Posts Tagged ‘Triple Aim’

Infographic: Connecting the Triple Aim and Supply Chain Management

August 17th, 2016 by Melanie Matthews

Supply chain processes that support caregivers as well as the products that are selected and sourced directly and indirectly impact patient safety and patient satisfaction, according to a new infographic by the Association for Healthcare Resource and Materials Management.

The infographic examines how supply chain management aligns with the Institute of Healthcare Improvement’s Triple Aim.

Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower CostsWritten by the President and CEO of the Institute for Healthcare Improvement (IHI) and a leading healthcare journalist, this groundbreaking book examines how leading organizations in the United States are pursuing the “Triple Aim”: improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care.

Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs shares compelling stories that are emerging in locations ranging from Pittsburgh to Seattle, from Boston to Oakland, focused on topics including improving quality and lowering costs in primary care; setting challenging goals to control chronic disease with notable outcomes; leveraging employer buying power to improve quality, reduce waste, and drive down cost; paying for care under an innovative contract that compensates for quality rather than quantity; and much more. The authors describe these innovations in detail, and show the way toward a healthcare system for the nation that improves the experience and quality of care while at the same time controlling costs.

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AltaMed Constructs Business Case for Care Coordination Team

May 19th, 2015 by Patricia Donovan

The AltaMed multidisciplinary care team targets dual eligibles with multiple chronic conditions and functional and cognitive impairments.

When the largest FQHC in the country set out to quantify the contributions of its multidisciplinary care team, it found the concept didn’t fit neatly into return on investment models.

So at budget time this year, leaders of AltaMed Health Services Corporation’s care coordination model for its highest risk patients identified seven performance metrics to present to its CFO, explained Shameka Coles, AltaMed’s associate vice president of medical management, during A Comprehensive Care Management Model: Care Coordination for Complex Patients, a May 2015 webinar now available for replay.

The evidence that ultimately secured funding for the care coordination project’s next phase included the model’s impact on specialty costs, emergency room visits, and HEDIS® measures, among other factors.

These were all areas examined early on, back in phase one, when the care coordination team set a number of strategic goals that aligned with the corporation’s five pillars: service, quality, people, community and finance.

Rolled out in four phases beginning in July 2014, the model is aimed at AltaMed’s dually eligible population— Medicare-Medicaid beneficiaries with high utilization, multiple chronic conditions, and multiple functional and cognitive impairments, Ms. Coles explained.

Phase one of the project was devoted to understanding and engaging the duals population via telephonic and print outreach, then developing a care management model reflecting both Triple Aim and patient-centered medical home goals. (The 23-site multi-specialty physician organization in Southern California has earned Joint Commission primary care medical home designation.)

At the heart of the model is a multidisciplinary care team, which counts a care coordinator, clinic patient navigator and care transitions coach among its eleven roles. Patients are stratified as high, moderate or low risk and matched to risk-appropriate interventions.

“Each member is activated based on where the patient is at in the continuum of care,” noted Ms. Coles, who also reviewed team member roles and responsibilities and a host of complementary programs supporting care coordination during the May 2015 program sponsored by the Healthcare Intelligence Network.

In phase two, focused on development of end-to-end workflows, staff assessments and ratios, and team training, AltaMed hired an educator, fleshed out the patient navigator role, and examined integration of behavioral health and long-term services and supports (LTSS).

Phase three triggered a deeper dive into case manager caseloads and utilization patterns as well as several quality improvement activities.

Now in phase four, the goal of AltaMed’s care coordination model is to ensure it can reflect a financial impact. “We’ll look very closely at our per member per month cost and our inpatient metrics,” Ms. Coles concluded.

Infographic: HIMSS Leadership Survey Results

April 20th, 2015 by Melanie Matthews

Healthcare IT is helping organizations achieve Triple Aim goals for improving the health experience, according to the HIMSS Annual Leadership Survey released this week.

The survey also revealed that a clear majority of organizations expect consumer and patient considerations, such as patient engagement, satisfaction and quality of care to have a major impact on their organization’s strategic efforts over the next two years. Survey highlights have been captured in a new HIMSS infographic.

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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Making a Case for Embedded Case Management: 13 Factors Driving Onsite Care Coordination

April 16th, 2015 by Patricia Donovan

Compliance with Triple Aim goals, participation in CMS pilots to advance value-based care, formation of multidisciplinary teams and avoidance of CMS hospital readmissions penalties are among the factors driving placement of case managers at care points, according to HIN’s 2014 healthcare benchmarks survey on embedded case management.

Participation in the Medicare Physician Group Practice Demonstration, the Comprehensive Primary Care Initiative, and the Multi-Payer Advanced Primary Care Practice demonstration has prompted a number of the survey’s 125 respondents to embed case managers in primary care practices, hospital admissions and discharge departments and emergency rooms, among other sites.

To help organizations make the case for embedded case management, here are nine more program drivers, in respondents’ own words:

  • “Face-to-face contact with complex patients and their family to build trust and relationships, working directly with providers and staff.”
  • “Five to 8 percent of patients account for 40 to 60 percent of costs. It is logical. Second, ED visits and discharges represent at-risk patients where interventions can make a difference. Third, focus needs to be placed on fostering better screening results. Effort to reduce utilization.”
  • “Pursuing medical home model and team-based care, along with continuum care coordination.”
  • “Integration work between medical and behavioral healthcare.”
  • “Employer, health system, and payor collaboration to provide population health management in a medical home-like model. Also working on reducing readmissions for high-cost, high-risk conditions such as heart failure, and hospital wanted to develop an ambulatory component to reduce readmissions and improve patients’ quality of life and satisfaction.”
  • “Increased care fragmentation related to transitions in care, challenges in utilization between military and civilian network access-to-care, increased need for complex care coordination, etc.”
  • “We felt we needed to ensure the case managers were considered a part of the patient-centered medical home (PCMH) team.”
  • “Research shows [case managers] embedded at the point of care caring for the whole person in all healthcare environments produces better outcomes.”
  • “As a rural hospital, it made sense to make the best use of resources.”

Source: 2014 Healthcare Benchmarks: Embedded Case Management

2014 Healthcare Benchmarks: Embedded Case Management provides actionable data from 125 healthcare organizations leveraging embedded or co-located case management to improve healthcare quality, outcomes and spend—including those applying a hybrid embedded case management approach.

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

High-Risk Patient Roster Helps Atrius Pioneer ACO ‘Beat the Benchmark’

May 17th, 2013 by Patricia Donovan

Webinar Replay: Lessons from Atrius Health Pioneer ACO

They don’t call them pioneers for nothing.

A high-risk patient roster, a retooled geriatric care model and a preferred SNF network are just a few Atrius Health innovations on the healthcare frontier.

Atrius Health is one of 32 participants in the CMS Pioneer ACO program testing alternative payment and program design models for accountable care organizations. Emily Brower, Atrius Health executive director of accountable care programs, shared first-year lessons during a recent webinar, Medicare Pioneer ACO: Case Study on Atrius Health’s Focus on the Triple Aim.

Atrius was drawn to the three-year Pioneer ACO program for a number of reasons. First, it offered the non-profit alliance of six independent medical groups a chance to showcase its core competencies, including its rich data environment, foundation in the patient-centered medical home (PCMH) model and new home care services, Ms. Brower said.

Also, it gave the Massachusetts organization a chance to build a population-based approach to managing its Medicare population as a whole, with Triple Aim goals as a foundation.

And finally, they had a lot of faith in the staff of the CMS Center for Medicare/Medicaid Innovation, where the project resides. “We feel they really understand the issues we face in being accountable for care across the continuum,” noted Ms. Brower.

The Pioneer ACO shared savings and loss model challenges participants to perform against nationally identified trends. CMS take a participating ACO’s population and creates from the national Medicare database a reference population, she explained. “We’re trying to beat the trend in that national population, or ‘beat the benchmark.'”

In 2012, Atrius launched six clinical and technical initiatives to address the program’s 33 quality measures — “the gate through which the ACO achieves savings.” Key among them is its eight-step high-risk patient roster review, a hallmark of Atrius’s redesigned geriatric care model.

“We used a new risk stratification tool to identify our high-risk patients, who go on a roster reviewed by a multidisciplinary team in the primary care practice to identify care gaps, including a need for advance directives.” One outcome of the roster’s use has been an increase in end-of-life conversations, she says.

On the technical support side, Atrius Health developed new tools within its EPIC® electronic health record (EHR) for tracking quality efforts, advanced care planning, medication reconciliation and other key metrics.

Ms. Brower estimates the total investment to launch the ACO, including the EHR, quality measurement tools and other efforts, to be between $2 and $3 million; the medical groups themselves likely spent that much again for additional care management resources.

“In terms of payback, we expect that we will be able to reduce the cost of care — to bend the cost curve so that we are beating the benchmark and creating savings that then support our additional investments.”

Among programs on the drawing board: new ways to use the geriatric well visit, a home-based primary care program for high-risk patients, two programs for dual eligibles, and a patient advisory group.

Atrius Health is committed to the Pioneer ACO program, despite concerns from some participants over the program’s quality measurement process communicated to CMS last month. “We know it’s going to take time. As we would say, ‘We’re not called pioneers for nothing.’ It took us that first year to identify develop most of the tools and infrastructure that CMS needed.”

She continues: “The new measures that I mentioned that are coming out of the EHR being reported directly to CMS — that piece that we had to put together. There just wasn’t an existing pool of data to build benchmarks for those measures. Now that we have data, CMS will use this to create empirical benchmarks, which was one of the recommendations in that Pioneers communication.”

Listen to an audio interview with Atrius Health’s Emily Brower.

Infographic: Patient Data Flow in an ACO

March 19th, 2013 by Patricia Donovan

As more health systems and hospitals fully modernize, utilizing electronic health records, health information exchanges, and other digitally captured patient data — the triple aim of accountable care — transitions from a remote ideal to a reality. Health IT capabilities continue to roll out across the United States, but at different levels of readiness and utilization.

This original infographic from Healthcare IT Connect examines the flow of patient data in an accountable care model as it begins in a doctor-patient setting and moves across different settings with a variety of goals. The ultimate aim is simple, to improve the patient experience, boost wellness outcomes, and save on healthcare spending.

ACO patient data flow

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You may also be interested in this related resource: Guide to Accountable Care Organizations.