Posts Tagged ‘Care Management’

9 Remote Monitoring Technologies Enhance Telephonic Care Management

April 2nd, 2014 by Cheryl Miller

From home sensors that monitor daily motion and sleep abnormalities, to video visits using teleconferencing, Humana is doing its best to ensure that the frail elderly can remain at home as long as possible.

When integrated with a telephonic care management program, these remote monitoring technologies have helped Humana to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges, says Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. The pilots are part of a continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.

Most Americans are living longer, and suffering fewer deaths from acute illness, Miller said in a recent Healthcare Intelligence Network webinar, Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results. But they are also developing more chronic illnesses and functional limitations, which are often the costliest to manage.

Despite their growing frailty, however, nine out of 10 Americans prefer to age at home, she continues. To help them live independently and age gracefully at home, Humana, which has over 30 years experience in the Medicare program, and over two and a half million Medicare advantage members, launched the Humana Chronic Care Program (HCCP). Targeting the members most in need, or the sickest 20 percent, which drive 75 percent of the company’s costs, the company implemented a series of nine healthcare remote monitoring pilots for individuals with congestive heart failure (CHF) and diabetes as well those with medication adherence problems. The pilots also target those with functional challenges that make activities of daily living (ADL) challenging.

“There is a clear need to look beyond disease and address functional limitations,” Miller says.

One of the pilots includes strategically placed home-based sensors that monitor ADL levels of those with functional impairment. Algorithms detect abnormalities in the patients’ activities, i.e. erratic sleeping behaviors or toileting patterns that can signal infections, which then generate alerts for recommended interventions.

Video visits include two way audio-video communications so that care managers can interact with their sickest members as an adjunct to home visits. Members are given tablets to use for face-to-face contact with their care manager, or to go over any educational materials their care managers or physician provides them.

Ranging from passive to active monitoring, all of the technologies are senior-friendly, and designed to help members manage their conditions, reduce hospitalizations and improve the patient/member experience, Miller says.

A mobile Personal Emergency Response System (PERS), for those that live alone or have limited caregiver support, has been the most popular, Miller says. Members are mailed a cellular device that can be activated manually by a button, or automatically via an accelerometer. Once turned on, the PERS device connects the member to clinically trained emergency support. Many patients have asked if they could extend their use of this particular device once the pilot was over, Miller says. She explains why:

Besides being a health issue, I think the device also speaks to the level of safety concerns that a lot of seniors who have multiple chronic conditions, and who live alone, have. They don’t want to necessarily reach out to their neighbors all the time. This provides them some peace of mind, which is the ultimate goal of the program.

Listen to an interview with Gail Miller of Humana Cares/SeniorBridge here.

What are your organization’s efforts in remote patient monitoring? Participate in our e-survey, 10 Questions on Remote Patient Monitoring, by April 22, 2014 and you will receive a free summary of survey results once it is compiled.

3 Components of Geriatric Health Management for Dual Eligibles

March 27th, 2014 by Cheryl Miller

When designing care management programs for dual eligibles, you need to recognize the strong connection between the medical, the social and the behavioral, explains Timothy C. Schwab, MD, FACP, former chief medical officer of SCAN Health Plan. Ultimately, you are caring for the individual; one person in charge of the whole program.

I’d like to give a broad overview of the care management model that we’ve been using at SCAN. It begins with assessment care planning and care management. But we see it as a continuum — a cross between very traditional medical care management and traditional social care management. We’ve combined it into a centralized spot we call our ‘geriatric health management program.’

We meld all that into one care management program — the medical, the social, the behavioral. And then we utilize expertise from the medical sides; for instance, for a patient with diabetes, we use our diabetic disease management module by that geriatric care manager. Or for behavioral health issues, we use the behavioral health side of the program. But again, it all focuses on the individual; one person in charge of the whole program.

When you design for the dual eligible population, you can divide the population into those that are frail and disabled as a primary type of program, but also recognize that this is a low income population with multiple complex chronic conditions. Coordination is the critical link between the social and the medical. Incorporating the traditional things like disease management, utilization management, transition management and complex care management is essential, since all of these are very critical and interrelated.

Excerpted from Community Care Connections for Dual Eligibles: Closing Social Gaps to Improve Health Outcomes.

5 Considerations for Developing a Dual Eligibles Program

February 5th, 2014 by Jessica Fornarotto

Congress has responded to the differences and unique needs of the dual population, states Dr. Timothy Schwab, former CMO of SCAN Health Plan, creating the Office of the Duals and the Innovation Center.

Dr. Schwab stresses the importance of defining the goals and the population when developing or participating in a dual eligible program.

If you’re developing or participating, you need to define your goals, which will ultimately lead to how you develop the care management program and the metrics. Everything relates back to the Triple Aim of better health, better care and better cost.

It’s important to get as much information about the population you’re going to serve as possible. You need to look at the age bands, which is relatively easy for most states. You need to also look at how many people are in each age band, and what the program is going to serve.

Third, it’s important to understand the functional status of this population. This may be a little bit harder to get from the state because they probably only have information available for the population currently being served by the long-term supports and services programs in the community. And we know that there are people who aren’t being served that the state is not aware of.

When it comes to the medical status, the state has very little information on this because Medicare is the primary payor and the state only secondarily gets any information on medical status.

Fifth, the social status is also critical: Where do they live? What is their caregiver status? What percent of them have caregivers? What percent live in their own home? Then, you must consider issues such as language, literacy, and culture: What percent of them are non-English speaking? What cultural improvements must you consider when serving certain parts of the population?

Excerpted from: Population Health Management for Dual Eligibles: Blueprint for Care Coordination

Pioneer ACO Repurposes Care Management for Accountable Care

February 4th, 2014 by Jessica Fornarotto

As a top performer in Year 1 of the CMS Pioneer ACO program, Monarch HealthCare is paving the way to accountable care with a foundation of patient- and provider-centered strategies that support Triple Aim goals, which is to improve quality, improve health outcomes and reduce cost. Here, Colin LeClair, executive director of ACO for Monarch HealthCare, recounts how Monarch recast its Medicare Advantage (MA) care management program to target about 1,200 high-risk patients who have a similar constellation of issues.

Monarch repurposed our Medicare Advantage (MA) care management program for the ACO. Monarch’s ACO care management team was designed to anticipate and prevent acute events and then to facilitate transitions of care for patients post-discharge.

This interdisciplinary team is comprised of a primary care physician who quarterbacks the team, and a care navigator, also known as a care coordinator, who performs most of the patient onboarding into the care management program and performs an initial triage of the patient’s needs. The care manager is often a non-complex patient’s primary point of contact. The complex care manager is responsible for most of the complex cases.

Then as needed, we also deploy a behavioral health clinician, a community services coordinator, a clinic dietician and a palliative care nurse. The other resources may include a pharmacist or Pharm D to perform post-discharge medication reconciliation. Then we have a team of medical directors, employed and contracted hospitalists, and employed and contracted skilled nursing facilitators (SNFs) to support us as well.

The idea is that the team is tailored for the patient’s need at enrollment, and it can then be augmented as the patient’s health status changes. This model scales best when you can target large patient populations with a fairly common list of conditions, which allows you to hire and assign clinicians with the appropriate expertise to each patient. For example, we can afford to hire and assign a registered nurse (RN) or a nurse practitioner (NP) who has experience in a dialysis clinic or a nephrologist office if we have enough renal disease patients to fill their case load.

Excerpted from: Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care

4 Trends for Healthcare Providers in 2014

January 30th, 2014 by Jessica Fornarotto

Dual-track medical homes, e-visits, retooled patient handoffs and more post-acute care are predicted provider trends for 2014, according to Steven Valentine, president of The Camden Group. HIN interviewed Valentine prior to his presentation during an October webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: What is the physician practice going to look like in 2014? How has the primary care team evolved to meet the Triple Aim values inherent in the PCMH and accountable care models?

(Steven Valentine): We should expect to continue to see consolidation amongst the medical groups. The independent practice associations will begin to assimilate together because they need to put more money into their infrastructure. And many of the organizations have underperformed, in all honesty.

The primary care team is still critical. We’ve benefitted by keeping many primary care doctors around because they were negatively hurt with their net worth in the recession in 2008-2010. But it’s slowly coming back and we’re starting to see those physicians thinking about retirement again. The reality is, we’re never going to replace all of these primary care doctors as they wind down their practice. We need to do a better job of getting telehealth going and utilizing e-visits. We’re seeing the health plans starting to pay for those e-visits, as well as having the consumer who uses them use a credit card and pay at that time, just like a visit.

We’re going to have to look at different models. Obviously, the nurse practitioner is getting more involved with the primary care. And yes, they’re still pursuing the Triple Aim. We know that quality scores, satisfaction scores and trying to manage cost per unit is still a critical focus of the triple aim moving forward with population health.

Lastly, with a PCMH in accountable care, while some of the pioneer accountable care organizations (ACOs) reduce themselves out of pioneer into the Medicare Shared Savings Program (MSSP), we still have a number of organizations and it’s growing. The commercial ACOs have been very successful in California.

We fully expect accountable care to continue. We think the PCMH will evolve into two tracks. The first track is a primary care PCMH. The spinoff is a chronic care medical home that has the multidisciplinary team organized around a chronic disease. This is a model developed by CareMore years ago in Southern California and it’s been expanded across the country. As I travel the country, I run into organizations that have set up these chronic care centers around the chronic disease.

HIN: Regarding the Pioneer ACO program, one of the top performers in the CMS pioneer program, Monarch HealthCare, told us that it’s going to be working to engage specialists in care coordination roles in year two and year three. What’s ahead for specialists in terms of quality and performance improvement as well as shouldering perhaps more care coordination duties, especially for Medicare patients?

(Steven Valentine): The specialists are going to be a critical piece to this whole solution. They have been a tremendous asset in the area of bundled payments, where you have the facility fee and physician fee combined into one payment. That works for both the Medicare as well as the commercial side. You’re beginning to see more of the bundled payments within an ACO.

The ACO manages what we call ‘frequency’ — in other words, the number of procedures to be done. Specialists are involved in satisfaction, quality scores, and resource consumption once the decision is made that the procedure needs to be done.

We expect the specialists to be involved with quality and performance. Everybody is putting in incentive programs to help drive higher quality, better performance, and a lower cost.

HIN: Hospitals have tightened the patient discharge process as a means of shoring up care transitions. But what other work needs to be done in terms of collaborations, perhaps with skilled nursing facilities (SNFs), long-term care and home health, for example, to improve patient handoffs and reduce hospital readmissions?

(Steven Valentine): Handoffs have probably been one of the areas where we’ve seen the most disappointment or underperformance within many ACOs. They have not effectively involved the hospitalists and the care/case managers who are typically embedded within the medical group that would oversee the patient throughout the care continuum. Or if it’s a health system, emanate centralized care/case management function where they manage all of the transitions from pre-acute, acute to post-acute. We think this will get better. As the doctors are more at risk, they will get more engaged with the care/case managers to manage these transitions and handoffs.

We also know that, while not in 2014 but the trend will start, we’ll see lower acute care utilization, pushing more patients to post-acute care. This means, in any given area, acute care hospitals will begin to convert excess capacity to post-acute care services like skilled nursing, long-term care, palliative care, hospice care, home care and rehab care. You will begin to see a closer proximity. The care managers will be able to work more effectively with the doctors and hospitals to manage the patient through the continuum, smooth out these transitions and have a better patient experience with better satisfaction scores at a lower cost.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

Infographic: Dementia in the United States

January 23rd, 2014 by Jackie Lyons

In 2013, the cost of dementia for the United States was estimated at $203 billion. It is expected to increase to $1.2 trillion by 2050, according to a new infographic from

This infographic focuses on Alzheimer’s disease, which is the most common form of dementia. The facts and statistics identify prevalence, mortality rates, time and money invested in care, as well as statistics specific to California.

Statistics and Trends of Healthcare in the U.S.

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.

You may also be interested in this related resource: The Encyclopedia of Elder Care, Third Edition.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

3 2014 Trends for Health Plans

January 21st, 2014 by Jessica Fornarotto

Influencing primary care, aggregating and mining data, and embracing bundled or episode-based payments are three trends that will influence health plans in 2014, predicts Catherine Sreckovich, managing director in the healthcare practice at Navigant Consulting.

HIN interviewed Sreckovich on these trends prior to her presentation during HIN’s tenth annual webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: Where will data analytics take health plans in the coming year, and how will this shape population health management offerings?

(Catherine Sreckovich): We’re certainly hearing a lot about big data, and it will be an integral approach to merging this practice’s or population’s health, the ability to aggregate and mine data is going to be an essential capability for health plans for their predictive models. And the outputs of these models are going to enable the health plans to identify and stratify their members or population health. Member and patient demographics can also inform consumer engagement strategies to support population health. And the analytics are going to inform the effectiveness of different care management interventions and consumer engagement strategies.

HIN: Health plan case managers embedded alongside providers has become almost a de facto model. How will payors influence primary care delivery in the year to come?

(Catherine Sreckovich): There is a number of approaches evolving right now and that will continue to evolve as payors attempt to influence primary care delivery. One is the use of patient-centered medical homes (PCMHs) and other integrated models to expand the payor’s role as the primary care case manager.

In addition to paying primary care providers to hire case managers and care coordinators, payors are pushing for shared savings arrangements with these primary care providers, such as within an accountable care organization (ACO), and to push them to manage the care for those with chronic conditions.

We’re also seeing payors paying for primary care physicians to become certified PCMHs and to implement electronic health records (EHRs), either by paying directly for the certification of the technology or by adding bonus payments to their FFS rates.

Payors are also paying for incentives for primary care physicians to offer wellness programs such as smoking cessation or weight loss programs and are trying very hard to influence where and to whom primary care physicians refer their patients by giving them information about the cost and quality of other provider types, such as specialists and hospitals.

And we will continue to see that payors will target the larger primary care physician practices with whom they have a critical mass of members to achieve enough savings to offset the added costs of incentives, bonuses and shared savings arrangements. As a result, we expect that some of the smaller primary care practices will likely not receive the same level of support and push from payors.

In another example, we see payors increasingly partnering with non-traditional providers, such as retail-based clinics and community health centers to offer easily accessible primary care at lower costs. And this will certainly be an opportunity to address some of the physician supply shortages that we anticipate seeing in the next year or so as more and more people have access to healthcare insurance and coverage.

Finally, another approach payors are using is to offer members access to virtual doctor visits via webcam, for example, and other telemedicine approaches that are giving individuals access to these primary care providers to increase access to convenient and low cost primary care for their patients.

HIN: CMS and top-performing Pioneer ACOs are heavily invested in bundled or episode-based payments. Will more private payors embrace this reimbursement method as well?

(Catherine Sreckovich): Definitely. The bundled or episodic-based payment approaches are here to stay. We’re starting to see this take off in a number of states. For example, there are state innovation grants that CMS has provided to states like Arkansas, Ohio, Delaware and others looking for opportunities to implement multi-payor bundled payment initiatives. Although these are not necessarily the traditional ACO model, they built off of that ACO model.

We also see that the large health plans in various states are starting to build and develop ACOs. Key to these are the shared savings arrangements that they’re implementing with these payment approaches. So whether they’re bundled or episodic-based payments or whether they look more like a traditional ACO, if there is such a thing, we’re starting to see takeoffs on those kinds of models as payors and health plans become more creative in the development of their alternatives.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

Care vs. Case Management: 7 Structural Differences

December 12th, 2013 by Cheryl Miller

While there’s no law defining the differences between care and case managers, there are seven structural differences, says Jullie Gray, MSW, LICSW, CMC, principal of Aging Wisdom, and president of the National Association of Professional Geriatric Care Managers, NAPGCM.

Despite the differences, geriatric care and case managers ultimately face the same issues: an aging population, a dwindling supply of geriatricians, and caregivers that need help caring for their ailing family members, while at the same time honoring their “autonomy and safety,” Gray says.

Following is her assessment, based on reviews of NAPGCM’s standards of practice compared to the Case Management Society of American’s (CMSA)’s standards of practice, and various national and regional group member meetings.

To find a care manager, go to National Association of Professional Geriatric Care Managers To read an interview with Gray, click here.

Care Management

Case Management

Background of professional

Diverse – Social work, nursing, psychology, gerontology, other health related fields

Social workers and nurses primarily (with some mental health counselors)


Primarily private for profit (some nonprofits)

Agency/organization: insurance company, hospital, community mental health, etc.

Government: Medicaid program, housing authority, adult/children’s protective services, veterans’ programs, etc.


Client defines the scope of work (based on a care plan that is developed with the client’s input)

Agency defines the limits/scope of work. Typically will be managing a specific disease, issue, condition or event, and focus may be constrained by regulations, policies and funders


Holistic, client/family centered approach

Understanding underlying client/family dynamics

Advocating for client needs & the client’s maximum benefits (i.e., from an insurer)

Client/patient centered but also considers medical/legal/financial issues that can involve stakeholders

Eliminating  non-compliance and over-utilization



Can be a funding source (i.e., insurance company, entitlement, hospital, etc.)


Client pays cost (occasionally some reimbursement from long-term care insurance but this is not typical)

Agency specific funding (hospital system, insurance company, government program, for example)


Promote better quality of life, maintain independence to the extent possible, improve communication among those involved in client’s care, ensure client’s needs are met and client’s goals are achieved, provide education to client and family members

Improve health status, cost effective outcomes and efficiencies, reduce overutilization of services

New, FREE Case Management Trends Download

For additional data on care and case management trends, download the FREE executive summary: More Care Team Integration; Face-to-Face CM Encounters Edge Out Telephonic

With each year, a larger swath of the healthcare industry comes to rely upon the skills of healthcare case managers to influence clinical, quality and financial outcomes. According to the 2017 Case Management Survey by the Healthcare Intelligence Network, the percentage of healthcare organizations enlisting case managers in care management rose from 88 percent in 2013 to 94 percent in 2017. Further, patients are much more likely to encounter a case manager in a provider’s office this year than they might have been four years ago. Two-thirds of 2017 respondents embed or colocate case managers alongside care teams today, versus 54 percent in 2013.

Download this HINtelligence report today for more data on the top clinical targets of healthcare case managers; the top means of identifying and stratifying individuals for case management; and the most common locations of embedded or colocated case managers.

Meet Geriatric Care Manager Trish Colucci: ‘Jersey Girl’ Finds Passion Helping Others

November 26th, 2013 by Cheryl Miller

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success and the challenges ahead.

Trish Colucci, RN, Certified Geriatric Care Manager, Certified Gerontological Nurse, Certified Case Manager, current president of the New Jersey chapter of NAPGCM, Owner of Peace of Mind Care Management Services, LLC

HIN: Tell us a little about yourself and your credentials.:

(Trish Colucci) I have been a N.J. state Registered Nurse (RN) since 1985 and have additional certifications in gerontological nursing, case management, and life care planning. Currently, I am the president of the N.J. chapter of the National Association of Professional Geriatric Care Managers (NAPGCM). Prior to that I served two years as treasurer and two years as vice president.

What was your first job out of college and how did you get into case management?

When I graduated, I started working as a floor nurse at a local hospital. Although I always saw myself in pediatrics, there were no positions available at the time, so instead I accepted a position on the orthopedic floor. It was serendipitous! In that unit, I developed a love for working with elderly folks. I was later offered a shift in career to insurance case management, at the time when that field of nursing was brand new. In that position, I developed valuable organizational skills and clinical knowledge that helped me coordinate care for our catastrophically ill or injured claimants and to ensure that they received the best medical care possible.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

Years later, I gave birth to my son who has Down Syndrome, and who had a lot of special medical needs. I was able to utilize my case management skills (which were now second nature) to coordinate a team of top-notch doctors who addressed Michael’s multitude of medical problems and worked together, with my management. It was after that that I noticed friends coming to me to ask advice for coordinating care for their own loved ones. It helped me realize how valuable my case management skills were and how they could be helpful to others trying to navigate the confusing worlds of medical care and insurance.

In brief, describe your organization.

Peace of Mind Care Management Services, LLC is a care management firm that assists families, guardians and caregivers with the management of their loved one’s personal and medical care. We specialize in crisis management, often finding families confused and overwhelmed by their responsibilities in an arena with which they are not familiar. As care managers, we assess the situation and create a specialized plan of care that addresses the needs of the client within the available budget. We offer support, resources and guidance so that families feel more comfortable and informed in making important decisions for the care of their loved one.

Serving as president of the New Jersey chapter of the NAPGCM has opened my eyes to opportunities for care managers on both the local and national levels. Although the field of geriatric care management has been around for over 25 years, it is not well known by the general public. Our chapter’s main focus over the past year has been on developing a solid, working public relations committee, and to make, “geriatric care management” a household word and the first point of contact for families who need help with their loved one.

What are two important concepts or rules that you follow in care management?

  • The most important concept in care management is a trusting relationship. Our clients need to know that as care managers we provide honest, caring advice that is in their (or their loved one’s) best interests. We are not financially connected to any resource we may offer to a family, and this keeps our advice objective and trustworthy. We refer to resources we would use for our own family members and this provides an extra level of trust with our clients.
  • Compassion is another important concept. At Peace of Mind, each client is as precious as the next, coming to us with his or her own history and special needs. We reach out to our clients and their caregivers with compassion and empathy, developing an understanding about where they’re coming from so we can tailor our guidance in a way that makes them the most comfortable.

What is the most satisfying thing about being a care manager?

What I derive the most satisfaction from is the look on the face of a client or caregiver we’ve helped. Seeing on their faces the signs of relief…of tensions easing…because they got the help they needed to care for their loved one, provides me, as the care manager, the signs that I’ve done a good job for the family. Even in situations where clients are in the process of dying, knowing that I have coordinated their care such that they will leave this world feeling comfortable and loved, makes me feel good about the work I do.

What is the greatest challenge of care management and how are you working to overcome the challenge?

What I love about being a geriatric care manager is the diversity of duties, however that’s one of the things that makes this job such a challenge! Each day brings forth some new challenge, and my schedule can change hour-to-hour. It helps to be flexible! I am fortunate to have a strong, warm and wonderful care management team made up of nurses and social workers. When we are faced with tight situations, we reach out to one another for assistance and support. Whether it’s a race against time to get medical equipment in the home before a client comes home from the hospital, or a family member who needs extra hand-holding and reassurance on a particular day, or an unexpected emergency with a client that needs immediate attention, we are ready to act.

Where did you grow up?

I grew up in Denville, N.J. and am the eldest of three girls. I am a “Jersey Girl” through and through. My dad was a police officer and my mom was a bank teller. Sounds like the makings of a good Bruce Springsteen song, doesn’t it?

Click here to learn how you can be featured in one of our Case Manager Profiles.

Kaiser Permanente Population Health Management: Team Approach, One Member at a Time

August 8th, 2013 by Patricia Donovan

Kaiser Permanente population health management

It takes a team to manage the health of Kaiser Permanente’s 9 million members. And like all winning teams, Kaiser’s has a mantra: total panel ownership.

That motto describes a transition within the integrated healthcare delivery system that occurred about ten years ago: when doctors shifted from being accountable solely for the patients presenting for care on a particular day in their clinic setting to being accountable for all patients in their panel, explains Jim Burrows, Ph.D., senior director of evaluation and analytics for Kaiser Permanente.

This quest for total panel ownership is achievable with a focus on three key areas: people, systems and technology, he says. Burrows shared highlights from these areas during a recent webinar on Managing Population Health with Integrated Registries and Effective Patient Touchpoints.

At the outset, Kaiser eschewed a condition-specific approach in favor of developing robust infrastructure that could support management of all conditions. At the heart is an integrated regional outreach system that tracks patients’ clinical touchpoints as they move through the system via an outpatient visit or a call to a nurse advice line.

In Kaiser Permanente’s “Proactive Care” approach, even specialists are part of its population health management approach: presenting at a dermatology appointment, a patient might be reminded of an overdue colonoscopy.

“The specialists themselves can view themselves as managers of populations and not only as physician specialists for whom individual patients are consulted,” notes Burrows.

At the primary care level, there’s an integrated panel management assistant who interacts with the physician and performs pre- and post-visit tasks so patients get the most from their visits.

Technology provides a backbone for Kaiser’s proactive care: its EPIC® EHR provides evidence-based support; its patient portal an opportunity to review past visits and perform a myriad of tasks; its proprietary integrated registry tool the identification of care gaps for all members and specific patient recommendations.

With Kaiser’s health registries in high demand within the organization, how does the health plan determine which ones to develop? “It comes down to a Triple Aim assessment where we think we can do the best job of improving health, improving care and improving the affordability of our system,” answers Burrows.

Kaiser Permanente has achieved excellent results in public reporting: the plan leads the five-star space, notes Burrows, with ninety percent of Americans in five-star Medicare Advantage plans belonging to a Kaiser plan. It can also boast of having the most HEDIS® measures in which it’s the number one health plan not in the local market area, but in the country.

Click here for an audio interview with Jim Burrows in which he discusses Kaiser’s registry use in more detail.