Posts Tagged ‘home health’

How a Data Dive Makes a Difference in ACO Care Coordination Efficiency

March 30th, 2017 by Patricia Donovan

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UTSACN used data analytics to trim its home health network from more than 1,200 agencies to 20 highly efficient home health providers.

How does UT Southwestern Accountable Care Network (UTSACN) use information to inform and advance care coordination programming? As UT Southwestern’s Director of Care Coordination Cathy Bryan explains, a closer look at doctors’ attitudes toward a Medicare home health form initiated a retooling of the ACO’s home health approach.

We realized our home health spend was two times the national average. When we reviewed just the prior 12 months, we identified more than 1,200 unique agencies that serviced at least one of our patients. With this huge number of disparate home health agencies, it was difficult to get a handle on the problem.

Our primary care doctors told us they found the CMS 485 Home Health Certification and Plan of Care form to be too long. The font on the form is four-point type; it’s complex, so they don’t understand it. However, because they don’t want a family member or patient to call them because they took away their home care, they often sign the form without worrying about it.

As we began looking at these findings, we wondered what they really told us. Are some agencies better than others, and how do we begin to create a narrow network or preferred network for home care? We knew we couldn’t work with 1,200 agencies efficiently; even 20 agencies is a lot to work with.

We began to analyze the claims. My skilled analyst created an internal efficiency score. She risk-adjusted various pieces of data, like average length of stay. For home health, there were a number of consecutive recertifications. We looked at average spend per recertification, and the number of patients they had on each agency. We risk-adjusted this data, because some agencies may actually get sicker patients because they have higher skill sets within their nursing staff.

We created a risk-adjusted efficiency score based on claims. We narrowed down the list by only looking at agencies with 80 percent or higher efficiency. That left us with about 80 agencies; we then narrowed our search to 90 percent efficiency and above, and still had 44. That was still too many, so we cross-walked these with CMS Star ratings to narrow it even more. Finally, after looking at our geographic distribution for agencies that serviced at least 20 patients, we eliminated those with one and two patients. We sought agencies that had some population moving through them.

Ultimately, we reduced our final home health network to about 20 agencies that were not creating a lot of additional spend, and not holding patients on service for an incredibly long period of time.

Source: Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives

advanced care coordination

During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a 2016 webinar available for replay, Cathy Bryan, director, care coordination at UT Southwestern, shares how her organization’s care coordination model manages utilization while achieving its mission of bridging the gap from where patients are to where they need to be to adhere to their care plan.

Breaking Down UTSACN Advanced Care Coordination: “Data Analyst Is Your Best Friend”

October 6th, 2016 by Patricia Donovan

advanced care coordination

Data is useless unless transformed into actionable information, notes Cathy Bryan, UTSACN director of care coordination.

Although the care coordination director for UT Southwestern’s Accountable Care Network (UTSACN) insists there’s no secret sauce that ensures ACO success, Cathy O’Brien readily proposes eight ingredients to season care management initiatives.

It’s a recipe heavy on data analytics, and one destined to fail unless extracted data is transformed into actionable information, emphasized Ms. Bryan during Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a September 2016 webinar now available for replay.

For that transformation, the Year Three Medicare Shared Savings Program (MSSP) ACO relies heavily on its data analyst. “Your analyst is your best friend. You need someone who is skilled and knows how to analyze large, complex data sources like you get with ACO claims data and other sources,” Ms. Bryan said.

To better manage its nearly 250,000 ACO-attributed lives (up from 19,000 in 2014), UTSACN leverages data from a number of sources, including paid claims data from CMS and commercial payors; more than 100 disparate electronic medical record (EMR) systems; and ADT feeds. This data mining has helped UTSACN to identify and bridge care and quality gaps, manage transitions in care, and risk-stratify its population for care management, including ‘risking risk’ patients exhibiting signs of struggle with adherence to care plans.

It’s also provided a starker picture of utilization, especially on the home health front. When data indicated UTSACN home health use had risen to levels more than twice the national average, UTSACN’s analyst created an internal efficiency index to categorize the more than 1,200 home health agencies in use. The use of this claims-based, risk-adjusted score ultimately pared the home health network to a manageable twenty agencies and saved approximately $6 million in home health utilization costs in the first quarter of 2016 alone.

To engage physicians, UTSACN supported the rollout of this narrow network with a large-scale reeducation effort. Presented with the rationale for this change, providers now better understand Medicare’s home health utilization rules and their accountability to the ACO for their share of costs, utilization and outcomes, notes Bryan.

“You’ve got to create buy-in. You don’t just take providers a list and say, here’s your problem. You’ve got to take a solution to them.”

Another solution designed to support providers is UTSACN’s primary-care-centric model, in which care coordination teams are paired geographically with eight to fifteen physician practices. Composed of embedded care coordinators (as well as field staff that do in-home work), the care coordination teams reach out to the practices’ patients on their behalf.

“We really see our team as an extension of the primary care practice, and we function as such. As we introduce ourselves to patients, we say we’re with the UT Southwestern Accountable Care Network calling on behalf of Dr. Smith, your primary care physician.”

As that extension, embedded care coordinators help physician practices to address barriers to patients’ medical plans of care, from lack of transportation to medication costs to the presence of falls risks in the home.

Click here to listen to an interview with Ms. Bryan.

Infographic: Calculating the Cost of Home Care

June 6th, 2014 by Jackie Lyons

The cost of nursing and assisted living facilities in the United States ranges from $41,124 to $94,170 annually, while the average cost of in-home care is $29,640 per year, according to a new infographic from Interim HealthCare.

This infographic also outlines some of the key factors that compare in-patient facilities to in-home healthcare options in terms of reliability, convenience and affordability.

Remote monitoring is a key care coordination strategy for at-home individuals with complex illnesses. 2014 Healthcare Benchmarks: Remote Patient Monitoring delivers a comprehensive set of metrics from more than 100 healthcare organizations on current practices in and ramifications of remote monitoring for care management of chronic illness, the frail elderly and remote populations.

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3 Nurse Navigator Tools to Enhance Care Management

January 29th, 2014 by Jessica Fornarotto

Where does the nurse navigator spend their day? Certainly on transitions of care. Bon Secours Health System nurse navigators use a trio of tools to identify patients’ obstacles to care and connect them to needed resources, explains Robert Fortini, vice president and chief clinical officer of Bon Secours Health System.

One tool that our nurse navigators use that’s built into our EMR is the hospital discharge registry from Laburnum Medical Center, one of our largest family practice sites with about nine physicians. This tool is used to identify which patients the navigators need to work with, and it’s where the navigators begin and end their day. This registry provides a list of all the patients who have been discharged from one of our hospitals in the last 24 hours, and each patient is listed by the physician. The navigators have to reach out to each of these patients and make telephonic touch within 24 to 48 hours of discharge. Medication reconciliation is extremely important at this time and can be very challenging. When a patient goes into a hospital, often their medications get scrambled, and they come out confused and taking the wrong prescriptions. Nurse navigators spend a lot of time on medication reconciliation at this point.

The Navigators also conduct ‘red flag’ rehearsals with this tool, so that the patient knows the signs and symptoms of a worsening condition and what to do for it. We also schedule the patient with a follow-up appointment, either with a specialist who managed the individual in the hospital or with their primary care physician. We try to do it as close to the time of discharge as possible, within five to seven days, or more frequently if the risk of readmission is higher.

Second, nurse navigators also use a documentation tool to help manage the care of heart failure patients. This tool allows the navigator to stage the degree of heart failure using a hyperlink called the ‘Yale tool.’ The Yale tool allows us to establish what stage of heart failure the patient is in: class one, two, three, or four. Then, a set of algorithms is launched based on these stages’ failure; we manage the patient according to those algorithms. For example, if a patient falls into a class four category, we might bring them in that same day, or the next day, for an appointment rather than wait five or seven days because they’re at more risk. We might also make daily phone calls or network in-home health, as well as make sure that the patient has scales for weight management and an assessment of heart failure status. All of those interventions will be driven by the patient’s class of heart failure.

The last tool we use is a workflow for ejection fractions. The patient’s ejection fraction will define specific interventions that the navigator will follow.

Excerpted from: Profiting from Population Health Management: Applying Analytics in Accountable Care.

3 Key Post-Acute Partnerships that Reduce Readmissions

January 22nd, 2014 by Cheryl Miller


Developing post-acute partnerships with home health organizations is one of the three top ways healthcare professionals are seeking to reduce readmissions, according to more than half of the respondents to the Healthcare Intelligence Network’s fourth comprehensive Reducing Hospital Readmissions Benchmark Survey.

Almost three-fourths (67 percent) cited skilled nursing facilities (SNFs) as their preferred post-acute partner, and 50 percent said they were partnering with hospices to reduce readmissions.

Other partnerships cited included telemedicine, free/low cost clinics, physician networks, and transitional care programs.

Among other key facts:

  • Nearly all of the respondents said that partnering with post acute providers helped them to streamline processes, educate their staff, and implement effective changes of value to the patient.
  • Among respondents from hospital systems (42 percent) that partnered with home health organizations, identifying high risk individuals most likely to be readmitted post-discharge and communicating this information to providers was key to successfully averting readmissions. Involving the patient’s designated caregivers in follow-up dialogues and transactions also improved the odds of prevention.
  • In addition to post-acute correspondence with their home health organization within 24 hours of discharge, one hospital system also practiced medication reconciliation and education and physician scheduling.
  • Follow-up appointments for patients with their home health and/or SNF provider within seven days for Medicare and Medicaid patients with no primary care doctor factored into one hospital system’s readmissions prevention plan. Assuring that medication reconciliation information was made available to their post discharge providers, particularly for high risk utilizers, was also critical to prevention.
  • A hospital system that partnered with low-cost clinics in addition to home health organizations maintained daily and weekly telephonic education meetings with patients, coordinated by its diabetes disease management nurse, diabetes educator and clinical pharmacist.

The ultimate goal in partnering with post-acute providers was to engage with patients while in their facility and continue to follow up with them upon discharge, with continued education and teach back as well as monitoring and overseeing their patients’ progress.

4 Ways to Boost Staff Safety During Home Visits

January 20th, 2014 by Patricia Donovan

Ensuring the safety of staff conducting home visits is a key consideration for organizations caring for recently discharged or medically complex patients in their homes, notes Jessica Simo, program manager with Durham Community Health Network for the Duke Division of Community Health.

First and foremost, we let our staff in the Care Partners pilot know that they would be supported if they felt they needed to cancel a home visit at the last minute because they didn’t feel safe once they arrived in a certain neighborhood. That should always be an option for people who are doing home visits.

Second, in situations where it is critical to get a view of what is going on in someone’s home to mitigate those safety concerns, we frequently “buddy up,” which is having somebody go with another member of the team to conduct that visit. To maintain efficiency, we try to make that the exception, not the rule, but there are situations that are merited.

Third, during training, experienced staff recommend to new staff to conduct home visits in the morning in particularly unsafe neighborhoods. Many people about whom you would tend to worry for safety reasons are not awake in the morning. Therefore, most of our home visits are conducted before noon.

And finally, when appropriate, we also meet people in places besides their home. We may meet them before or after a doctor’s visit at the clinic or another community agency near their home where they feel comfortable meeting a care manager.

Excerpted from: Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients

Infographic: Home Health Patients Versus All Medicare Beneficiaries

August 15th, 2013 by Jackie Lyons

In recent years, the home health benefit has been hit with spending cuts, which have the potential to directly impact the services offered to vulnerable Medicare recipients.

Seventy-eight percent of Medicare’s Home Healthcare Patients are non dual-eligible patients and are not covered by Medigap insurance, according to a new infographic from the Partnership for Quality Home Healthcare. This infographic explains the differences between Medicare home health beneficiaries and the average Medicare beneficiary, as well as the most chronic conditions treated by home health.

Home Health Patients Versus All Medicare Beneficiaries

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You may also be interested in this related resource: Population Health Management for Dual Eligibles: Blueprint for Care Coordination.