Healthcare Intelligence Network

When tracked within its electronic medical record, key interventions like transitional care coaching and an expanded Patient Health Questionnaire not only improve the care provided to John C. Lincoln ACO's population but provide a clearer picture of the accountable care organization's performance, note Karen Furbush, business consultant, and Heather Jelonek, chief operating officer of the John C. Lincoln Network ACO. Additionally, the ACO's Physician Advisory Network, made up of its leading physicians, tracks patterns and trends within the ACO and helps the care team to adhere to best practices in evidence-based medicine. Monthly webinars with the physician advisory network and its EMR specialists provide opportunities for evaluation and training in these best practices. Karen Furbush and Heather Jelonek shared how the John C. Lincoln Network ACO has modified its reporting process, from workflow changes to customizations within its EMR to improve performance results during a July 17, 2013 webinar, "Performance Quality Measurement and Reporting for Accountable Care," a 45-minute program sponsored by The Healthcare Intelligence Network.

When health coaches employ motivational interviewing during patient encounters, expect upticks in medication adherence, weight loss, HbA1c levels and overall engagement, notes Alicia Vail, RN health coach for Ochsner Health System. Ochsner's eight health coaches focus on patients with diabetes, hypertension and obesity who have come to their attention by way of physician referrals, health screenings and pre-chart reviews. In this podcast, Ms. Vail describes how Ochsner Health System incorporates health coaches in its clinic structure and describes the benefits that result from the coaching intervention. Alicia Vail and Bill Appelgate, executive director of the Iowa Chronic Care Consortium, shared how an evidence-based health coaching focus drives returns in a value-based payment delivery system during a June 19, 2013 webinar, "Health Coaching's Value in Accountable Care and Medical Homes."

Primary care and the patient-centered medical home offer a great opportunity for health coaches to become allies with patients in improvement of their health, notes William Appelgate, executive director of the Iowa Chronic Care Consortium. Individuals with the highest health risks should be given priority, but those on the cusp of a serious health event also merit coaching assistance, he says. For providers new to the coaching conversation, Appelgate shares three benefits of incorporating health coaches in the care process --- including the upping of their 'outcomes game.' Bill Appelgate and Alicia Vail, RN health coach for Ochsner Health System, shared how an evidence-based health coaching focus drives returns in a value-based payment delivery system during a June 19, 2013 webinar, "Health Coaching's Value in Accountable Care and Medical Homes."

To rise to the challenge of non-compliant patients, providers should ask how they can work together to empower patients toward self-management rather than why patients are non-adherent in the first place, suggests Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC). CFMC coordinates the work of state-based Quality Improvement Organizations (QIOs), who have been working with hospitals and community providers to improve care transitions and reduce readmissions. In this interview, Ms. Goroski describes some of the interventions focused on patients, providers or both groups that have not only lowered key Medicare readmission rates but also reduced participants' overall admission stats. Ms. Goroski shared lessons learned from the 14 communities that participated in the CMS care transition demonstration project and details on program rollout to over 12 million Medicare beneficiaries in 400 communities during a May 22, 2013 webinar, now available for replay "Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions."

A core desire to create a single population-focused model of care for all Medicare beneficiaries, rather than multiple payor-driven approaches, drives Atrius Health's participation in the CMS Pioneer ACO program, explains Emily Brower, executive director of accountable care programs at Atrius Health. The success of the Atrius ACO hinges on several preferred partnerships it has cultivated, including a collaboration with skilled nursing facilities, as well as outreach by population health managers, who guide patients in the management of chronic illness and prevention. Ms. Brower shared the first year lessons from its experience as a Medicare Pioneer ACO and how the program is evolving in year two during a May 9, 2013 webinar, "Medicare Pioneer ACO: Case Study on Atrius Health's Focus on the Triple Aim," now available for replay.

There are two key mistakes healthcare companies make when adopting social or mobile technologies, explains Andrew Dixon, senior vice president of marketing and operations, Igloo Software. Dixon describes what's driving the aggressive growth of interactive patient care communities and suggests how responsibility for social strategy --- which he defines as both an internal and external communications strategy --- should be assigned. Dixon discussed the key elements of an effective social strategy, along with and best practice guidance from healthcare social strategies having a bottom line impact during a May 1 2013 webinar, "Healthcare Social Business Strategy: Driving Adoption with Social, Mobile and Cloud Technologies," a 45-minute program sponsored by The Healthcare Intelligence Network.

Low scores on patient outcomes measures within the CMS Star Quality ratings program --- metrics CMS weights most heavily in its assignment of stars --- can typically be traced to poor provider and member engagement, notes Joseph Johnson, vice president of L.E.K. Consulting. Johnson suggests ways to enlist support from these two stakeholder groups, and describes how MA plans should prepare for the possible display in 2014 of CAHPS care coordination ratings along with with its star scores (though the care coordination ratings will not be factored into star ratings). Johnson shared tactics to improve quality ratings as well as insight into the future direction of the CMS Star Quality program during an April 16, 2013 webinar, "A Strategic, Best Practice Approach to Improve CMS Star Quality Ratings," a 45-minute program sponsored by The Healthcare Intelligence Network.

The initial goal of Cullman Regional Medical Center's "Good to Go" program was to reduce readmissions. But CRMC didn't anticipate the effect that recording discharge instructions and sharing them with patients via phone and computer would have on the patient experience. Cheryl Bailey, CRMC's vice president of patient care services, talks about the unexpected benefit of the award-winning initiative, the minimal investment required to get "Good to Go" off the ground, and planned expansion for the initiative that is bridging the patient communication gap. Ms. Bailey, along with Joshua Brewster, director of care management at Regions Hospital, a HealthPartners hospital, shared the key features of their care transition management programs during an April 24, 2013 webinar, "Care Transition Management: Strategies for Effective Patient Handoffs," a one-hour program sponsored by The Healthcare Intelligence Network.

Since the idea of payment bundling was first introduced 10 years ago, justification for the episode-based reimbursement model has shifted from quality and innovation gains to its proven ability to reduce the total cost of healthcare, notes Jay Sultan, associate vice president and chief product portfolio architect for Trizetto. Healthcare entities testing bundled payments should keep two key factors in mind when trying to engage physicians in the model, Sultan adds, describing the type of message most likely to foster provider support. And finally, Sultan also identifies the major decision primary care must make now that CMS has introduced bundled payments for care coordination tasks. Sultan provided perspectives on the emerging bundled payment trend during a March 13, 2013 webinar, "Moving Forward with Payment Bundling," a 45-minute program sponsored by The Healthcare Intelligence Network.

With ACA reforms underway, thecase manager is fast becoming a major player in the patient-centric, qualityover volume healthcare mindset, taking on more standardized, collaborative approaches to care coordination and its changing delivery systems. But as crucial as case managers are to the evolvinghealthcare landscape, they also need to realize that they are, in many ways,the new kids on the block. Embedded casemanagers in particular need to understand that how they relate to theirprofessional partners is one of the most important keys to their success, explains Teri Treiger, president of Ascent Care Management. Here she shares her views on this and other aspects of the industry, including the opportunities for home-based care and how case managers can maximize the use of technology to manage patient care plans. Teri Treiger provided perspectives on the changing healthcare landscape for case management and care coordination during "The Role of Case Managers in Emerging Care Delivery Models," a February 21, 2013 webinar.

Outcomes-based rewards have a place in an overall incentives offering, notes John Riedel, president, Riedel and Associates Consultants, Inc., but despite the growth in these offerings, companies should keep their incentive options open. To maximize effectiveness, programs should include something for all: simple items like gift cards and tee shirts for sign-on, progress-based rewards to move individuals along, and outcomes-based incentives for individuals who take their health seriously. Reidel examines the staying power of extrinsic incentives and suggests eight questions companies should ask themselves to determine whether they've truly constructed a culture of health for the population they serve. John Riedel shared the key strategies in sustaining a health and wellness incentive program and moving toward outcome-based results during "Health and Wellness Incentives: Positioning for Outcome-Based Rewards," a February 4, 2013 webinar, now available for replay.

Physician-hospital organizations have been around before, but it's the emphasis on quality that sets today's PHO apart from the 80's version. In PHO 2.0, where healthcare value is favored over volume, clinical integration of participating physicians is a prerequisite, agree Greg Mertz, director of Healthcare Strategy Group, and Travis Ansel, its manager of strategic services. In this interview, they talk about the essential first steps of PHO creation and the perennial challenges of physician engagement and clinical leadership in this emerging collaborative model. Greg Mertz and Travis Ansel explored the key contractual elements to consider when creating a PHO during a January 23, 2013 webinar, "Physician Hospital Organizations: Developing a Collaborative Structure for Shared Savings Agreements," a 45-minute program sponsored by The Healthcare Intelligence Network.

SCAN Health Plan's Interdisciplinary Care Team for dual eligibles is a diverse multiprofessional group encompassing many geriatric specialists, explains Dr. Timothy Schwab, chief medical officer of SCAN Health Plan. Dr. Schwab describes some of the challenges of risk stratification in a dual eligible population, and details case management support for the percentage of dual eligibles that require support for disabilities. Dr. Schwab shared his organization's strategic approach to serving the dual eligible market during a December 6, 2012 webinar, "Care Coordination for Dual Eligibles: A Results-Oriented Approach," a 45-minute webinar sponsored by The Healthcare Intelligence Network.

A presidential election, more post-ACA milestones and a remodeling of healthcare funding and delivery will no doubt make for an exciting year ahead in healthcare. In this preview of their October 17, 2012 strategic planning session for healthcare executives, Dennis Eder and Hank Osowski, managing directors of Strategic Health Group, and Steven Valentine, president of the Camden Group, predict the direction of physician reimbursement, trends in ACO administration, the technology to embrace in the year to come, and the industry's response to a softened demand for service. Eder, Osowski, and Valentine presented during the Healthcare Intelligence Network's ninth annual "Healthcare Trends and Forecasts in 2013: A Strategic Planning Session" presentation, a 60-minute webinar on October 17, 2012, now available for replay.

Enhanced reporting and efficiency, significant reductions in readmissions in congestive heart failure patients and added leverage at contract negotiation are just a few advantages Bon Secours is deriving from its EHR-based data collection tools, explains Robert Fortini, vice president and chief clinical officer at Bon Secours. Fortini talks about the health system's shift from home-grown methodologies to the sophisticated IT knowledge base powering its population health management program, resulting in data that has a "compelling" effect at contract time. Robert Fortini drilled down on Bon Secours' tools and protocols for data analytics during an October 3, 2012 webinar, now available for replay, "Improving Population Health Management Through Effective, Efficient Data Analytics," a 45-minute webinar sponsored by The Healthcare Intelligence Network.