Posts Tagged ‘RNs’

Registries Identify High-Risk Patients, Support Evidence-Based Protocols

January 6th, 2015 by Cheryl Miller

Obtaining a clear snapshot of a patient population is the first step in managing health outcomes in an accountable care organization (ACO), says Gregory Spencer, MD, FACP, chief medical officer with Crystal Run Healthcare. Registries are a major part of that, and at Crystal Run Healthcare, care managers use them to identify high-risk patients, implement evidence-based protocols, and coordinate care inside and outside the office.

We have used care managers for about seven years. Groups of nurses use our registries to identify high-risk patients and implement evidence-based protocols. We have used an EHR, and we use e-mail and Blackberries ® extensively within our practice so that when we have a new development, we can get the word out quickly to mobilize people or alert them that certain things are happening. Registries are a major part of this: getting your list of people with a high-risk condition.

Our care managers are nurses that pull the list of patients from the registry using evidence-based guidelines. They contact them, make sure they get certain things done that they need to have done, and smooth those efforts. They do care planning and then communicate with the patients outside of the office. We are also embedding a care manager at a few of our sites to try and catch patients while they are in the office as well.

The template we use is pretty basic. It keeps track of the patient’s last test, and includes certain results so that if the patient has a question or is due for some lab work, the care manager can quickly order it. If it’s not protocol-driven, they can send it to the physician for review or potentially do it themselves if we are able to cover it with a protocol. This is one way we use registries of patients who require referral tracking.

Again, workflow is the Achilles heel of some brilliant quality efforts. You don’t want to destroy your workflow and patient flow. Not to say that you can’t redesign your workflow if it is important, but this process can end in tears. Sometimes if the change is not well thought out, it has negative effects on workflow.

Source: Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care

http://hin.3dcartstores.com/Population-Health-Management-Tools-for-ACOs-Technologies-and-Tactics-to-Support-Accountable-Care_p_4204.html

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care examines the building blocks of population health management that drive improvements in healthcare quality and efficiency in ACOs — while positioning healthcare organizations for core measure improvement and increased reimbursement. In this 40-page resource, Dr. Gregory Spencer, chief medical officer of Crystal Run Healthcare, demystifies registry use and shares patient registry best practices.

3 Levels of Health Coaches

April 10th, 2014 by Cheryl Miller

While health coaches address the health risk continuum — keeping the healthy healthy without compromising the clinical support needed for high-risk, high utilization individuals, it is necessary to align individuals with the right coaching service at the right time, say Dennis Richling, MD, chief medical and wellness officer, and Kelly Merriman, vice president of service delivery for HealthFitness. Here they explain the three levels of heath coaches needed to address their clients’ wide-ranging needs.

Our approach engages the individual with the right coach for their need. We use three types of professional coaches: there are health coaches, who are lifestyle coaches, individuals with bachelors, masters and doctoral degrees in health-related fields. There are also advanced practice coaches, skilled senior health coaches who have been trained in clinical conditions in chronic disease management. And then there are nurse coaches, who are registered nurses, who also have been trained in behavior change techniques. We take a look at what happens and who fits into which category.

First, there are those people with no chronic disease but who have health risks. They have issues trying to manage their healthy lifestyle and are seeking help. Those individuals go to health coaches.

Next, there are those individuals with chronic diseases but they’re managing their medication appropriately and complying with the preventive and control measures for their chronic disease. But their underlying lifestyle issues remain, and these individuals go to advanced practice coaches.

Lastly, there are individuals who are not following their care plan, their care is not coordinated, they are seeing multiple doctors, and their medication compliance is poor. They do have underlying lifestyle issues, but their biggest problem right now is managing their chronic disease and these individuals go to the nurse coach.

Excerpted from Integrated Health Coaching: Reducing Risk and Empowering Change across the Health Continuum.