Posts Tagged ‘high-risk patients’

Infographic: Addressing Medication Complexity Through Community-Based Strategies

February 22nd, 2019 by Melanie Matthews

Juggling medications can be overwhelming for people with complex needs — individuals who often struggle with low health literacy, unstable housing, isolation, and other unmet issues. This population is often prescribed multiple medications from numerous providers taken on different schedules with no overall provider oversight, according to a new infographic by the Center for Health Care Strategies.

The infographic illustrates this issue and outlines community-based approaches to address it, such as developing risk algorithms to identify at-risk patients and simplifying medication use through comprehensive medication management.

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk PopulationsWhen it comes to medication management for Medicare beneficiaries, there are more than 25 different factors that can complicate proper use of prescribed medicines—from affordability issues, even among the insured, to fear of a drug’s side effects to potential dangers from high-risk medications or health conditions.

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations examines Novant Health’s deployment of pharmacists as part of its five-pronged strategy to deliver healthcare value through medication management services.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

AMITA Health Connected Care Management: Patients Transitioned But Never Really Discharged

August 23rd, 2016 by Patricia Donovan

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.

Infographic: A Journey Through Post-Acute Care

March 7th, 2016 by Melanie Matthews

With steeper penalties from the Centers for Medicare and Medicaid Services for hospital readmissions, healthcare organizations are not only looking at internal factors that impact readmissions, but are also partnering with post-acute care providers to shore up issues across the post-acute continuum that could lead to a readmission.

A new infographic by ECG Management Consultants looks at the expected path through the continuum for a high-risk, congestive heart failure patient and how this patient might be better supported in a high-functioning post-acute care model.

2015 Healthcare Benchmarks: Post-Acute Care TrendsHealthcare is exploring new post-acute care (PAC) delivery and payment models to support high-quality, coordinated and cost-effective care across the continuum—a direction that ultimately will hold PAC organizations more accountable for the care they provide. For example: two of four CMS Bundled Payments for Care Improvement (BPCI) models include PAC services; and beginning in 2018, skilled nursing facilities (SNFs) will be subject to Medicare readmissions penalties.

2015 Healthcare Benchmarks: Post-Acute Care Trends captures efforts by 92 healthcare organizations to enhance care coordination for individuals receiving post-acute services following a hospitalization—initiatives like the creation of a preferred PAC network or collaborative. Click here for more information.

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.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

11 Healthcare Data Analytics Trends to Know

March 3rd, 2016 by Patricia Donovan

Population health management is the driving force behind healthcare's data analytics explosion, according to new market metrics from the Healthcare Intelligence Network.

What’s driving healthcare’s data analytics delirium? Increasingly, it’s population health management.

A passion to enhance population health has motivated 25 percent of healthcare organizations to dive into data analytics, according to the latest Data Analytics and Integration metrics from the Healthcare Intelligence Network (HIN).

With reimbursement for services increasingly riding on readings from clinical outcomes, patient experience and cost of care, the desire to slice and dice patient and population data in order to provide value-based healthcare has never been stronger.

The healthcare publisher’s January 2016 survey identified a number of factors behind widespread analytics adoption. More than three-quarters of responding organizations—77 percent—already have delineated data analytics and integration strategies, the survey found.

Additionally, having applied the actionable information these programs yield to craft population-based interventions, 41 percent already report declines in total spend they attribute to data analytics. Hand in hand with these savings are appreciable spikes in quality ratings, report 58 percent of respondents.

Given their potential cost, risk and utilization patterns, it’s not surprising high-utilizers or hot-spotters—patients with frequent ER visits and hospital stays—are the key target of data analytics programs for 74 percent of responders.

But hot-spotters are by no means the only data analytics targets. A majority of adopters—60 percent—collect data on upwards of 75 percent of patient and member populations served.

“As the path to value-based purchasing becomes clearer, care management platforms without a vast warehouse of clinical, claims and cost data that they can draw upon in order to measure provider and organizational performance will flounder,” noted Melanie Matthews, HIN executive vice president and chief operating officer. “To survive in healthcare’s new ‘fee for quality’ world, organizations must be ready to back up their claims with hard data.”

Here are some other highlights from HIN’s inaugural Data Analytics and Integration survey conducted in January 2016:

  • Clinical and operational dashboards lead the list of data analytics tools for 62 percent of respondents.
  • Diabetes is the top clinical condition targeted by data analytics, say 58 percent of respondents;
  • „„The collection of healthcare data is the top challenge of analytics and integration efforts for 28 percent of respondents;
  • „„Beyond population management, predictive analytics and cost savings are key goals of data analytics efforts for 15 percent of respondents; and
  • Almost two-thirds of respondents experienced a drop in ER utilization that they attribute to data analytics.

Download a complimentary executive summary of HIN’s 2016 Healthcare Data Analytics and Integration trends to learn why data analytics is the framework for population health management.

Yale New Haven’s High-Risk Care Management Commences with Its Employees

January 14th, 2016 by Patricia Donovan

A care management pilot by YNHHS for employees and their dependents with diabetes was a template for future embedded care management efforts.

Disenchanted with vendors it engaged to provide care management for its workforce, Yale New Haven Health System (YNHHS) launched an initial care management pilot for its high-risk employee populations. The pilot went on to become a very robust program and served as a training ground for two more embedded on-site care management initiatives. Here, Amanda Skinner, YNHHS’s executive director for clinical integration and population health, provides details from on-site face-to-face care management for YNHHS employees and their dependents.

We have an RN care coordinator based on each of the four main hospital campuses of our health system: one in Greenwich, one in Bridgeport and two in New Haven. All of the RN care coordinators in this program are trained in motivational interviewing. The intent is for them to work with our high-risk, high-cost employees who have chronic diseases, and with their adult dependents that also fall into that population.

The care coordinators work with these employees across the entire system to help them access the care they need, identify their goals of care, get under the surface a little to determine barriers to their being as healthy as they can be, and manage them over time. We did create some incentives for employee participation in this program, including waived co-pays on a number of medications (for example, any oral anti-diabetics).

When we initially launched the program, we limited it to employees and dependents that had diabetes, because that was the population for which we had very robust data. We also knew that diabetes was generally a condition that lent itself well to the benefit of care coordination; that there were a lot of gaps in care. When we looked at our data, we saw that ED utilization was very high for this population; that their past trend was rising, that utilization of their primary care provider was actually below what you would expect. This meant that they were under-utilizing primary care, over-utilizing hospital services, and were not particularly compliant with care.

With that population, we saw a lot of opportunity that a care management program could help address. In general, diabetes is a condition that lends itself to accepting a helping hand, to help people understand their condition and address the medical and social issues so they can manage that condition more effectively.

The program has been tremendously successful. We expanded it this year to include wellness coaches based at all of our delivery networks’ main campuses as well. These coaches work with a lower risk population and are available to any health system employee that wants to work with a coach to set care goals and then meet with the coach monthly or quarterly to track improvements against those goals. This expansion is because we’ve seen such positive results from this program.

Source: 3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients across the Continuum examines YNHHS’s three models of embedded care coordination that deliver value while managing care across time, across people, and across the entire continuum of care. In this 30-page resource, Amanda Skinner, executive director for clinical integration and population health at Yale New Haven Health System, and Dr. Vivian Argento, executive director for geriatric and palliative care services at Bridgeport Hospital, present a trio of on-site care models crafted by YNHHS to manage three distinct populations.

Infographic: 7 Critical Steps in Caring for High-Need, High-Cost Patients

November 13th, 2015 by Melanie Matthews

Patients with multiple health problems, often referred to as high-need, high-cost patients, often need assistance with areas outside of the typical medical environment, such as housing and everyday tasks in managing their health, according to a new infographic by The Commonwealth Fund.

The infographic looks at seven key features of programs that are effective in managing these patients.

7 Critical Steps in Caring for High-Need, High-Cost Patients

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.

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.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Registries Identify High-Risk Patients, Support Evidence-Based Protocols

January 6th, 2015 by Cheryl Miller

Obtaining a clear snapshot of a patient population is the first step in managing health outcomes in an accountable care organization (ACO), says Gregory Spencer, MD, FACP, chief medical officer with Crystal Run Healthcare. Registries are a major part of that, and at Crystal Run Healthcare, care managers use them to identify high-risk patients, implement evidence-based protocols, and coordinate care inside and outside the office.

We have used care managers for about seven years. Groups of nurses use our registries to identify high-risk patients and implement evidence-based protocols. We have used an EHR, and we use e-mail and Blackberries ® extensively within our practice so that when we have a new development, we can get the word out quickly to mobilize people or alert them that certain things are happening. Registries are a major part of this: getting your list of people with a high-risk condition.

Our care managers are nurses that pull the list of patients from the registry using evidence-based guidelines. They contact them, make sure they get certain things done that they need to have done, and smooth those efforts. They do care planning and then communicate with the patients outside of the office. We are also embedding a care manager at a few of our sites to try and catch patients while they are in the office as well.

The template we use is pretty basic. It keeps track of the patient’s last test, and includes certain results so that if the patient has a question or is due for some lab work, the care manager can quickly order it. If it’s not protocol-driven, they can send it to the physician for review or potentially do it themselves if we are able to cover it with a protocol. This is one way we use registries of patients who require referral tracking.

Again, workflow is the Achilles heel of some brilliant quality efforts. You don’t want to destroy your workflow and patient flow. Not to say that you can’t redesign your workflow if it is important, but this process can end in tears. Sometimes if the change is not well thought out, it has negative effects on workflow.

Source: Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care examines the building blocks of population health management that drive improvements in healthcare quality and efficiency in ACOs — while positioning healthcare organizations for core measure improvement and increased reimbursement. In this 40-page resource, Dr. Gregory Spencer, chief medical officer of Crystal Run Healthcare, demystifies registry use and shares patient registry best practices.

11 Statistics about Stratifying High-Risk Patients

November 20th, 2014 by Cheryl Miller

Healthcare organizations use a range of tools and practices to identify and stratify high-risk, high-cost patients and determine appropriate interventions. Most critical to the stratification process is clinical patient data, say an overwhelming 87 percent of respondents to the Healthcare Intelligence Network’s (HIN) inaugural survey on Stratifying High-Risk Patients. However, obtaining and verifying patient data remain major challenges for many respondents. Following are 10 more statistics from our survey.

  • „„Hospital readmissions is the metric most favorably impacted by risk stratification tools, according to a majority of respondents.
  • „„In addition to high utilization, clinical diagnosis is considered a key factor in stratifying high-risk patients, according to 16 percent of respondents.
  • „„Case management as a post-stratification intervention is offered by 83 percent of respondents; health coaching by 56 percent.
  • Reducing heart failure (HF), pneumonia (PN), and atrial myocardial infarction (AMI) are among the greatest successes of risk stratification programs.
  • Diabetes is considered the prominent health condition among high-risk populations, according to 37 percent of respondents; other prominent conditions include hypertension (20 percent) and mental health/psychological issues (15 percent).
  • Physician referrals are cited by 76 percent of respondents as an important input for stratification, followed by case/care manager referrals (71 percent).
  • „„Home health and/or home visits are available to risk-stratified populations of 56 percent of respondents.
  • „„LACE (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Nearly half of respondents (45 percent) cite high utilization of the emergency department (ED) or hospital as the most critical attribute of high-risk patients.
  • „„While more than half of respondents have a program in place to identify and risk-stratify complex cases, the majority admit it is too early to tell the ROI achieved.

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

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.

4 Ways to Pinpoint High-Risk, High-Cost Candidates for Case Management

June 24th, 2014 by Patricia Donovan

case management patients

Doctors don't always know when their patients are in the hospital.

Providers in a physician practice are a good starting point for case managers to identify high-risk or high-cost patients for case management, explains Annette Watson, RN-BC, CCM, MBA, senior VP of community transformation for Taconic Professional Resources (TPR).

The process of identifying high-risk, high-cost patients can be formal or informal. You can use internal sources; when TPR goes in, that is one of the baselines of understanding. We understand who the patients are and what the population is, because if they have not been using data or have not been in an Advanced Primary Care initiative, it is highly unlikely the practice will have a quantitative method in place when we arrive.

We begin by asking the practice providers who the sickest patients are. Second, we can use data available at the practice level, such as registries or reports that can be run from the EHR.

Third, we also look at the kind of data they get from external sources. For example, do they receive reports from payors that show some utilization activity? Many of those reports may be somewhat aged. They are not necessarily timely, which raises actionability questions. However, we found there are reports coming out from payors, particularly about recent ER use or hospital discharges, that are more timely, which allow the practices to look at data—still retrospectively in most cases but much more quickly than they were able to in the past.

And finally, hospital admission and discharge information is important. Depending on the model in a PCP, if a physician is not the admitting physician— that is, 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.

(Note: Taconic Professional Resources offers professional training and practice optimization to organizations aspiring to become a patient-centered medical home and/or join a medical neighborhood.)

Excerpted from: Advancing Primary Care with Embedded Case Management: Lessons from the Taconic IPA Pilot

Award-Winning Protocol Puts Readmission Prevention Manager in ER to Reduce Rehospitalization Rates

February 13th, 2014 by Cheryl Miller

Call it a bouncer of sorts for the emergency room: the readmissions prevention manager, or RPM for short, has helped Torrance Memorial Health System reduce all cause readmissions by nearly 5 percent, and earn its hospital system kudos from the industry, says Josh Luke, Ph.D., FACHE, vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative.

Designed to determine whether newly admitted high-risk patients are ready for the emergency room (ER), or could be placed elsewhere, the RPM is an integral part of a strategy implemented in 2013 for Total Wellness Torrance (TWT) to reduce preventable readmissions, Luke said during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers , a 45-minute webinar on January 8th, 2014, now available for replay.

He shared the key features of this program, which was recognized by California Association of Healthcare Facilities as a Program of Excellence in 2013. At the time, the 401-bed not-for-profit hospital was achieving readmissions rates that were in step with national averages, generally within 18 to 20 percent, and some quarters exceeding that. Torrance felt it could do better, approaching the problem from an all-cause, rather than disease-specific perspective, Luke says.

Creating the RPM was the first step in the process, he says. This person would function as the leader of the hospital readmission prevention team, making sure only patients who meet criteria and need to be hospitalized are admitted either to the observation floor or to the inpatient unit.

As Luke explains: the RPM gets a real-time email alert any time a patient comes to the ER and their social security number is entered into the hospital’s electronic system. Their number one priority is then to go right to the ED to meet the patient and work with the attending doctor, case manager and nursing team in the ER to see if this patient can be cared for at a lower level of care.

That’s essentially what the Affordable Care Act has encouraged us to do and incentivized us to do and penalized us when we don’t do that efficiently, which is not to admit patients to the hospital that don’t need to be here. We are very encouraged by the success of that program in its initial six months.

The RPM then follows those patients who were not admitted to the ED to a post-acute network facility, at all times keeping in mind patient choice. TWT includes a post-acute network of eight skilled nursing facilities (SNFs), all within five miles of the hospital, and a home health agency. Along with a home health department navigator, the RPM goes to each SNF once a week to follow up on patients, determining discharge plans and employing an ambulatory case manager if the patient goes to a home health agency outside the Torrance network, and keeps tabs on them long after the 30-day readmission period is over.

Collaboration and communication with the post-acute network (PAN) is key to success, Luke says. “Whenever I’m asked if I could name three basic things to prevent readmissions, the first thing I always refer to is telling your skilled nursing facilities to invest in predictive software because it doesn’t cost you as a hospital anything. It enables you to share data with the SNFs.”

That, and always be a champion of choice for your patients, Luke adds, even when they’re being bounced out of the ER.