Posts Tagged ‘high-risk patients’

Pioneer ACO Repurposes Care Management for Accountable Care

February 4th, 2014 by Jessica Fornarotto

As a top performer in Year 1 of the CMS Pioneer ACO program, Monarch HealthCare is paving the way to accountable care with a foundation of patient- and provider-centered strategies that support Triple Aim goals, which is to improve quality, improve health outcomes and reduce cost. Here, Colin LeClair, executive director of ACO for Monarch HealthCare, recounts how Monarch recast its Medicare Advantage (MA) care management program to target about 1,200 high-risk patients who have a similar constellation of issues.

Monarch repurposed our Medicare Advantage (MA) care management program for the ACO. Monarch’s ACO care management team was designed to anticipate and prevent acute events and then to facilitate transitions of care for patients post-discharge.

This interdisciplinary team is comprised of a primary care physician who quarterbacks the team, and a care navigator, also known as a care coordinator, who performs most of the patient onboarding into the care management program and performs an initial triage of the patient’s needs. The care manager is often a non-complex patient’s primary point of contact. The complex care manager is responsible for most of the complex cases.

Then as needed, we also deploy a behavioral health clinician, a community services coordinator, a clinic dietician and a palliative care nurse. The other resources may include a pharmacist or Pharm D to perform post-discharge medication reconciliation. Then we have a team of medical directors, employed and contracted hospitalists, and employed and contracted skilled nursing facilitators (SNFs) to support us as well.

The idea is that the team is tailored for the patient’s need at enrollment, and it can then be augmented as the patient’s health status changes. This model scales best when you can target large patient populations with a fairly common list of conditions, which allows you to hire and assign clinicians with the appropriate expertise to each patient. For example, we can afford to hire and assign a registered nurse (RN) or a nurse practitioner (NP) who has experience in a dialysis clinic or a nephrologist office if we have enough renal disease patients to fill their case load.

Excerpted from: Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care

HINfographic: 7 Care Transition Models for High-Risk Patients

January 21st, 2014 by Jackie Lyons

Many current care transitions models support safer transitions for patients with complex comorbid conditions – initiatives aimed at the patient, hospital, community, or in some cases, a state or region of the country.

One initiative reduced 30-day all-cause readmissions by 21 percent, according to a new infographic from the Healthcare Intelligence Network. This HINfographic takes a high-level look at seven popular care transition programs.

7 Care Transition Models for Complex High-Risk Patients

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Information presented in this infographic was excerpted from: Care Transitions Toolkit. If you would like to learn more about care transitions for complex high-risk patients, this resource includes even more information, including contributions of embedded case managers to care transition management, best practices to improve medication adherence and compliance, health literacy tools to promote behavior change, and strategies for matching high-risk patients with the appropriate clinical intervention.

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4 Population Health Management Tools to Identify At-Risk Patients

February 15th, 2013 by Jessica Fornarotto

Our EPIC platform at Bon Secours Health System consists of different tools that our nurse navigators can use to identify at-risk patients, for instance the ability to create registries, states Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Bon Secours uses four main tools to help better manage the health of its population, including a tool that identifies barriers and non-adherence, as well as a risk calculator that measures frequent ER visits.

Inside of our EPIC platform, the documentation tool or encounter type that is created by using our discharge registry falls into one of four categories. It’s either a post-hospital admission, a post-emergency department visit, it could be for ongoing case management and the referral can come from any direction — the PCP, a managed care partner, or hospital case management. Then, if someone falls into a place where they’re at a gap in care, we use a number of different tools to identify those gaps in care.

To illustrate the documentation tool, take a patient who’s been admitted to the hospital, has spent some time there, and has been diagnosed with congestive heart failure (CHF). Everybody is focused on CHF these days because of value-based purchasing. And everyone is trying very hard to improve 30-day readmission rates now that there’s a penalty associated from that Medicare reimbursement.

We’re using a tool that allows our nurse navigators to stage the degree of heart failure. From within the documentation’s work space, we can launch the ‘Yale tool,’ which allows us to establish what stage of heart failure that patient is in; class one, class two, class three, class four. Then, a set of algorithms are launched based on these stages’ failure and we will then manage the patient according to those algorithms.

If a patient falls into a class four category, for example, we may bring them in the next day or that same day for an appointment, rather than wait five or seven days because they’re at more risk. We may also make daily phone calls or interventions; we may network in the home health and make sure that they have scales for weight management and assessment of heart failure status. All of those interventions will be driven by the class of heart failure that patient falls into.

The second tool that we use is a workflow around ejection fractions. Depending on the patient’s ejection fraction, we will define specific interventions that the nurse navigator will follow.

We have a third tool that’s part of the encounter type in the EPIC where we identify barriers and non-adherence. We look at several elements: Are there communication preferences that the patient requires in order to be clearly communicated with? Is there any cognitive impairment? Are financials a barrier? What are their utilities at home? What’s their learning style?

Each of these categories launches another subset or agenda that we can document in detail; specifically on what obstacles exist for that patient and then what goals we should be setting to breach those obstacles.

Finally, we have a risk calculator that’s specific to frequent ER visits. Using this risk calculator, we enter length of stay (LOS) in the hospital, acuity, comorbidities and the number of ED visits in the last six months. That will then generate a risk index. If that risk index is 11 or greater, that person is considered in a higher risk category and that will drive interventions that are more intensive; daily calls, being brought in sooner, maybe the implementation of a dosage titration, an algorithm around diuretic management for weight in a heart failure patient, etc.

10 Considerations When Preparing a Practice for the Embedded Case Manager

September 20th, 2012 by Cheryl Miller

Embedded case management

Practice-based case management is driving improvements in healthcare delivery and efficiency.


As practice-based case management continues to grow, resulting in more efficient and high quality care coordination of high-risk patients and chronically ill health plan members, one question looms large: how does a practice determine if it’s ready to take the leap?

We asked our case management experts for their opinions, and found that while there was no ‘one-size fits all’ method, many considerations were considered essential to a successful ECM practice.

  1. Find the right practice.

    Are your head physicians proponents of the medical home model? Because you don’t want to put efforts into a group that isn’t interested in embracing a new model of care. Says Irene Zolotorofe, administrative director of clinical operations at Bon Secours, “We began with the physicians who were absolutely willing to go ‘medical home,’ who were excited about this model of care. We like to go into a practice where they are motivated to do that type of transition with their patient population.”

  2. Involve all members of the practice in the selection process.

    Getting all members involved in selecting the case manager is key to sustaining a successful transition, says Diane Littlewood, RN, BSN, CDE, regional manager of case management for health services at Geisinger Health Plan. “We found great value incorporating and including the primary care doctor, the site and the team in the selection process. That case manager is embedded; she’s part of their team and that’s where she spends 100 percent of her time. It is key to each site’s success that the provider be involved with the selection. With this model, we’ve brought the provider at the medical home sites into the process and said, “Sit down with us, interview the candidates and help us with the final selection.’ “

  3. Assemble case manager hiring criteria.

    Although experience, education and training is important in this role, they should not be the main selection criteria, says Zolotorofe. “Is the case manager able to think quickly and critically given the newness and lack of infrastructure in place for this new program?” Other criteria for choosing a solid case manager included strong communication skills, people skills, patient engagement and activation skills, and negotiating and conflict resolution skills.

  4. Determine how much control your practice will have over your case manager’s work.

    Keeping everyone in the loop fosters an atmosphere of collaboration, says Littlewood. “As you roll out your model and educate providers and staff, you have to explain the case manager’s role and educate the site as to her duties.”

  5. Spend time building strong relationships among group members.

    Once the case manager is part of the team, it’s important that she sustains good relationships with all, says Dr. Randall Krakauer, Aetna’s Medicare medical director, during a recent HIN webinar: “You need to work out an arrangement in each case that works best for this particular medical or provider group. They’re all going to be somewhat difernt and it’s going to be up to your own management and your own embedded case managers to work out how best to work with this particular group, how best to support this group and how best to relate to this group. That relationship is absolutely key. The case manager and your staff must build a good supportive relationship. Your case manager has to feel to them like their case manager.”

  6. Allow case managers to build strong relationships with their patients, and provide tools to facilitate this.

    Geisinger Health Plan implemented a direct telephone line to embedded case managers for all patients, says Littlewood. “As simple and basic as it sounds, the ability for our case managers to have a direct line at the site for patients makes a difference. All the patient has to do is pick up a telephone, say hello and they will have a case manager on the phone. They’re not trying to navigate through the complex telephone lines as they call in to the clinic sites, which could be confusing for the patient. This is a direct access phone line. The case manager does the assessment and collects the information, and then the patient meets with the provider. This process takes out all of the middle people and we’re able to then handle acute issues much sooner. Since the nurse case manager is embedded in the site, she can walk right down the hallway and have a personal conversation with the provider about the person on the phone and their problem or issue. That leads to success with our communication.”

  7. Ensure you have the proper IT tools on hand for an effective program.

    Is there a minimum IT requirement for practices to participate in a practice-based case program, such as a patient registry or EMR? Explains Dr. Krakauer: We do have participating practices that don’t have EMR’s. An EMR will facilitate the process and will make collaborative care management and the work of the participating physicians easier. I don’t think it’s a requirement that there be an EHR. Going forward, as we start getting into more and more information exchanges and more and more reporting requirements promulgated by others, for sizeable groups doing this type of work, increasingly an EHR will be important.

  8. Make sure that your practice has enough eligible patients and the right case mix.

    It’s essential to consider both patient population and eligibility in the beginning, says Charlene Schlude, director of case management at CDPHP. “First, we consider the case mix in a practice. We use a predictive modeling tool that allows us to see the chronic nature of the patients in the practice. We like to see what products they have: is there a higher ratio of Medicare and Medicaid or even chronically ill commercial members in the practice? We use some reporting to do that. Another key element is an EMR in the practice because we want to be efficient and have information at the nurses’ fingertips to make this a valuable experience. We want them to have enough information to interact with the patients in a practice in a way that is going to impact that cost and quality.”

  9. Establish how the case manager will be reimbursed.

    Having a mutually agreed upon reimbursement plan is key to the program’s success, explains Dr. Krakauer. “Normally Aetna will provide this resource; we will provide our own trained experienced case manager who is capable of doing everything. Under certain circumstances, when the medical group already has case managers that are doing a good job, and knows how to do it, some assistance in this regard might be in order. But case management is a specialty in its own right. It’s not something you just hire a nurse to do — have her read a manual and put her at the desk or on the telephone. That’s kind of a prescription for it not to work.”

  10. Determine how you will judge the program’s effectiveness.

    Says Dr. Krakauer: “If I were to pick one single characteristic that’s positive of a good result, I would say it’s the level of commitment of the participating physicians to the concept, to the collaboration and to the idea that doing better will get good results, as opposed to those told to do it as a part of their job or those doing it just to receive an incentive payment.”

11 Innovations in Healthcare Case Management

July 23rd, 2012 by Jackie Lyons

According to respondents from HIN’s third annual healthcare case management survey, successful case management efforts focus on transition coaching, discharge planning, reward programs and a patient-centered approach to case management.

Despite the challenges of staffing and operating a successful case management company brought on by healthcare reform and the changing industry, respondents contributed innovative interventions that improve health and reduce costs in the populations they serve.

Eleven case management program interventions that proved to be successful are:

1. Working with local community collaboratives for transition coaching. For example, respondents collaborate with a company that performs in-home health assessments on members identified with chronic diseases. The information is sent to them and they use it to direct care for their members.

2. Scheduling home visits by nurse practitioners for selected patients.

3. Redirecting to in-network providers and coordinating services in an efficient manner to prevent delay in discharges.

4. Holding case conference meetings with the treating physicians, case managers, medical directors and other related parties to address issues related to challenging or high-risk patients.

5. Verifying medication and home healthcare strategies to prevent readmission for chronic illness within 24 to 48 hours.

6. Partnering with social workers who will spend time dealing with complex family problems and end-of-life care.

7. Getting high-risk obstetrical clients to assume greater accountability for the outcome of their pregnancies and communicating with providers and educators. Respondents noted a significant decrease in low birth weight infants for RN case-managed programs focused on these objectives.

8. Utilizing diabetes reward programs to keep measures in line.

9. Integrating case management (medical and behavioral health) for a patient-centered approach.

10. Using neutral assessment and family trust to establish realization that case managers can identify affordable and appropriate resources.

11. Attaining the Advanced Achievement in Transplant Management Certification (through Interlink Health Services) so case managers better understand and educate patients about the benefits of using a Transplant Center of Excellence for the best possible clinical and financial outcomes when a transplant is needed. Respondents report successful clinical outcomes and savings range in the 40-50 percent range.