in the United States and around the world. This book thoroughly examines the critical role of literacy in public health and outlines a practical, effective model that bridges the gap between health education, health promotion, and health communication.

Step by step, Advancing Health Literacy: A Framework for Understanding and Action outlines the theory and practice of health literacy from a public health perspective. This comprehensive resource includes the history of health literacy, theoretical foundations of health and language literacy, the role of the media, a series of case studies on important topics including prenatal care, anthrax, HIV/AIDS, genomics, and diabetes.

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.

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STAAR’s 4 Domains of Process Improvement to Enhance Patient Health

June 18th, 2013 by Jessica Fornarotto

Amy Boutwell, MD, MPP, president of Collaborative Healthcare Strategies, recommends hospitals follow the four domains of process improvement from the State Action on Avoidable Rehospitalizations (STAAR) in order to improve the standards of care for each patient to prevent future health woes.

During HIN’s webinar Readmission Penalties in 2013: A Cross-Continuum Approach To Lessen the Financial Impact, Boutwell listed STAAR’s four domains, which include enhanced assessments, enhanced teaching, real-time communication and timely follow-up care.

STAAR’s four general domains of process improvement do not constitute a cookbook. We recognize that hospitals need to adapt and implement these concepts in various ways to fit their settings, whether rural, urban, academic or community hospitals.

The four major domains are an invitation to reflect. If your hospital is not providing these four elements of care for every single patient leaving your care, regardless of risk, then I invite you to reflect upon why you wouldn’t do this for everyone. Why wouldn’t we make sure that we update our standard of care as people leave our hospital ‘sicker and quicker,’ and take upon themselves a greater burden and more responsibility for after-hospital care? Why wouldn’t we improve our standard of care for everyone in these four areas? The four domains are as follows:

1. Enhanced assessment. This means that we assess patients. That’s what we do in the hospitals; that’s what nurses, doctors and therapists do all the time. But this is the concept of expanding that view, especially of our frequent flyers or our frail patients to the big picture. What is the longitudinal care need beyond the acute episodic presenting need?

2. Enhanced teaching and learning. This is a change from putting packets of information on meal trays to using the three or four days of the hospitalization as a learning opportunity. Identify who is the right learner, because it’s not always the patient. Engage in that health literacy-appropriate teachback technique to convey the key elements — not the entire 85-page booklet on heart failure but the key elements of self-management as the patient transitions from our setting to the next setting.

3. Real-time communication. This is communication both to the receiving providers as well as better updates in communication to the patients and family members. It can’t be okay for us to have rounds at 7:00 or 8:00 in the morning and then tell the patient to call their daughter because they are being discharged at 2:00. This is the experience of many of our patients still. Keeping people updated as to their care plan and their after-hospital care needs is something that we identified as a major theme in many root cause analyses of early readmissions.

But even more to the point around real-time communication is that we’re still not doing a great job in letting the outpatient providers know that their patients are being admitted and discharged and defining the reasons for their hospital stay. What was their course treatment? What were the new results and what medicines were they prescribed? Root cause analyses from every community across the United States now find that real-time communication with their receiving providers is still lacking.

4. Ensuring that there is timely post-acute care follow-up. This will vary based on patient risk, but if your patient is moderate or high-risk, a call to their doctor’s office and an appointment in one to two weeks is not going to do it anymore. We have so much data. If you run your own hospital’s data as to the average time between discharge and readmission, you will find that 25 percent of your readmissions are coming back within three to four days, and 50 percent are coming back within seven to 10 days. We need to get touch points. It doesn’t need to be a follow-up appointment; there are many good models of phone calls, visiting nurses, lay-care providers, etc. We need to follow up with patients to make sure that when they get home, they understand their plan of care, they get their medications and they are not confused.

6 Data Analytics Driving Successful Population Health Management

April 2nd, 2013 by Jessica Fornarotto

population health data analytics

Webinar Replay: Achieving Population Health Management Results in Value-Based Healthcare

The development of a successful population health management (PHM) effort starts with the data and the data analysis, states Patricia Curran, principal in Buck Consultants’ National Clinical Practice. Curran describes the role of data and data analysis, the six critical PHM data areas, and the “influences” and the “influencers” that affect a population’s road to better health.

Where are we today and where do we want to be in the future? All of the data that you can gather is carefully evaluated to consider several points: the culture of the company and the employees, the business objectives, the health literacy of the population, compliance and risk scores and the utilization trends.

Data is essential to understanding the population you wish to manage and designing programs to meet the needs of a specific population. Buck Consultants takes all the raw data that we can gather, analyzes it, and transforms it into knowledge. The ‘aha’ moment is when it all comes together and we use it to build a strategy for an organization’s PHM program. It’s important to use your own data to identify the population’s specific needs and target your program to those needs. There are six areas that form the foundation for a successful PHM program:

  • Clinical data is biometric data or lab data, and possibly health risk assessment (HRA) data, that helps identify risks and cost drivers and is used to monitor the program’s success.
  • Utilization data would be the utilization patterns. For example, how are people accessing their healthcare?
  • Adherence is beginning to replace the word ‘compliance.’ This refers to how well members and providers are adhering to evidence-based medicine guidelines. Are they filling their prescriptions consistently? Are they getting preventive care?
  • Operational data is participation data, productivity data, disability data and other information that helps to monitor and develop the programs.
  • Financial data shows how this healthcare activity that you’re offering translates to dollars and opportunities for real hard dollar savings. This data is key in order to get senior management support and finances to continue the program.
  • Satisfaction data is necessary to monitor how participants and your key stakeholders view your efforts.

Part of the data analysis also includes identifying all the things that influence the decisions people are making and the influencers that are affecting what you’re trying to accomplish. For example, influencers might be spouses, family members, friends, healthcare providers, and employer management staff. Influences might be a fear of financial issues, ignorance, indifference, and inconvenience.

Take this scenario as an example: an employer may have a goal to increase the level of mammogram participation or people getting mammograms on a regular basis. They bring in a mobile unit to provide on site mammograms. But after they do this, they find that there is still no change with mammogram compliance. They will then go back to their employee population and discover that the reason they didn’t have any improvement was because the supervisors on the line didn’t allow people off the line to participate. The line supervisor is the influencer that needs to be identified and rectified before there’s going to be any change.

Infographic: The Cost of Health Literacy

December 5th, 2012 by Melanie Matthews

Individuals with low health literacy have an average annual healthcare cost of $13,000. An infographic by the Institute for Health Technology Transformation illustrates the correlation between health literacy levels and healthcare costs and quality.

Health Literacy

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