Posts Tagged ‘Medical Neighborhood’

Guest Post: 7 Ideas to Improve Communication and Coordination between Care Sites

September 22nd, 2015 by Richard A. Royer, CEO, Primaris

With access to some of the most highly educated and trained medical professionals in the world, providing Americans with the best patient care possible should be simple. Unfortunately, that’s not often the case. Poor communication between specialists, duplicate tests and unnecessary procedures are frequently the norm rather than the exception, leading to costly, dangerous and sometimes deadly consequences. With so many specialists and resources readily on hand, how is this happening?

The problem is a lack of care coordination. Simply put, care coordination is the idea that all specialists treating a patient should communicate and share information to ensure that everyone acts as a team to meet patient needs. This includes reporting all results back to a primary care practice or to someone coordinating patient care, and ensuring that labs, specialists, hospitals, and long-term care facilities work together to communicate information quickly and appropriately. It’s about primary care physicians, nurses, technicians, specialists, and caregivers collaborating on patient care rather than working as separate entities.

The average Medicare beneficiary interacts with seven physicians in four different practices during a single year, according to the New England Journal of Medicine. For those with chronic conditions, the numbers can be even higher. And, nearly one-fifth of Medicare patients who are hospitalized are readmitted within 30 days of discharge, and 75 percent of these readmissions could have been prevented by improved care coordination.

Too often, patients discharged from hospitals don’t get the support and encouragement they need to take their medicine, follow their diets, and adhere to the regimens doctors have prescribed during their stay. Many of these problems can be solved by improving care coordination, and that starts with communication between care sites.

Here are seven suggestions for improving communication between care sites—as well as across the care continuum:

  • Start the dialog: As a rule of thumb, improving communication between care sites begins with healthcare providers asking themselves what they know that others need to know, and sharing that information with the patient’s care team. What do patients need to know when they’re referred to a specialist? What do the specialists that patients are being referred to need to be aware of, e.g. what tests have already been completed? Has the primary care physician been informed?
  • Create a team and make it accountable: Organizations should start by assigning a team of people to be accountable for managing patient care. Define the extent of their responsibilities for key activities such as following up on test results and communicating information to other physicians. Establish when specific responsibilities should be transferred to other care providers—whether that means specialty physicians, long-term care facilities, or home care providers.
  • Designate care coordinators: Designate staff that will act specifically as care coordinators can help to reduce hospital readmissions. Before patients leave the hospital, care coordinators should meet with them to make sure they understand the treatment plans they need to follow at home as well as any changes to their medication regimens. The hospital care coordinators also must follow up on any pending labs and imaging studies and contact primary care physicians to communicate updated medications, treatment plans, and test results for their patients. The likelihood of readmission drops significantly when patients leave with a clear understanding of their treatment plans and when their primary care physicians know what is necessary during follow-up care.

    This same communication protocol should also apply to patients who leave the hospital for long-term care facilities. In this instance, the hospital care coordinator should communicate discharge instructions to the long-term care staff. As soon as residents return to the long-term care facility, staff there should meet with residents to review their discharge instructions, answer their questions, and communicate with the hospital if any further clarification is needed. Long-term care staff should also follow up regularly with these residents to ensure they continue to comply with instructions the doctor has recommended and intervene if any problems arise.

  • Standardize communication processes: Create a protocol for filling out patient charts in a standard way so they are easy to interpret and key elements aren’t overlooked. You also should standardize communication by using structured forms to ensure primary care providers, specialists, and long-term care providers all have the same and necessary information.
  • Develop a referral tracking system: Creating a system to internally track and manage referrals and transitions— including consultations with specialists, hospitalizations and ER visits, and referrals to community agencies—can go a long way towards improving communication between care sites. It will help to ensure patients are well prepared for their referral visit and know what to expect afterwards. And, it simplifies follow-up with referral providers about findings, next steps and treatment plans.
  • Follow up on referrals: When a primary care physician refers a patient to a specialist, for example, office staff should follow up to make sure the appointment was made and completed. In addition, office staff needs to ensure the specialist shares his findings with the primary care physician so he can be well versed on the patient’s progress and any additional steps to be taken.
  • Notify providers in the patient’s medical neighborhood: Similarly, when patients visit the emergency room or are admitted to the hospital, communication should be a priority. In this instance, hospital staff should notify the primary care practice so the primary care doctor can follow the patient’s progress through discharge and institute a care plan to prevent future admissions. In addition, the practice can reach out to patients when they leave the hospital to make sure they understand discharge instructions and schedule follow-up appointments. When the patient comes in for follow-up care, the primary care physician should have a complete history of specialists seen during the hospital admission, their recommendations, and tests performed, along with the results.

The healthcare industry can no longer simply “discharge” patients. Providers must now work collaboratively with all others across the continuum of care to transition and coordinate the ongoing care of every patient. That’s what care coordination is all about.


Richard Royer

About the Author: Richard A. Royer has served as the chief executive officer of Primaris since 2001. He has extensive administrative healthcare experience and is actively involved in several statewide healthcare initiatives. In 2006 he was appointed by the Missouri governor to the Missouri Healthcare Information Technology Task Force and chaired the resources workgroup. He also serves on the board of directors as treasurer for the Excellence in Missouri Foundation. In his over 35 years of medical business experience he has held positions as chief executive officer at Cuyahoga Falls, Ohio, General Hospital; executive director of Columbia Regional Hospital in Missouri; and founder and president of Avalon Enterprises, a medical financial consulting firm.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

4 Goals for Furthering Care Coordination in the Medical Neighborhood

August 28th, 2014 by Cheryl Miller

With the advent of the medical neighborhood, care coordination is no longer the sole domain of the primary care practice (PCP), but a responsibility shared among all providers that touch the patient. But how to formalize co-management of patients by PCPs and specialists — in a way that both assures efficient delivery of high-quality healthcare and addresses the ‘pain points’ of each provider group? Here, Robert Krebbs, director of payment innovation at WellPoint, Inc., discusses the four goals for furthering care coordination in the medical neighborhood.

The care compact isn’t intended to solve all the world’s problems. We know it’s not going to make care coordination perfect, but it’s a starting point. Just like the PCMH provides a foundation for the medical neighborhood, the care compacts provide a foundation for care coordination between practices. It’s an essential starting point to further care coordination expectations across the medical neighborhood.

First, with the care compact, we’re helping the pilot practices by identifying the PCPs they can collaborate with to put care compacts in place. We’re playing connector for these two practices.

Second, we’re assessing the current care coordination capabilities of the specialist practices in the pilot and looking at where they’re starting from in terms of care coordination.

Third, we’re watching them customize the care compact and monitoring how they adapt it to their practice needs so we can come up with a stronger template at the end of this pilot than we started with that guides this last point.

Finally, we’re going to disseminate best practices throughout the process to all participants in the pilot. Everyone will benefit from the hard work of each participating practice.

Excerpted from Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination.

9 Things to Know About Patient-Centered Medical Homes in 2014

April 29th, 2014 by Patricia Donovan

Having established a firm foundation by providing over two decades of patient-centered care, the medical home model is poised for a makeover, expanding into medical neighborhoods and opening the door to specialists’ enhanced role in care coordination—two new metrics documented in the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN).

Here are nine benchmarks gleaned from the 2014 PCMH survey:

  • The annual percentage of respondents implementing the medical home model continues to rise, with a high of 58 percent reporting PCMH adoption, up from 52 percent in 2012, when the survey was last conducted.
  • The percentage of respondents with at least a fifth of patients assigned to medical homes more than doubled in the last two years, from 27 to 50 percent.
  • Today’s medical home is especially welcoming to Medicaid beneficiaries, who were targeted by only 3 percent of medical homes in 2012 but now are included in 37 percent of respondents’ patient-centered approaches.
  • Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransforMED&#8480 as “a strong foundation of transformed primary care practices aligned with health systems and specialists to ensure that care is maximally coordinated and managed.”
  • At the same time, 37 percent of 2014 respondents identified practice transformation, or the process of adopting the attributes of the patient-centered medical home model, as the most formidable challenge of medical home creation.
  • In new metrics from this year’s survey, nearly half of respondents (46 percent) include specialists in their patient-centered medical homes.
  • With an eye toward care coordination, the inclusion of case managers in medical homes jumped from 56 percent in 2012 to 76 percent in 2014.
  • Today’s medical homes are a little more crowded, with three-quarters of respondents reporting 21 or more physicians participating, up from 58 percent in 2012.
  • Undaunted by recent studies to the contrary, all 2014 respondents with medical homes believe the model can reduce cost and improve care delivery.

Excerpted from 2014 Healthcare Benchmarks: The Patient-Centered Medical Home.

Medical Neighborhood Bridges Gap Between Health Systems and Physicians

February 18th, 2014 by Patricia Donovan

The medical neighborhood is one approach to defragmenting care coordination in the United States.


The need for better coordination within the U.S. healthcare system cannot be refuted, notes Terry McGeeney, MD, MBA, director of BDC Advisors, who introduces the trend toward medical neighborhoods.

We need to start talking about the solution to bridge the gap between health systems and physicians. We can do that as we talk about the medical neighborhood concept and the integrated network concept. I have come to realize that the medical neighborhood in many environments is a physician term that’s been embraced widely by both specialty organizations and primary care organizations.

A clinically integrated network (CIN) is a hospital term. These CINs have been around since the late nineties, when they were established by the Federal Trade Commission (FTC) and Federal Communication Commission (FCC). And you will often hear hospitals talking about clinical integration. The difference is that until the last couple of years, clinical integration has often been within the four walls of the hospital, where now it’s being expanded to broader networks around population management.

What are these medical neighborhoods that we are talking about and where are they? When you want to look for a medical neighborhood, look no further than your CIN for the foundation of that network. The challenge you often see is that the CIN or clinically integrated entity was set up as a legal entity and is not necessarily a high functioning medical neighborhood. It may have been set up by a law firm, or an accounting organization. It meets all the legal requirements, but it may not meet the requirements needed for improving quality of care in lowering cost.

But that existing CIN does create a foundation from which you can work. What you want to work and think about is transitioning your clinically integrated entity to a high functioning medical neighborhood. And to me that’s the real opportunity, but also a significant challenge.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

ABC’s of Healthcare 2014: Accountability, Bundled Payments and Consolidation

November 6th, 2013 by Patricia Donovan

Webinar Replay: 2014 Healthcare Trends & Forecasts, A Strategic Planning Session

“Use performance metrics and hold people accountable to the metrics. The days of all the excuses have really come to an end.”

Rationalizations for the poorly performing ObamaCare Web site aside, Steven Valentine’s advice during HIN’s tenth annual Healthcare Trends & Forecasts program underscores the accountability factor in value-based healthcare.

There really aren’t any more excuses for poor clinical outcomes or wasteful spending — not with the proliferation of evidence-based, patient-centered care models and tools to track population health.

Accountability is part of the Triple Aim mentality that pervades the industry and colored predictions by both Valentine, president of The Camden Group, and Catherine Sreckovich, managing director in the healthcare practice at Navigant, during HIN’s tenth annual Healthcare Trends & Forecasts in 2014 Strategic Planning Session. Prognostications by these industry thought leaders on the care delivery and reimbursement strategies to watch in the year ahead bolster the notion that big data, risk-stratified accountable care and performance-based reimbursement are here to stay.

Although healthcare will continue to live in a fee-for-service world for a while longer, acquisition and consolidation by physicians and hospitals will continue, and integrated delivery networks powered by bundled payments are healthcare’s best bet for value and integration, Valentine said. It’s one reason he’s “bullish on medical homes: they can be effective and have in many cases been able to reduce hospital admissions by 5 to 7 percent.”

Accountability also extends to new models of care delivery — the medical neighborhood, an amped-up version of the patient-centered medical home that pulls specialists, care coordinators and community linkages into the care continuum, or the “Team Approach, One Member at a Time” population health management philosophy of Kaiser Permanente, which Valentine hailed as “the poster child for the Obama administration as to what an ACO might look like.”

Dual eligibles, whose care is often fragmented, present an opportunity to benefit for monies available for Medicare-Medicaid beneficiaries. However, Valentine urges caution in the duals arena. “Dual-eligibles are extremely difficult to manage, they are non-compliant patients. Unless you manage care really well, being in a dual-eligible managed care system will probably cost you money.”

The accountable care organization continues to hold promise, he said, but despite the proliferation of ACOs, not all have delivered as expected. He advises ACOs to shore up infrastructure and focus more on medical management.

Ms. Sreckovich, parsing the healthcare year ahead for payors, concurs with Valentine on the potential of the ACO, but also cautioned that as with other shared savings models (bundled payments and patient-centered medical homes, for example) there are hurdles to ACO implementation that remain, including their high setup cost. “Organizations have to have the right resources, staff, time, money, etc., to meet their accountability targets,” she said.

On recommended reimbursement models for ACOs, Ms. Sreckovich was partial to bundled payments, shared risk, and incentives tied to value and wellness outcomes. “Those are the payment models that health plans are starting to emphasize as they’re negotiating terms of new arrangements.”

in her payor-focused comments, Ms. Sreckovich pointed out the extreme variation in the number and types of available health plans at this time — a scenario complicated by the problematic rollout of the health insurance exchanges. It remains to be seen what impact the government’s technical difficulties will have on the industry, but as of right now, Ms. Sreckovich doesn’t expect the low tax penalties for the uninsured to be enough of a motivator for enrollment.

The recent ACA-related troubles may result in the creation of more private insurance exchanges such as the one Walgreen’s created earlier this year. The discount retailer is moving 120,000 employees to a private health insurance exchange from coverage provided directly from carriers.

For her part, Ms. Sreckovich is bullish on big data, but advised health plans “not to use data for data’s sake but instead use analytics to transform from ‘payor’ to ‘value generator.'” It is also critical to get more data into consumers’ hands, she stressed.

“So far, data for consumers has been relatively limited, which is a problem because we want consumers to make decisions based on cost and quality. So we really have to get the data to them.”

Listen to interviews with Mr. Valentine and Ms. Sreckovich.