Tag Archives: Care Management

Weathering Change and the Promise of Digital Transformation in Healthcare


Post by Neal Singh


Chief Executive Officer, Caradigm

Providers are among those most impacted by the turbulence in today’s healthcare landscape – whether it be adding facilities, covering more patients, changing leadership, providing additional services, or entering new value-based programs such as MACRA, Bundled Payments, or DSRIP. The “Quadruple Aim” was put forward to address the experience of providers in delivering care that is increasingly tied to cost and quality metrics. The so-called, second wave (post-EHR) of digital technology might be their greatest hope as providers manage this massive transformation to new value-based care and reimbursement models.

With clinicians supporting new populations, managing multiple data sources, and being tasked with additional processes, the burden of administrative tasks should be eased through the availability of resources that drive efficiency and enable a community-oriented, risk-based care approach. Paradoxically, it seems the introduction of new technology and processes can often be an added weight for clinicians to learn and adapt to. As we continue down the path of digital transformation, these tools should evolve to smoothly integrate into workflows and yield quick, measurable benefits for teams.

So how do organizations scale activities and enable their teams to deliver care more efficiently and consistently throughout this period of rapid change?

Weather the Uncertain Regulatory Environment

While lawmakers continue to battle it out we should face one fact: value-based care is here to stay.  Providers should push forward with a “no regrets” strategy. Prioritize efforts to drive more consistent, efficient and coordinated care, integrate your IT systems to support accurately forecasting patient risk, lowering cost structures, and building deeper relationships and loyalty with patients. Providers should not miss out this is an incredible time of innovation in healthcare that I believe is going to accelerate even more as healthcare organizations build off their early successes and learnings. With uncertainty in legislative direction for healthcare (ACA, Value Based Payment Reforms, etc.), providers may feel uncertain about their IT buying decisions. Rather than feel uncertain, I suggest providers should continue moving forward, with a keen focus on flexible and extensible solutions to support any outcome of legislative direction.

Quick Time to Value with an Eye for the End Game

Healthcare organizations need strong capabilities to aggregate data from across the community to connect all clinicians responsible for a targeted population. Providers should demand short implementations to ensure rapid time to value. Beyond this, seeking a flexible and configurable solution “future proofs” the organization to accommodate new programs that may be launched. This “future proofing” will provide organizational agility to rapidly configure to meet continuously evolving payment reforms and legal requirements. Selecting a population health tool should include an evaluation of the vendor’s ability to meet organizations where they are and grow with them across programs, such as Medicare Shared Savings Program, Comprehensive Primary Care Plus, Bundled Payments, etc.

Intelligent Analytics and Sophisticated Tools

Finding tailored software applications that enable clinicians to streamline workflows will drive positive results throughout your organization and help achieve scalability. Tools that facilitate targeted care management activities for prioritized patients will support care team efficiency. Interoperability is especially key in the case of mergers and acquisitions, considering the critical need to bring together data from potentially dozens of systems. Sophisticated risk stratification tools that consider clinical and claims data, financial information, social determinants, behavioral factors, and that employ predictive analytics will further help organizations determine where to focus constrained resources to achieve the highest return and greatest impact on patient outcomes. These are all factors to consider when searching for the right IT solutions to support your organization’s growth and goals, while advancing the health of the population.

Application Integration into Clinical Workflows –  They Can Only Use It if They Can Find It

While many providers recognize the value of using data and analytics to improve the quality of care and lower costs, there are many that have not yet integrated these directly into clinical workflows to realize the greatest impact and efficiency. This integration is especially important for accountable care organizations (ACOs) and clinically integrated networks (CINs). Timely access to data is critical when you are responsible for the health of a population of patients who may be geographically dispersed and receiving care from several hospitals or specialists. IT solutions should be leveraged to surface gaps in care, risk scores, and full medication histories so that a clinician can make educated care decisions while in the presence of the patient.

Value-based care initiatives should be addressed as a series of interconnected activities rather than as distinct, siloed efforts. A successful strategy takes a team-based approach and engages staff across different facilities to focus not only on individual patients with individual diagnoses, but also the health and wellness of the community. IT solutions need to create a unified user experience to support the interconnectedness that plays an integral role in an organization’s evolving strategy. ACOs and CINs should integrate an enterprise solutions portfolio encompassing the capabilities critical to success in value-based care programs, including: data control, healthcare analytics, and care coordination and engagement. Providers should also partner with vendors that have deep industry experience to provide advisory services. The pace of change in our industry continues to accelerate, and no organization should feel they are navigating these waters alone.

The CMS and NAACOS results are in… What they are really telling us…


Post by Cindy Friend, RN, BSN, MSN, MBA/HCA


Vice President of Clinical Population Health Solutions & Transformation

Earlier this month, the Centers for Medicare and Medicaid Services (CMS)  released the 2016 shared savings results for the Pioneer and Next Generation (Next Gen) accountable care organizations (ACOs).  In addition, the National Association of ACOs (NAACOS) released the findings of its annual survey.  The results give us hope that this whole “let’s work together to make it better” attitude might just actually work, but we must evaluate the findings a little deeper to better understand correlations between the results and where ACOs need to focus to be successful in value-based risk arrangements.

While CMS did not post the quality results for the Next Gen program participants, it is likely that a few did not have good insight to their financial performance as they must share in losses.  CMS did publish the overall quality score for the Pioneer program participants.  Most notably, a couple of Pioneer ACOs that did not receive shared savings had outperformed many of their counterparts in quality.  As a case in point, Partners Healthcare ranked 3rd with an overall quality score of 94.51% and while it appears that they did not generate losses, they may not have met the minimum savings rate (MSR) required to share in savings.  Michigan Pioneer, on the other hand, had the lowest overall quality score, though still commendable, at 88.93% and achieved a shared savings of almost $7.5M!  These are impressive results and give optimism to others that are on the cusp.  An interesting statement from the introduction of the NAACOS survey:

“Overall, we found that a large number of ACOs are currently considering or have firm plans to participate in future risk-based contracts (47 percent planning for shared savings/shared risk and 38 percent planning for capitation), although care management strategies are largely unchanged. This and the data below suggest that ACOs are slowly becoming willing to accept increased financial risk, but they are largely still learning how to actually manage populations.”

Many organizations spend years focused on building governance, engaging physicians, and talking about what to do – what they fail to or wait too long to focus on are the key items for which they will be measured.  I understand that gaining buy-in and establishing governance are important when you’re first putting an ACO together, but the CMS shared savings results illustrate why ACOs must focus on two additional core tenets to help drive their success – analytics and improved care management strategies.  A few tips to help you advance your analytics and care management efforts are outlined below.

  • KNOW YOUR NUMBERS
    Successful ACOs have acquired and adopted some sort of analytics technology, but those that are most successful identify IT systems that are able to provide insight across three domains: 1) population risk, 2) quality measure, and 3) cost. ACOs must evaluate their current data analytics capabilities, identify any gaps, and determine the best approach to resolving these gaps.  In some instances, an organization may choose to implement a new enterprise platform; in others, it may be most efficient to integrate a solution to fill the need.  Regardless of the system architecture approach, for a complete view of the population’s health an organization must have the following analytic capabilities:

    • Risk stratification – This type of system will integrate an industry-accepted risk adjustment scoring methodology that will stratify the entire population, while also providing additional data points for analysis. Ideally, the system allows the user to electronically assign these patients to care management for intervention.
    • Clinical quality measures – A clinical quality measures system will provide insight to performance at the quality program level (e.g., HEDIS, CPC+, MIPS, etc.). The system must allow drill down through the measure into the practice, to the provider, and to the patient level.  As patients with gaps in care or measure compliance issues are identified, the system should allow the patient to be electronically transitioned into care management.
    • Financial and utilization insights – These systems provide analytic views of integrated clinical and claims data to reveal, in real time, utilization patterns across populations, care settings, networks, and payers. Systems that can track and trend utilization and cost information, including drill down to the per member per month, is key.  As with the other systems above, the user should be able to electronically forward patients directly  into a care management system.

The capabilities of population health analytics tools have grown significantly over the past several years.  ACOs and other clinically integrated networks, as well, have a tremendous opportunity to position themselves for success by securing the tools and systems that will equip them with the information and insights needed to manage their patient population.  Failure to leverage the power of a complete view (including cost and quality data) analytics platform will have a detrimental impact on an ACO in a risk-based arrangement because they may succeed in quality but not have visibility to their costs and vice versa.

  • SUPPORT CARE MANAGEMENT
    Organizations that are thinking ahead will select an analytics system that enables users to electronically send patients identified for care management during the analytics process directly to a care management system. ACOs must have the proper tools to support care management activities to effectively manage and measure performance and drive patient outcomes.  ACOs need to carefully evaluate and select a system that can support workflows and processes across the care management paradigm including:

    • Care management – The system must provide the clinician with a holistic view of the patient’s health information including, though not limited to: past medical history, problems, medications, allergies, vitals, personalized goals, etc. The system needs to allow the care team to efficiently document care management activities such as conducting assessments, performing medication reviews, developing care plans, etc.
    • Care coordination – The care management system should allow the clinician to track tasks and follow-ups (e.g., consult notes, patient call, etc.). The system should permit the care team to coordinate care amongst themselves, as well, such as assigning a task like a nutrition or social work consult, for example.  In addition, the care manager can electronically transmit a summary of care documents to another provider that is involved in the patient’s care.
    • Care transitions – The system should alert to the care manager regarding a change in care setting (i.e., ADT feed), and automatically create a task for the care manager to follow-up and support the patient in receiving the right care, at the right time, in the right location.

Organizations that opt to adopt care management technology tools will feel the effects in operational efficiency, team job satisfaction, and quality results.  It is practically impossible to manage the vast, complex, and diverse healthcare needs of a population without technology.

The NAACOS survey results express that many organizations that have not started any risk arrangements are very uncertain and feel as though it will be an average of three years before they are ready.  This uncertainty is likely spawned from the unknown but just remember while uncertainty is expected, avoidance is not an option – ultimately, it’s the right thing to do to improve quality outcomes and address unsustainable costs.  Those making a move today have it a little better than their predecessors with the advancement of population health technology for analytics and care management.  With these advanced tools, organizations are better equipped to take on the risk because they have a deeper insight to their population with the ability to identify and act on those patients who will benefit most from care management intervention.

 

On a final note, as a nurse, I couldn’t be more delighted as I read the section in the NAACOS piece about the value that the care manager role brings to improving healthcare.  It’s been years in the waiting as nurses have always held education, prevention, and wellness as core to our practice – and the recognition is heartfelt for all nurses.  While we have probably only begun to scratch the surface on improving our industry, it makes me proud to be a part of the transformation.

 

References:

Becker’s Hospital Review.  2017.  How the Pioneer ACOs stacked up on shared savings, quality in 2016https://www.beckershospitalreview.com/accountable-care-organizations/how-the-pioneer-acos-stacked-up-on-shared-savings-quality-in-2016.html

Becker’s Hospital Review.  2017.  How the Next Generation ACOs compared on shared savings in 2016https://www.beckershospitalreview.com/accountable-care-organizations/how-the-next-generation-acos-compared-on-shared-savings-in-2016.html

Health Affairs Blog.  2017.  The 2017 ACO Survey: What Do Current Trends Tell Us About The Future Of Accountable Care?  http://healthaffairs.org/blog/2017/10/04/the-2017-aco-survey-what-do-current-trends-tell-us-about-the-future-of-accountable-care/

https://www.naacos.com/press-release-national-association-of-acos-and-leavitt-partners-release-2017-annual-aco-survey-results

 

Embedding Evidence-Based Medicine into Transitions of Care


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

Population health is a journey over time and provider organizations understand they must begin with the most impactful programs. Providers have to prioritize and focus initial efforts to quickly bend the needle on patient outcomes such as reducing readmissions. When organizations ask me where others are seeing tangible initial success, I often tell the following story.

An outpatient care manager at one of Caradigm’s existing customers shared with me that the value of population health technology became clear for her after getting a real-time alert one day that one of her patients was in the ED. She called the ED and was told that the patient’s blood glucose levels were extremely high, and the ED nurse thought the patient should be admitted. However, the care manager informed the nurse that the patient’s numbers were actually the patient’s baseline, and recommended that the patient did not have to be admitted, which saved an unnecessary admission. The outpatient care manager was able to devise and implement an effective plan of care to address a variety of contributing barriers to care, and the patient outcome was improved.

This story is about taking the right action, in the right time frame, in the right care setting. In other words, how do you embed best practices into workflows to reduce variation in care? How do you help patients move through a confusing and disjointed healthcare system that can be overwhelming to navigate? Transitions of care is an area central to population health that for many organizations is an excellent place to focus your population health efforts. The following are a few best practices to think about as you develop your strategy.

Facilitate access to primary care

Coordinated care is a proven value for high-risk patients, however, it is often a challenge for patients to access primary care soon after being discharged. Some organizations have found it effective to enroll high-risk patients into a Patient Centered Medical Home (PCMH) as a standard practice to get them better connected to primary care, a care coordinator and other community resources. Another approach is to partner closely with primary care clinics and even embed a care manager, a transition focused mid-level practitioner or social worker into the clinic to specifically serve high risk transitions patients. Even offering telephonic transitions of care support to coordinate scheduling for patient can help.

Standardize interdisciplinary care

When multiple levels of clinicians partner effectively with defined pathways and shared information, it’s amazing to see the impact. For example, psychiatrists and social workers going to a PCP’s office to speak to patients. Pharmacists calling physicians to say a prescription ordered is far more expensive than other options. Home health that directs patients back to lower acuity centers if needed, and works with patients to prevent unnecessary ED stays. Some provider organizations have had success identifying non-employed physicians interested in adding home visits as an additional revenue opportunity. Population health is truly a team sport and technology can help support transparency and care traffic control, making patients more confident in a team based delivery model.

Embed practices into workflows

After establishing your care protocols and pathways, care management tools can help ensure they’re followed consistently. Intelligent plans of care can have pathways embedded in the patient care plan, assuring that steps aren’t missed. Role-based tasking can help a team of clinicians take the right steps, in the right sequence, all while working at top-of-license. As mentioned in the story earlier, alerts can let the appropriate care team member know when a patient has a change in status, whether an ED visit, observation stay or inpatient admission. Lastly, as it is common for patients to be managed in multiple EMRs, technology can play a big role in streamlining medication review and in overall information sharing by aggregating data from multiple EMRs. Performing standardized readmissions assessments can help determine root cause, support an automated plan of care to mitigate barriers and perhaps even identify patterns or discharge practices of care that require change.

Improving transitions of care, supports long term success in advancing quality, patient experience of care as well as managing the cost of care. Organizations should be thinking about strategies for scaling, risk stratification, solving for social determinants and reducing variations in care. Wherever your organization is today, if you focus on meeting patients where they’re at and guiding them through what is a complex healthcare system, you will have succeeded in a foundational strategy for long term success.

How Bundled Payments is Driving Care Transformation and Patient Engagement


Post by David Lee


Product Marketing Manager, Caradigm

Bundled payments was one of the most discussed topics at the recent Caradigm Customer Summit, our annual gathering of industry leaders to share best practices in population health and information security. Matt Stevens, Senior Director with The Advisory Board highlighted bundled payments in his presentation as a program that CMS believes will push the needle in reducing cost variability while improving outcomes for high volumes of patients. He said more mandatory bundles (e.g. cardiac, expansion of Comprehensive Care for Joint Replacement) could be coming and that the intersection between bundled payments and MACRA is only likely to grow as it could become tied to the Advanced Alternative Payment Model (APM) track in the future. Matt recommended that hospital systems prepare to deliver both a broad clinically integrated network as well as excellence in individual bundles that can be decoupled and offered to patients in ways that offers them greater value.

We also heard a number of provider organizations (St. Luke’s University Health Network, United Surgical Partners International, Genesis HealthCare and Greenville Health System) explain why bundled payments is one of the most important pieces of their overall value-based strategy. The bundled payment program drives operational learning and experimentation so that expertise and care process improvements can be built, which then trickles down to other parts of the organization and to multiple populations of patients (e.g. Medicare, commercial populations). As that expertise grows, workflows improve and patient quality metrics improve (e.g. reduced readmissions, lower utilization), Our customers said this helped them gain confidence to scale their programs and also engage in additional value-based initiatives.

Another key aspect of bundled payments discussed was that it pushes providers to develop a high-touch patient engagement model. We heard from everyone that developing patient relationships is not easy, and that they take time. Not only is it a major change for patients to communicate more frequently with providers, the conversations are also different. For example, providers are now discussing with patients why it could be beneficial in certain situations to recover in their own homes rather than stay in a skilled nursing facility. We also heard one customer say that patients often hang up on them during a follow-up call thinking it’s a solicitation call. In this shifting dynamic, providers are trying to establish the groundwork for deeper patient relationships earlier in the care process so they can set the right expectations ahead of time.

Overall, it was exciting to hear that the bundled payments program is having a meaningful impact on patient outcomes and is helping organizations achieve financial success in value-based initiatives. We heard throughout the Caradigm Customer Summit that population health is where healthcare has to go to improve the health of the highest-risk patients. Bundled payments is a key program that will help healthcare providers advance down the path to population health. If you’d like to learn more about how Caradigm is supporting bundled payment initiatives through its enterprise care coordination software, then please send us a note here.

Filling The Care Management Tool Box


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

As I talk to many providers across the country about how to transform to value-based care, the conversation inevitably turns to the need for care coordination and care management. With many Centers for Medicare and Medicaid Services (CMS) initiatives including the recently announced Comprehensive Primary Care Plus program emphasizing the need for better care coordination, many providers have concluded that they need to evolve how they deliver care for high risk or at risk patients. This is both exciting and a little bit scary. The hard part is figuring out the right way to go about it given that there is no single blueprint that works for all providers.

One of the best written articles on care coordination that I’ve seen was this one written by Patti Oliver, RN, BSN and Susan Bacheller, BA.[1] I could not agree more with Oliver and Bacheller when they say there is a growing movement toward greater care coordination, as more health systems realize there are better ways to deliver care:

“From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults”

Oliver and Bacheller then explored the essential functionality that care coordination software should deliver naming the following five features:

  1. Care coordination tools should be tailored to your patient population.
  2. Care coordination tools should have a single place the care coordinator can visit to get the full picture at the panel and patient levels.
  3. Care coordination tools must allow for convenient use of clinical pathways and be flexible for the care coordinator.
  4. Care coordination tools need to have strong communication features among providers to facilitate care hand-offs and to involve family/caregivers when appropriate.
  5. Care coordination tools should integrate with other systems—or at least be straightforward about their ability to do so.

These five items are solid foundational features to seek when it comes to care coordination and care management tools. Having worked closely with providers to identify their requirements for success in coordinating care across the continuum, I would also respectfully highlight a few other key areas.

Workflow automation – as most organizations are looking to scale their population health initiatives, one of the biggest challenges is how to manage large populations given constrained resources. One of the key components to look for in software is the ability to automate time-consuming manual workflows so that the care team can work more efficiently and also at top-of-license. Care management software should be able to auto-generate care plans and assign tasks based on patient answers to assessments.

Evidence-based guidelines – While flexible clinical pathways are important, so is the need to ensure consistency of care. This is especially true for more complex, co-morbid patients who often require care from a larger care team. Care management solutions should help reduce variation of care by embedding evidenced-based guidelines directly into care workflows to guide action. Tools should also be able to help identify best practices so that they can be shared throughout the care team.

Support for multiple programs – Care management technology requirements vary by program. For example, in the CMS Chronic Care Management program, providers must be able to track and report on time spent per month on core care management processes. For the Bundled Payments For Care Improvement (BPCI) program, providers need to be able to transition and track patients to post-acute care. Look for flexible care management solutions designed to support multiple programs so that you can maximize your return on investment.

As Oliver and Bacheller noted in their article, many new technology solutions for care managers are starting to appear. It can certainly be confusing given the broad range of features and different classes available (i.e. enterprise to basic). Ultimately, identifying the right solution will depend on your organization’s specific goals and the scope of what you are trying to achieve with population health. I look forward to having more conversations with providers this year about how they want to transform care.

 

 

[1] Patti Oliver, RN, BSN; and Susan Bacheller, BA. ACOs: What Every Care Coordinator Needs in Their Tool Box. American Journal of Managed Care. 9.24.15.

 

Time to Value in Population Health


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

The stakes are high when it comes to population health as improved patient outcomes and long-term financial success are on the table. By now, most providers recognize the need to evolve. They must participate in new value-based programs, collaborate with other providers, and tailor workflows to support the changes. Implementing these changes is not easy! It takes significant amounts of time and resources from across the organization. When it comes to acquiring health IT tools to support population health, it often takes providers 9-12 months to evaluate the myriad of available solutions. I don’t blame providers for wanting immediate results after spending so much time investigating population health tools.

One of the key reasons why Caradigm formed its Care Transformation Team is to help customers achieve fast time to value following the acquisition of solutions. Our team serves as a sounding board for our customers who are making the shift to value-based care. We find that some organizations have been engaging in population health initiatives for years and are more mature in their processes while others can benefit from additional support. We tailor our approach to each customer’s strategic vision because it’s not one size fits all. The uniqueness of each organization has to be respected as we seek to identify common best practices and turn them into consistent processes.

I believe that all organizations should seek quick wins soon after acquiring population health technology. They are critical to building positive momentum for workflow transformation. The following are a few suggestions to consider when trying to achieve fast time to value in population health.

Plan early to achieve early success – establishing metrics and what quick wins look like prior to technology implementation provides a huge leg up in achieving them. Our team often collaborates with providers before contract signing to help clarify goals and expectations, and then align technology to them.

Define top value propositions – in addition to meeting specific metrics, population health tools can also deliver other types of value to end user clinicians. For example, the reduction of inefficiency or frustrating pain points for clinicians brings tremendous value to organizations and can be realized immediately. It’s important to document what the pain points and value propositions are in order to recognize that value.

Consider starting with care management – care management tools offer one of the quickest paths to value in population health because they can help remove numerous workflow inefficiencies that are impeding providers today. These can be items like having to hunt for data from multiple sources, having to manually generate care plans, or even being unaware when a patient is admitted to the ED. Care management solutions also give providers flexibility in where to start as they can begin by improving how they manage patients in a particular program, by disease category, or by focusing on a particular area of care management such as improving transitions of care.

While the road to population health can be long, organizations can achieve significant victories along the way. In fact, achieving those smaller wins should be celebrated as care transformation takes many small steps in the right direction. If you’d like to discuss how Caradigm can help you achieve quick time to value in population health, then please reach out to us here.

Engaging High Risk Patients through Care Management (Part 2)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

In part one of this post on engaging high-risk patients through care management, I discussed how different patient segments require different levels of care management relationships and tools. For the highest risk patients, a patient engagement strategy is centered on high intensity care management. Next, let’s look at how technology can help care management have a greater impact on outcomes for the highest risk segment.

Coordinating Care Across a Multi-Disciplinary Team

The care for a high risk patient can involve a large team including multiple specialists, pharmacists, care managers, office assistants, community health organizations and family members or friends. Coordinating activities among a diverse team requires shared access to a longitudinal patient record that gives a comprehensive “360 degree view” of the patient. The 360 degree view includes information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Dynamic care plans
  • Lab results
  • Medications
  • Patient outreach information
  • Patient supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Barriers to care
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

With this enriched view of the patient, care team members across the continuum can work more efficiently together closing gaps in knowledge and communication while operating at the top of their license. This can result in reduced redundancy in assessments, surveys and tests. Today, enterprise population health technology can bring together and make available all of this information in a shared workspace even if the information is stored in disparate IT systems.

Incorporating a patient-centered approach

A deeper understanding of patients helps drive a patient-centered approach, which is critical for patient engagement. For example, if a patient is motivated to achieve a certain goal such as travel to her daughter’s wedding, then every member of the care team can reinforce her motivation and encourage the patient and engage them in the plan of care. If every care team member has access to all patient information, then patients won’t have to repeat the same information to different care team members and patients begin to sense coordination among providers. If there is a family member, friend or community organization that plays a key role in the patient receiving care, then that critical piece of info will be incorporated into the assigning of tasks. The end result is a personalized plan of care. If patients see that the entire team “knows” them, it improves the overall patient experience, builds trust and can improve engagement.

Optimizing time with patients

Care managers are often challenged by a high volume of daily manual tasks. For example, in order to assess a patient and complete a care plan, care managers must track down and synthesize information from multiple systems and offline sources. With a full case load, efficiency is a challenge that ultimately impacts the amount of time care managers can spend focused on patients. Technology can help care managers spend more time with patients by automating time-consuming tasks. For example:

  • Care plans, task lists and interventions can be automatically generated and updated from assessment responses
  • Complete medication histories can display order history and fill history to enable faster review and support compliance review
  • Patient workloads or specific tasks can be reassigned to other care managers or support staff, assuring “top of license” activity
  • High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).

To summarize the main takeaway from both posts, patient engagement and care management strategies are closely linked and should be tailored by segment. As part of population health initiatives where the focus is often on high-risk patients, patient engagement strategies should be on a one-to-one basis, and linked to relationship building through high-intensity care management. New population health technology has emerged to help coordinate care for the highest risk patients. As more providers make the shift to value-based care and seek efficiencies to help them scale programs, I believe that technology will play a central role in helping the highest risk patients. If you’d like to discuss your care management strategies in more detail then send us a note here.

Engaging High Risk Patients through Care Management (Part 1)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

One of the most challenging issues in healthcare today involves “patient engagement”. It is defined by the Center for Advancing Health as “Actions individuals must take to obtain the greatest benefit from the health care services available to them”. The importance of patient engagement is undeniable. Patients active in the participation of their own care have a greater likelihood of achieving successful outcomes. How providers should approach patient engagement for different patient segments is still an evolving science. Patient engagement requires different levels of care management relationships and tools for different segments. In this two-part blog post, I am going to focus on the highest risk segment, and will address lower risk segments at another time.

Population health management is a large undertaking, requiring a variety of approaches to assure broad impact. The figure below shows an example of patient segmentation along with the types of care management relationships and tools appropriate for each segment. At the top of the pyramid is the highest 5 percent in terms of risk. In the middle are the 30 percent of patients with rising risk. The base of the pyramid is the 65 percent identified as having low risk. Let’s examine the segments more closely to see how patient engagement and care management strategies can vary between the segments.

CM Pyramid

 

High Risk

The top 5 percent of patients require high-intensity, 1 to 1 care management involving a multi-disciplinary team. Patients may have comorbidities that require more complex coordination across the continuum of care. Due to the high clinical risk for this group of patients, a care manager needs to play a lead role within the care team, guiding patients to take the actions needed to obtain the greatest benefit from the health care services available to them. Therefore, a patient engagement strategy for high-risk patients is really centered on high-intensity care management providing direction to the appropriate level of care and education about symptom monitoring and action plans.

Rising Risk

In general, the rising risk segment requires moderate intensity care management services, referred to as condition management in the diagram. These patients can pose an escalation risk if unmanaged, so the emphasis is on providing a consistent set of evidence-based care or education about self-management of a newly diagnosed condition. Patient engagement for medium risk patients is often a combination of consistent patient outreach and communication along with tools to encourage self-management. Within this group, there can be a subset of patients identified as “movers”, patients whose level of clinical risk is predicted to increase over the next 12 months. Higher intensity care management can be appropriate for “movers” in order to proactively address their conditions before they become more acute.

Low Risk

The low risk segment is the largest group, nearly two-thirds of the population. The focus for this segment is on preventive health and wellness to provide age and gender appropriate recommendations for care. Wellness tools including patient education and coaching may center around lifestyle choices and illness prevention based on health risk assessment data. Due to the size of this segment, low-risk patients must take on more of the responsibility for self-care. They are the ideal segment to benefit from patient engagement and outreach tools such as an interactive portal and patient reminders.

In the second part of this post that will be published next week, I will go deeper into technology designed to achieve effective high-intensity care management.

How Population Health Enriches the Patient Record


Post by Sameer Bade, MD


Vice President of Clinical Solutions, Caradigm

As providers seek new capabilities to help them in their journey to population health, one of the first items they usually target is analytics. Analytics are undoubtedly an important piece of a population health strategy, however, this is just one of a number of important capabilities providers must obtain. In my experience collaborating with providers, a sometimes overlooked capability is creating and sharing a comprehensive, enriched longitudinal patient record. With the shift from physician-focused, episodic-care to team-based care involving multiple clinicians and care givers, it has become essential to have a real-time, 360 degree view of the patient that is shared among the entire team. With that enriched view, a care team can more effectively and efficiently deliver coordinated and proactive patient-centered care that drives improved outcomes. Let’s explore this issue in greater detail.

The reality is that clinical information from a single electronic health record (EHR) provides only a small portion of the information needed for population health management. If there are multiple EHR’s in a clinically integrated network, clinical data for patients may be siloed in disparate EHRs. Also absent from patient records are numerous other key pieces of information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Care plans
  • Lab results
  • Patient outreach information
  • Patient submitted / supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Analytics that measure medication compliance
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

Enriching the patient record with this information enables a depth of patient understanding required to support the transformation to value-based care. Here are a few examples of how the enriched patient record can have an impact.

Scenario 1

With pharmacy benefits claims data automatically augmenting the patient record, a care manager can quickly see which prescriptions have been filled without having to log into multiple systems. They can complete a medication review faster and more accurately and can share this with the care team. It is well known that improper or inadequate medication management can  play a major factor in readmissions and complications (shown to cause as much as 20 percent of hospital readmissions[1]). However, having just EHR based medications (list or prescriptions) and pharmacy benefit / fill data is not enough. Being able to capture what the patient is actually taking can provide enhanced insight.  After medication review, a care manager can determine that a pharmacist needs to be added to the care team to help manage dosing regimens and timing of medications. The care manager can then assign a task to the appropriate care team member working at top of license to make arrangements with the pharmacist and add a note to the patient record that is shared with all other care team members. 

While completing medication review, a care manager may also discover life events that are barriers to medication compliance such as an inability to pay for medications, not having transportation to pick them up, or patterns such as sharing/splitting doses with a spouse. The care manager can then assign a task to an appropriate care team member to make transportation services arrangements for the patient or enroll them in an financial assistance program, and add another note to the patient record that is shared with all other care team members. 

Scenario 2

The same high-risk patient described above goes to see a primary care physician who is part of a clinically integrated network. When the physician looks up the patient’s record in their own EHR, the enriched longitudinal information and actions taken in Scenario 1 are carried forward to the point of care. In this scenario, the physician or nurse can have a deeper and more informed conversation with the patient about medication compliance. Furthermore, easy access to a  comprehensive, validated medication review as part of the enriched longitudinal record, can help speed up the medication reconciliation process in the clinic. With full context on the patient that also includes all care programs they are enrolled in, lab results, visits history, readmissions risk score and relevant patient documents such as a care plan, the provider is better equipped to evaluate and direct additional care. Simultaneously, the provider can also see gaps in care and quality measures (e.g. need for a depression screening) that can be closed while the patient is still in the clinic. From a patient perspective, the provider’s enhanced understanding of issues and plan of care can improve the overall experience. The physician can even see what motivates the patient (perhaps the care manager noted that the patient has a goal to be able to attend their grand daughter’s college graduation) and encourage continued participation.

In the big picture, successful population health management requires addressing a population of patients as individuals. An enriched longitudinal patient record as described here can help providers gain a better understanding of their patients and enable the care team to be more effective, efficient, coordinated and patient-centered.

To learn more about how your organization can obtain and share a longitudinal patient record across a care team, send us a note here to schedule a discussion. 



[1] Guitierrez, David. “Drug Side Effects Blamed for 20 Percent of Hospital Readmissions.” Posted from http://www.naturalnews.com/027866_drugs_side_effects.html# 1.4.10.

 

 

The Future of Healthcare: Innovating Coordinated Care


Post by Scott McLeod


Director of Product Marketing, Caradigm

One of the most impactful developments in healthcare today is the movement towards coordinated care. It’s essential as more healthcare organizations engage in population health management and participate in a broader health network with a variety of partner providers. Many providers have recognized that the care of a high-risk patient is a team-based activity that requires the coordination of a variety of clinicians and care givers serving different roles. It also involves a series of processes – intake, screening, assessment, developing a plan of care, reviewing a plan of care, making contact with care givers, reviewing medications, etc. To deliver the best patient outcomes possible, providers need to ensure that these processes are being completed efficiently and consistently across the team.  

The idea of coordinated care is not new, but being able to deliver it effectively is starting to become a reality as new health IT emerges to help enable it. A care team is made up of a diverse group of clinicians and family members that can include primary care physicians, specialists, a lead case manager, an in-patient case manager, a field coordinator that works on non-clinical tasks, a pharmacist, community organizations, and family and friends that may be providing support such as transportation or helping pick up medications. That’s a lot of people and a lot of information that is needed to properly care for just a single patient. Multiply that by potentially thousands of patients in a care management program, and it becomes clear why coordination and efficiency can be challenging.

Here’s how health IT can innovate care coordination. First, it brings together all the data and information needed to care for a patient from all systems across the health network. All care givers have a 360 degree view of the patient that includes the plan of care, medications, lab results, vitals, documents, immunizations etc. When an update is made, all care givers have that update in real-time. With a full 360 degree view of patients, the care team can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient-centered care by incorporating patient personalized goals.

Second, it transforms the efficiency of clinician workflows, which leads to increased productivity and consistency of care. Physicians can see care gaps and close them while still in the presence of a patient. Care plans, task lists and interventions can be automatically generated from the patient’s clinical information and assessment responses. Complete medication histories can be brought into single patient views that display order and fill history for easier review. Patients that may need immediate attention can also be tracked across the continuum through event-based alerts (e.g. admissions, discharges or Bluetooth device alerts). Lastly, all of the needed tasks are being assigned to the right team members assuring “top of license” activity.  

From the patients’ perspective, they’re on a better path to become healthier as they receive care focused on wellness and preventive measures. They’ll also receive a better patient experience as they don’t have to repeat answers and all care givers are up-to-date on their information. Care coordination is one of the foundational strategies healthcare organizations must employ to achieve the Institute for Healthcare (IHI) Triple Aim of 1) Improving the patient experience 2) Improving the health of populations and 3) Lowering the per capita cost of care. With a little help from innovative new health IT, coordinated care can become a reality.