Posts Tagged ‘Patient Engagement’

10 Critical Care Coordination Model Elements for Medicaid Managed Care Members

May 17th, 2018 by Melanie Matthews

There are 10 critical elements of the care coordination model for Independent Health Care Plan (iCare) Medicaid managed care members, according to Lisa Holden, vice president of accountable care, iCare.

The first element and touchpoint for Medicaid managed care members is their care coordinator. “Every single one of our incoming SSI Medicaid members is assigned to a care coordinator,” Holden told participants in the May 2018 webinar, Medicaid Member Engagement: A Telephonic Care Coordination Relationship-Building Strategy, now available for replay. “That person is responsible for everything to do with that member’s coordination of care.”

Care coordinators are assigned to every Medicaid member and are responsible for engaging and coordinating member’s care needs.

“We want our care coordinators to make an initial phone call as early as a couple of days after the member is enrolled in our plan,” she said. “If the member is interested in having a conversation, we offer to conduct a health risk assessment. But if the timing isn’t right, then we offer to schedule another appointment. There’s no pressure except that we want them to feel engaged by us.”

Once completed, the health risk assessment forms the basis of an interdisciplinary individualized care plan created by the care coordinator with the member.

The care coordinator, who is a social worker by background, has access to a nurse, who is available for medically complex members, said Holden.

iCare also relies on health coaches. Health coaches are now teaming up with a care coordinator as much as, if not more than, the nurses are historically, Holden said.

“Our health coaches are literally assigned to work in the community to become very familiar with the resources that are available,” she added. “They are becoming steeped in the communities in which they serve. Each one is assigned to a neighborhood, and we’ve asked them, ‘Get to know the police. Get to know the fire. Get to know the food organizations and food pantries. Get to know the housing specialists in your area.'”

The health coaches also help the care coordinators locate difficult-to-contact members by being in the community as a boots on the ground force. They’re also focused on assessing and addressing social determinants of health.

“We really believe that health coaches are going to be the key to our success in this year and in years to come,” Holden explained.

In addition to the care coordinators, health coaches and nurses, the care coordination team includes two specialized positions…a trauma-informed intervention specialist and a mental health and substance abuse intervention specialist. “We brought those two specialties into this program for our Medicaid members because we know that there’s a high instance of behavioral health conditions, which usually has another diagnosis of alcohol and drug use, not always, but quite often. We wanted to have the team ready to engage the member,” said Holden.

Once the member is engaged, iCare’s care coordination team begins to identify unmet needs, she explained. “We want to know, ‘Is their life going well? Do they have appropriate medical care? Are they in a relationship with a primary care provider that they feel is co-respectful? Are they getting their answers to their questions?'”

To begin talking about medical needs, the care coordination team has to establish trust, said Holden. “We have to talk with the member in an honest way that reflects our respect for them and also engages them in order for them to tell us how they really feel.”

iCare uses the Patient Activation Measure tool to help identify where the member is in a spectrum of four different levels of activation. iCare then tailors its member engagement approach to build a trusting relationship and provide member education by recognizing where they are in their activation level.

Following up on preventive measures are key for the iCare care coordination model. Care coordinators reach out to members for care plan updates. The care plan has to be alive and very member-centric, said Holden. The health risk assessment is repeated each year and the care plan is updated based on those results.

iCare is also focusing on social determinants of health with the recognition that they impact a members’ health more than clinical care. Clinical care attributes to only about 20 percent of somebody’s health outcomes; the rest of that 80 percent is made up of by health behaviors, social and economic factors, and physical environment. “If we don’t get underneath those issues, we can ask for things to improve, but we’re going to see minimal success,” Holden added.

During the webinar, Holden also shared: how the care coordinators helps Medicaid members overcome barriers to care; seven rising risk/acuity identification tools; readmission prevention initiatives for high-risk patients; three programs aimed at reducing high emergency department utilization; and details on a Follow-to-Home program for members who are homeless. Holden also shared: details on language to use…and not to use…when engaging members; advice on the best time to connect with members by phone, such as time of day, specific days of the months; the role of the specialist interventionist compared to the care coordinator; and the background of iCare’s care coordinators and health coaches.

Click here to view the webinar today or order a DVD or CD of the conference proceedings.

Infographic: The Hyper-Connected Patient

December 4th, 2017 by Melanie Matthews

The hyper-connected patient provides a number of opportunities for healthcare organizations to manage and prevent chronic diseases, according to a new infographic by EMC2.

The infographic examines three ways healthcare organizations can engage and promote health to connected patients.

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System Encouraged by early success in coaching 23 patients to wellness at home via remote monitoring, CHRISTUS Health expanded its remote patient monitoring (RPM) enrollment to 170 high-risk, high-cost patients. At that scaling-up juncture, the challenge for CHRISTUS shifted to balancing its mission of keeping patients healthy and in their homes with maintaining revenue streams sufficient to keep its doors open in a largely fee-for-service environment.

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System chronicles the evolution of the CHRISTUS RPM pilot, which is framed around a Bluetooth®-enabled monitoring kit sent home with patients at hospital discharge.

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HINfographic: Patient Engagement: Educate to Overcome Social Determinants of Health and Low Health Literacy

October 30th, 2017 by Melanie Matthews

Social determinants of health (SDOH), conditions in which individuals are born, grow, live, work and age, and low health literacy pose the greatest barriers to engaging patients in self-care, say respondents to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network.

A new infographic by HIN examines the top components of patient engagement programs, the most challenging patients to engage and the return on investment from patient engagement programs.

Beyond hoped-for improvements in clinical outcomes from actively engaged patients, patient engagement metrics now factor heavily into the equations of risk- and value-based reimbursement models.

2017 Healthcare Benchmarks: Patient Engagement documents tactics, targeted populations and clinical conditions, program components, technology use, success measures, challenges and many other patient engagement metrics reported by 75 healthcare organizations responding to the 2017 Patient Engagement survey by the Healthcare Intelligence Network.

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Healthcare Hotwire: Patient Engagement

October 19th, 2017 by Melanie Matthews

Engaging patients in self-management contributes to healthier clinical and financial results in healthcare’s value-based reimbursement climate.

Beyond hoped-for improvements in clinical outcomes from actively engaged patients, patient engagement metrics now factor heavily into the equations of risk- and value-based reimbursement models. With continued anticipated growth in these types of reimbursement models, healthcare organizations are continuing to invest and refine their patient engagement strategies.

With this as a backdrop, it’s not surprising that a clear majority of respondents to HIN’s recent Benchmark Survey on Patient Engagement have created formal patient engagement programs, with 4 percent of the remaining slated to launch a program in the coming year. Nearly two-thirds (63 percent) mine clinical data analytics to risk-stratify individuals for engagement efforts.

And, it will continue to be an organizational priority for healthcare organizations in the year ahead, according to a new study of 2018 healthcare industry concerns by the Healthcare Executive Group.

In the new edition of Healthcare Hotwire, you’ll get patient engagement case studies from several industry leaders and details on some of the trends impacting patient engagement.

HIN’s newly launched Healthcare Hotwire tracks trending topics in the industry for strategic planning. Subscribe today.

Infographic: The State of Patient Engagement

September 27th, 2017 by Melanie Matthews

Value-based healthcare reimbursement models encourage healthcare organizations to better engage with their patients. In addition, social media is being used as a transformative tool, and an enhanced focus on digital will offer organizations new and different ways to interact with patients, according to a new infographic by Adelphi University.

The infographic examines five key ways to enhance patient engagement, common patient engagement obstacles and the most effective patient engagement tools.

Patient-centric interventions like population health management, health coaching, home visits and telephonic outreach are designed to engage individuals in health self-management—contributing to healthier clinical and financial results in healthcare’s value-based reimbursement climate.

But when organizations consistently rank patient engagement as their most critical care challenge, as hundreds have in response to HIN benchmark surveys, which strategies will help to bring about the desired health behavior change in high-risk populations?

9 Protocols to Promote Patient Engagement in High-Risk, High-Cost Populations presents a collection of tactics that are successfully activating the most resistant, hard-to-engage patients and health plan members in chronic condition management. Whether an organization refers to this population segment as high-risk, high-cost, clinically complex, high-utilizer or simply top-of-the-pyramid ‘VIPs,’ the touch points and technologies in this resource will recharge their care coordination approach.

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Infographic: What Benefits Do Patient Portals Offer Hospitals and Health Systems?

July 28th, 2017 by Melanie Matthews

As the use of electronic health records (EHRs) has increased, so has the functionality of patient portals that are often integrated with EHRs, according to a new infographic by UbiCare.

The infographic examines patient portal usage trends.

Understanding the factors that cause patient disengagement is a crucial first step in improving engagement rates, critical in today’s accountable healthcare systems.

Drilling into the customer comments from its Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey helped PinnacleHealth System frame the components of its patient engagement strategy…targeting patients with gaps in care and providing information and education to clinicians throughout the system on their role in increasing engagement rates.

During A Two-Pronged Patient Engagement Strategy: Closing Gaps in Care and Coaching Clinicians, a 45-minute webinar on August 17th at 1:30 p.m. Eastern, Kathryn Shradley, director of population health, PinnacleHealth System, will share her organization’s patient engagement framework, including its two-pronged approach to increase engagement rates across the health system.

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Infographic: Patient Engagement in the Age of Social Media

June 2nd, 2017 by Melanie Matthews

Effective patient engagement has been linked with increased adherence to medical plans, reduced hospitalizations, and higher revenues, according to a new infographic by ChartLogic. One way to generate these results is by meeting patients where they spend the most time, i.e. social media.

When healthcare consumers connect with physicians or healthcare providers through one of the major social channels (Facebook, Twitter, Instagram, etc), their first experience should be a positive one, with good information on how to get in touch. Links to helpful health apps and portals are also appreciated. Developing a social strategy should be a cornerstone of every organization’s patient engagement strategy.

The infographic examines how practices can increase patient engagement, why it’s a good thing, and potential benefits.

Patient-centric interventions like population health management, health coaching, home visits and telephonic outreach are designed to engage individuals in health self-management—contributing to healthier clinical and financial results in healthcare’s value-based reimbursement climate.

But when organizations consistently rank patient engagement as their most critical care challenge, as hundreds have in response to HIN benchmark surveys, which strategies will help to bring about the desired health behavior change in high-risk populations?

9 Protocols to Promote Patient Engagement in High-Risk, High-Cost Populations presents a collection of tactics that are successfully activating the most resistant, hard-to-engage patients and health plan members in chronic condition management. Whether an organization refers to this population segment as high-risk, high-cost, clinically complex, high-utilizer or simply top-of-the-pyramid ‘VIPs,’ the touch points and technologies in this resource will recharge their care coordination approach.

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.

Infographic: Improving Health Literacy with Data

May 10th, 2017 by Melanie Matthews

Individuals are not solely responsible for increasing their health literacy, healthcare organizations are accountable too, according to a new infographic by Sagitec.

The infographic examines health literacy trends, implications, possibilities and solutions.

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health SystemIntermountain Healthcare’s strategic six-point patient engagement framework not only has transformed patient care delivered by the Salt Lake City-based organization but also has fostered an attitude of shared accountability throughout the not-for-profit health system.

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health System details Intermountain’s multilayered approach and how it supports its corporate mission: Helping people live the healthiest lives possible.

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Infographic: Improve Patient Engagement To Increase Medication Adherence

March 3rd, 2017 by Melanie Matthews

Chronic illnesses treated with long-term use of medications could be more successful with improved medication adherence rates, according to a new infographic by Fleming. Some 50% of patients do not take their medications as prescribed.

The infographic drills down on the factors related to non-adherence, the cost of non-adherence and the impact of technology on patient engagement.

Improve Patient Engagement To Increase Medication Adherence

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health SystemIntermountain Healthcare’s strategic six-point patient engagement framework not only has transformed patient care delivered by the Salt Lake City-based organization but also has fostered an attitude of shared accountability throughout the not-for-profit health system.

Framework for Patient Engagement: 6 Stages to Success in a Value-Based Health System details Intermountain’s multilayered approach and how it supports its corporate mission: Helping people live the healthiest lives possible.

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.

Infographic: EHR + CRM = Superior Patient Engagement

February 13th, 2017 by Melanie Matthews

U.S. hospitals that provide superior patient experiences generate 50 percent higher financial performance than average providers…key in today’s shift from volume- to value-based healthcare, according to a new infographic by Evariant. True patient engagement is about creating trust between the patient and health system, nurturing a relationship over the course of a patient’s lifetime.

This understanding is possible by integrating healthcare CRM software and EHR systems. Combined, these two systems weave together patient data from a variety of sources, including demographic, social, behavioral, and clinical data.

The infographic examines how a combined EHR and CRM can bridge the patient engagement gap and extend the EHR investment.

Infographic: EHR + CRM = Superior Patient Engagement

Patient-centric interventions like population health management, health coaching, home visits and telephonic outreach are designed to engage individuals in health self-management—contributing to healthier clinical and financial results in healthcare’s value-based reimbursement climate.

But when organizations consistently rank patient engagement as their most critical care challenge, as hundreds have in response to HIN benchmark surveys, which strategies will help to bring about the desired health behavior change in high-risk populations?

9 Protocols to Promote Patient Engagement in High-Risk, High-Cost Populations presents a collection of tactics that are successfully activating the most resistant, hard-to-engage patients and health plan members in chronic condition management. Whether an organization refers to this population segment as high-risk, high-cost, clinically complex, high-utilizer or simply top-of-the-pyramid ‘VIPs,’ the touch points and technologies in this resource will recharge their care coordination approach.

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.