Healthcare Intelligence Network

Humana's remote monitoring pilots go beyond traditional targets of heart failure, diabetes and COPD to observe functionally challenged members, explains Gail Miller. This novel approach uses a Personal Emergency Response System (PERS) with a built-in accelerometer to monitor members challenged by activities of daily living (ADL), says the VP of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge. Another pilot, a collaboration with HealthSense, places sensors around the member's home to study algorithms of normal movement so Humana can detect changes and intervene before a member's crisis. All Humana remote monitoring pilots engage the circle of care surrounding the member --- be it home health, a family member, or a spouse. Gail Miller will share more details of Humana's telephonic care management and how remote monitoring pilots will enhance care coordination during a March 19, 2014 webinar, "Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results," a 45-minute program sponsored by The Healthcare Intelligence Network.

Relationships with community organizations that support mental health as well as recovery from addiction are essential to care coordination of Medicare-Medicaid beneficiaries, notes Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation (HCSC). These collaborations enable HCSC to address the needs of duals as "a whole sick person, and not just as a diagnosis," she explains, noting that duals often suffer from depression along with some physical disability. HCSC also has its own integrated team with behavioral health expertise. Julie Faulhaber will share her organization's approach to designing a care coordination model for dual eligibles and initial findings from these new programs during a March 12, 2014 webinar "Moving Beyond the Medical Care Coordination Model for Dual Eligibles," a 45-minute program sponsored by The Healthcare Intelligence Network.

Given changing reimbursement incentives and collaborative models for physicians and hospitals, Greg Mertz, managing director of Physician Strategies Group, LLC, discusses why the Congressional proposal "Better Care, Lower Cost Act" of 2014 is financially more attractive to providers than ACO models and whether he thinks it will be passed. He also deconstructs CMS' recently reported financial results for such health reform delivery initiatives as Medicare ACOs, Pioneer ACOs, and the Physician Group Practice demonstration, and weighs in on which, if any, model he considers the most sustainable. Greg Mertz helped healthcare organizations assess which value-based healthcare delivery model is right for their organization during "Physician Alignment: Which Model Is Right for You?," a February 19th, 2014 workshop at 1:30 p.m. Eastern.

There are three key benefits to prudent sharing of performance data among physicians, notes Cynthia Kilroy, senior vice president of provider strategy and business development at Optum, who suggests a four-step systematic approach for data dissemination that moves companies away from simply creating "metrics in a box." Besides the electronic health record, she recommends three other data sources to mine for provider performance metrics. Cynthia Kilroy explored the key structure, issues and challenges in these evolving reimbursement models during a January 29, 2014 webinar, "Accountable Care Reimbursement Models: Moving from Productivity to Population-Based Incentives," a 45-minute program sponsored by The Healthcare Intelligence Network.

Adventist Health's successful use of incentives to engage employees in population health sets a high bar for the program's imminent rollout to patients at Adventist-owned White Memorial Medical Center, notes Elizabeth Miller, Adventist's vice president of care management. In this interview, Ms. Miller describes the program's target population as well as the incentive that engaged 95 percent of its employees in health management. Elizabeth Miller will share the key features of the population health management program at White Memorial, the program's impact on Adventist's 27,000 employees and program rollout to its patient population during a January 22, 2014 webinar, "Managing Risk in Population Health Management," a 45-minute program sponsored by The Healthcare Intelligence Network.

With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital's Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF's and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over. Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during "Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers," a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.

Modifying a popular hospital admissions risk assessment tool for its own use helps Stanford Coordinated Care to prioritize home visits for its roster of high-risk patients, all of whom have complex chronic conditions, explains Samantha Valcourt, MS, RN, CNS, Stanford's clinical nurse specialist. Stanford's HARMS-11, based on Iowa Healthcare Collaborative's HARMS-8 hospital risk screening tool, looks at individuals' utilization, social support and medication issues, among other factors, to measure a patient's risk of readmission. The resulting home visits, a critical component of Stanford's care transitions management program, help to uncover health challenges the complex chronic patient may still face, including four common medication adherence barriers Ms. Valcourt describes in this interview. Samantha Valcourt shared how Stanford's Coordinated Care uses a home visit assessment to improve care transitions post-discharge during a December 19, 2013 webinar, "Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions."

If payment inequities can be addressed, communication and technology tools in place in large physician multispecialty groups make them ideal candidates for a medical neighborhood, suggests Terry McGeeney, MD, MBA, director of BDC Advisors. Dr. McGeeney, who spent 13 years of his practice career in a large multispecialty group, has also seen some FQHCs and managed Medicaid programs that do a good job of linking community and social supports required in medical neighborhoods. As for engaging patients in this emerging integrated care delivery system, try explaining the medical neighborhood's value proposition for them, he suggests. Patients already get why the integrated approach is good for physicians and insurance companies but need to hear why they should buy in to team care, patient portals and other aspects of centralized care coordination. Dr. McGeeney shared his expertise in developing medical home neighborhoods during a November 20, 2013 webinar, "Medical Home Neighborhoods: Uplinking Specialists To Create Integrated Systems of Care."

Despite the migration of some Pioneer ACOs to CMS's Medicare Shared Savings Program (MSSP), expect the surge in commercial accountable care organizations to continue in 2014, predicts Steven Valentine, president, The Camden Group. In this audio interview, Valentine suggests improvements to patient handoffs, an area in which ACOs have disappointed, in Valentine's view, as well as expectations for the other much-modeled care delivery platform, the patient-centered medical home (PCMH). In both the ACO and the PCMH, Valentine anticipates specialists will be critical parts of the solution, especially when it comes to emerging payment models, quality and performance. Steven Valentine and Catherine Sreckovich, managing director, healthcare, Navigant, provided a roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2014 during an October 30, 2013 webinar, "Healthcare Trends and Forecasts in 2014: A Strategic Planning Session."

From partnering with non-traditional providers like retail clinics to targeting larger physician practices to achieve savings and boost health outcomes, watch for health plans to continue to reshape primary care delivery over the coming year, predicts Catherine Sreckovich, managing director, healthcare, Navigant. Ms. Sreckovich outlines seven ways in which payors will influence primary care, advocates for big data for both payors and providers, and comments on the longevity of the bundled or episodic payment trend in this HealthSounds interview. Catherine Sreckovich and Steven Valentine, president of The Camden Group, provided a roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2014 during an October 30, 2013 webinar, "Healthcare Trends and Forecasts in 2014: A Strategic Planning Session."

In its quest to transform 70 to 80 percent of its physician practices to a patient-centered medical home (PCMH) over the next three years, WellPoint has adopted a "meet the practices where they are" philosophy, reports Julie Schilz, director of care delivery transformation for WellPoint. Each practice is at a different place in the transformation effort and requires specialized supports, she adds. Smoothing the transformation rollout is the simultaneous participation of 500 WellPoint practices in CMS's Comprehensive Primary Care (CPC) program, whose goals dovetail with key PCMH principles --- as though WellPoint had another partner in its transformation initiative, Schilz notes. Just as important as practice support is transparency with health plan members, Schilz adds, especially when it comes to explaining the concept of the medical home neighborhood --- where care coordination is a collaboration between primary care and the specialist. Ms. Schilz shared the key features of WellPoint's transformation initiative, including results from its pilot program that have led to a system-wide rollout, during an October 24, 2013 webinar, "Aligning Value-Based Reimbursement with Physician Practice Transformation."

There's education, there's experience, and then there's the 'right stuff' --- the indefinable personality traits that earmark an individual as a change agent, collaborator and ambassador of case management, says Annette Watson, senior vice president of community transformation for Taconic IPA (TIPA), of TIPA's requirements for the RN case managers it hires for its advanced patient-centered medical homes. Then there are the not insignificant contributions of the RN case manager to accountable and patient-centered care, which Ms. Watson describes in this interview. While staff-buy-in and communication continue to challenge the embedded case manager model, the participant in CMS Innovation Center's Comprehensive Primary Care (CPC) initiative says reimbursement for embedded case management is less of an obstacle today than in the past, due to funding-friendly care models and pilots descending from healthcare reform. Ms. Watson shared how TIPA has successfully embedded case managers in an open, multi-payor community during an October 9, 2013 webinar, "Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community."

The philosophy that healthcare is local --- and therefore, care needs to be local and community-based --- forms the core of WellCare's efforts to connect its dually eligible population to health services, explains Pamme Taylor, WellCare's vice president of advocacy and community-based programs. The Tampa-based healthcare company takes a culturally competent approach to assessing duals' unique personal circumstances, ensuring their "soft landing" into WellCare's care coordination system. Care managers at the heart of WellCare's multidisciplinary team, conducting a comprehensive needs assessment with each Medicare-Medicaid beneficiary and driving the resulting care plan, ensuring duals' complex care needs are met at the most appropriate time and level. Ms. Taylor shared Wellcare's strategies for meeting members' needs with community-based partnerships and engaging duals in self-management of their care during an October 2, 2013 webinar, "Dual Eligibles: Closing Care Gaps and Engaging Members in Self-Management."

Lauded for its care coordination service, Monarch had to overcome a few challenges when retrofitting the Naylor Transition of Care (TOC) model for the ACO --- among them insufficient patient access, patient skepticism and resource limitations. By focusing on readmissions reductions and four disease management conditions --- ESRD, COPD, CHF and diabetes --- and creating a care coordination team that included the newly created care navigator, case managers, and pharmacist, the organization has improved patient compliance, reduced negative drug interactions and hospital days and improved patients access to community services. During "Medicare Pioneer ACO Year One: Lessons from a Top-Performer," a September 18th webinar at 1:30 pm Eastern, Colin LeClair, executive director of ACO for Monarch HealthCare, shared first year lessons from its Medicare Pioneer ACO experience, how it evolved in year two and the impact on its organization's participation in other accountable care organizations.

A patient might expect a reminder about a missed colonoscopy during a primary care visit, but during a trip to the dermatologist? Providing health plan members with "consistent and ubiquitous reminders" via multiple touchpoints in their healthcare journey is one of Kaiser Permanente's key population health management strategies, reports Jim Bellows, PhD, senior director of evaluation and analytics for Kaiser Permanente. Another is the vigorous use of registries --- more than 50 in all, at last count --- even for relatively rare diseases. Dr. Bellows defines the criteria for registry creation, expands on the choice and availability of patient touchpoints and explains the evolution of other Web-based PHM tools in use by Kaiser Permanente. Dr. Bellows shared his organization's approach to population care and population health management during a July 31, 2013 webinar, "Managing Population Health with Integrated Registries and Effective Patient Touchpoints."