Posts Tagged ‘care coordinators’

HINfographic: Care Coordination Trends: Oversight of Complex Comorbid Spans Continuum

May 17th, 2017 by Melanie Matthews

Care coordinators organize patient care activities and share information among vested participants to achieve safer and more effective care, per the Agency for Healthcare Research and Quality (AHRQ). And for 86 percent of respondents to the 2016 Care Coordination survey by the Healthcare Intelligence Network, care coordination takes place across all care settings, including the patient’s home.

A new infographic by HIN examines patient care coordination touchpoints, patients by diagnoses prioritized for care coordination and care coordination touchpoint frequency and reimbursement models.

2016 Healthcare Benchmarks: Care CoordinationCare coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care, as defined by the Agency for Healthcare Research and Quality (AHRQ).

2016 Healthcare Benchmarks: Care Coordination examines care coordination settings, strategies, targeted populations, supporting technologies, results and ROI, based on responses from 114 healthcare organizations to the September 2016 Care Coordination survey by the Healthcare Intelligence Network.

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Yale New Haven’s High-Risk Care Management Commences with Its Employees

January 14th, 2016 by Patricia Donovan

A care management pilot by YNHHS for employees and their dependents with diabetes was a template for future embedded care management efforts.

Disenchanted with vendors it engaged to provide care management for its workforce, Yale New Haven Health System (YNHHS) launched an initial care management pilot for its high-risk employee populations. The pilot went on to become a very robust program and served as a training ground for two more embedded on-site care management initiatives. Here, Amanda Skinner, YNHHS’s executive director for clinical integration and population health, provides details from on-site face-to-face care management for YNHHS employees and their dependents.

We have an RN care coordinator based on each of the four main hospital campuses of our health system: one in Greenwich, one in Bridgeport and two in New Haven. All of the RN care coordinators in this program are trained in motivational interviewing. The intent is for them to work with our high-risk, high-cost employees who have chronic diseases, and with their adult dependents that also fall into that population.

The care coordinators work with these employees across the entire system to help them access the care they need, identify their goals of care, get under the surface a little to determine barriers to their being as healthy as they can be, and manage them over time. We did create some incentives for employee participation in this program, including waived co-pays on a number of medications (for example, any oral anti-diabetics).

When we initially launched the program, we limited it to employees and dependents that had diabetes, because that was the population for which we had very robust data. We also knew that diabetes was generally a condition that lent itself well to the benefit of care coordination; that there were a lot of gaps in care. When we looked at our data, we saw that ED utilization was very high for this population; that their past trend was rising, that utilization of their primary care provider was actually below what you would expect. This meant that they were under-utilizing primary care, over-utilizing hospital services, and were not particularly compliant with care.

With that population, we saw a lot of opportunity that a care management program could help address. In general, diabetes is a condition that lends itself to accepting a helping hand, to help people understand their condition and address the medical and social issues so they can manage that condition more effectively.

The program has been tremendously successful. We expanded it this year to include wellness coaches based at all of our delivery networks’ main campuses as well. These coaches work with a lower risk population and are available to any health system employee that wants to work with a coach to set care goals and then meet with the coach monthly or quarterly to track improvements against those goals. This expansion is because we’ve seen such positive results from this program.

Source: 3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients across the Continuum examines YNHHS’s three models of embedded care coordination that deliver value while managing care across time, across people, and across the entire continuum of care. In this 30-page resource, Amanda Skinner, executive director for clinical integration and population health at Yale New Haven Health System, and Dr. Vivian Argento, executive director for geriatric and palliative care services at Bridgeport Hospital, present a trio of on-site care models crafted by YNHHS to manage three distinct populations.