Posts Tagged ‘nurse navigators’

Bon Secours Next Generation Healthcare: Smart Tools Tell Care Transitions, Chronic Care Management Stories

February 4th, 2016 by Patricia Donovan

Next Generation Healthcare smart tools facilitate Bon Secours care plans for care transitions, chronic care management and Medicare wellness visits.

A key component of chronic care management is a comprehensive plan of care—the “refrigerator copy” patients can refer to, explains Robert Fortini, PNP, chief clinical officer for Bon Secours medical Group (BSMG).

Today, using smart tools built into its electronic medical record, Bon Secours nurse navigators document twelve-point care plans for the 50 patients they have enrolled via Medicare’s year-old Chronic Care Management (CCM) codes—a number Fortini expects will double this month.

The CCM assessment tool also captures frequently forgotten issues such as depression, pain and sleep problems that can derail care, Fortini said in a recent webinar on Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning.

Bon Secours’ seventy nurse navigators, embedded in physician practices, also tap these point-and-click smart tools to document transitions of care for patients recently discharged from the hospital. This Transition of Care smart note tracks 17 different aspects of patient care, including risk of readmission and medication reconciliation, and includes a placeholder for an advance medical directive.

Similar tools are in use for Medicare’s three types of wellness visits, he added.

“I have been in this business a long time, and the documentation that navigators produce using these workflows is extraordinary,” Fortini noted. “This is purposeful design. It tells a story and you have something actionable at the conclusion of reading it.”

The smart tools are but one aspect of Bon Secours’ Next Generation Healthcare initiative, which Fortini defined as “population health meets total access.” Next Generation Healthcare fortifies the team-based medical home foundation Bon Secours introduced six years ago with expanded care access and technology, among other components the organization leverages to improve clinical outcomes and value-based reimbursement.

In the Next Generation Healthcare model, the primary care physician is the quarterback of care, with embedded nurse navigators doing the “heavy lifting” of enrolling at-risk patients into care management, building comprehensive care plans, and scheduling Medicare beneficiaries for annual wellness visits, Fortini explained.

Additionally, Bon Secours has broadened its care access menu to include employee clinics, fast care and urgent care sites, self-scheduling, and virtual visits for primary care. The organization expects to expand virtual visits to specialist consultations and behavioral health in the near future, and also envisions virtual case management visits, allowing nurse navigators to conduct real-time medication reconciliations with at-home patients.

To round out its Next Generation Healthcare continuum, Bon Secours is training a portion of nurse navigators as facilitators in a Virginia advance care planning initiative called “Honoring Choices,” with the goal of formalizing the placement of advance directives in patients’ records.

Investing in resources necessary to manage end-of-life effectively is a critical aspect of Bon Secours’ strategic initiative, Fortini concluded. “Forty percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible.”

Listen to an interview with Robert Fortini in which he describes how Bon Secours nurse navigators have won over solo practitioners.

How Bon Secours Gets Paid for Providing Value-Based Healthcare

February 13th, 2015 by Patricia Donovan


Bon Secours 'Good Health' ACO is one of the largest in CMS's Medicare Shared Savings Program (MSSP).

Bon Secours Medical Group isn’t waiting for CMS to fully transition Medicare to pay-for-performance reimbursement models to get paid for providing value-based healthcare.

Instead, the 600-provider medical group has aligned itself closely with healthcare payment reform, applying a broad mix of patient-centered team-based care, technology and retooled care delivery systems to maximize quality and clinical outcomes and reduce spend associated with its managed patients.

Highlights of Bon Secours’ patient-centered approach were presented by Jennifer Seiden, administrative director, population health, and Lu Bowman, population health market program manager, during the recent webinar, Positioning for Value-Based Reimbursement: Workforce Development for Transitional Care, Chronic Care Management, now available for on-demand replay.

“The HHS’s historic announcement [of Medicare’s value-based payment timeline] was a clear signal to the industry and to the market that we better align ourselves and set ourselves up for it,” noted Ms. Seiden.

As far back as 2009, the prescient medical group had several pay-for-performance programs in place; in 2015, Bon Secours Good Health accountable care organization (ACO) is one of the largest participants in CMS’s Medicare Shared Savings Program (MSSP).

Today, most Bon Secours tactics emanate from the principles of the patient-centered medical home (PCMH), she said, with a focus on taking a population-wide view and closely managing “below-the-waterline” patients, guiding them to the most appropriate care settings and following up on them post-discharge.

The multidisciplinary care team is so essential to this patient-centered approach Bon Secours has constructed a business case to justify the team, she added, using a “Back to Basics” ROI equation developed by Robert Fortini, vice president and chief clinical officer.

Lauding Fortini’s efforts, Seiden explained the motivation behind his formula. “We had to develop a return on investment equation for the care team, because if you’re an independent practice or even if you’re employed, you’ve got to justify the expense of that additional overhead. That labor is not cheap.”

Results, revenue and key metrics like the number of post-discharge office visits and readmissions are tracked via electronic dashboards and rolled into the ROI equation.

Other strategies, including integration of behavioral health, embedding of case managers (nurse navigators) and EMTs, the use of ambulatory registries to stratify high-risk patients and a foray into retail healthcare contribute to Bon Secours’ impressive results, like a readmission rate of 2.08 percent for patients heavily monitored and managed by nurse navigators.

Ms. Bowman then described Bon Secours’ cohesive Care Management Services, which are divided into chronic care management services and complex chronic care management services. Nurse navigators are already working with Medicare’s new Chronic Care Management codes, another stepping stone in the federal payor’s volume-to-value transition.

“Nurse navigators are already providing chronic care management to patients. It was the natural next step for us to utilize these care management codes. The education for our team was focused on meeting the criteria, documentation and making sure the patient is always aware of and included in the care plan, which is so important to patient-centered care,” concluded Ms. Bowman.

Listen to comments from Jennifer Seiden.

Healthcare Business Week in Review: Care Coordination, Oncology Nurse Navigators, Readmissions, ACA

December 13th, 2013 by Cheryl Miller

Primary care outside the doctor’s office is getting its due. According to a final ruling from CMS, payment rates and policies for 2014 are focusing on improved care coordination, including a major proposal to support care management outside the routine office interaction.

The ruling also includes other policies to promote high quality care and efficiency in Medicare. CMS officials consider the care coordination policy a milestone, demonstrating Medicare’s recognition of the importance of care that occurs outside of a face-to-face visit for a wide range of beneficiaries beginning in 2015.

But there is a time and place for face-to-face visits: namely, between nurses and newly diagnosed cancer patients. According to a new study from the Group Health Research Institute, cancer patients who received support from a nurse navigator or advocate soon after being diagnosed had better experiences and fewer problems with their care, particularly in the areas of health information, care coordination and psychological and social care. Patients reported feeling that the healthcare team had gone out of its way to make them feel better emotionally. The extra help is especially welcome with new cancer patients, given that they and their caregivers need help translating medical jargon and navigating the healthcare maze, researchers say.

While the covering of catastrophic illnesses like cancer is one of the key issues behind healthcare reform, it is not enough to sell the nearly 30 percent of Americans opting out of coverage. According to the latest tracking poll from Gallup, one out of four uninsured Americans are planning on paying the government penalty rather than buy health insurance. The reason? Not what you think; details inside.

An automated prediction tool that identifies newly admitted patients at risk for readmission within 30 days of discharge has been successfully incorporated into the EHR of the University of Pennsylvania Health System.

The tool predicts at-risk patients as those who have been admitted to the hospital two or more times in the 12 months prior to admission. Once it identifies these high-risk patients, it creates a flag in their EHR, which appears next to the patient’s name in a column titled “readmission risk” once the patient is admitted.

We’d love to hear how your organization is working to reduce hospital readmissions by taking HIN’s fourth comprehensive Reducing Hospital Readmissions Benchmark Survey. Respond by January 3, 2014 and receive an e-summary of the results once they are compiled.