Technology: The Right Partner Makes All The Difference

Ed. Note: This is the fifth in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to view earlier entries and to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

Consistently, one of the biggest struggles in program development is implementing a solution that is scalable. You want to be able to start small with a cost effective “pilot,” yet have the option to rapidly deploy the solution across a broad set of patients in the event you see positive results.

That’s where technology comes in. You’ll need a partner who can grow with you. And, in the case of transitions of care, you’ll probably want someone with experience, knowledge and a track record of success with other clients to help you create or refine this concept in your organization. There are a few key elements to consider as you look for a vendor in this space:

1. Envision your end game, and then figure out your approach to get there

As you envision your transitions of care program, what elements will you add, and when? Will you start with risk stratification and home visits for high risk patients? Or will you use telephonic resources to make calls? What about your home care group or telehealth?

Now, step back and decide – what’s my pathway to get there?

Lots of questions, I know, but what is really important to understand is the step-by-step approach you’ll take towards improving transitions of care. I suggest starting with the piece that will have the highest quality (and/or financial) impact and then adding in the other elements as you continue to prove success. You’ll have far greater success negotiating with your decision makers if you can demonstrate success incrementally before  adding the next element.

Envisioning your end game and your pathway to achieve it will help you select vendors who are committed to your success and your strategy.

2. Find a vendor with the flexibility to work within the constraints of your IT systems

Each hospital has an assortment  of IT systems that automate the hospital workflow and case management, and perhaps even IVR, telehealth or home care. To potential technology partners these systems present both a challenge and an opportunity. You will want a product that can interface with all of these systems since each one contains relevant information that is best viewed in the aggregate to prevent readmissions.

More importantly, you’ll want a vendor that does not REQUIRE these interfaces to be successful. When developing a new program, it’s often a chicken and egg debate about whether to interface existing systems and set yourself up for the easiest path to success or to manually enter some information while you prove the model, and then add interfaces.  As you are constructing your clinical solution to transitions of care, you won’t want to be cornered into an issue where you require IT resources that might not be available to ensure success.

3. Find the right team

I know we are talking about technology here, but let’s not lose sight of the human element. It’s important that a technology vendor isn’t focused solely on technology and staffed with project management type folks. Given the pilot nature of this work and the fact that you’re breaking new ground, you’ll want a partner with clinical expertise and specialty knowledge in the realm of care transitions.

Ask to meet with the people who will be partnering with you to develop the program and solution AFTER the contract is signed.  Confirm what conferences the clinical consulting team attends and what training they receive. Call other clients – don’t just ask for references, but build relationships that you can maintain and call on to gather additional perspective on care transitions.

In the end, technology is intended to augment your care transitions program – to facilitate a measured approach that you outline and to scale your success across more patients and/or facilities in your system. It’s critical to find yourself a partner, not just a vendor. After all, success must be mutual.

January 4, 2011 – 2:56 pm Categories: Uncategorized | Post a comment

Outsourcing: Selecting a Vendor

Ed. Note: This is the fourth in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to view earlier entries and to be notified when new entries are published.

Author: Dr. John Loughnane, MD

One of the first and, at times, hardest lessons learned by a physician is that you are only as good as the consultants you choose.  Successful doctors quickly pick a cadre of like-minded, competent colleagues they can rely on for excellent medical care and high patient satisfaction.

Patient care facilities also understand that affiliations are a key to not only providing the best care possible for their patients but also to successful marketing endeavors.  Although institution reputations and name recognition matter, what is central to any successful partnership is an understanding of the goals and culture that drive patient care.  Without a clear understanding and working relationship on both ends, affiliations remain in name only and never provide the benefit envisioned.

The choice of where to outsource an electronic health record is as crucial as picking which surgeon will evaluate your patient’s acute abdominal pain.  Many factors go into choosing with whom you want to work and when.  Too often hospitals and other health care facilities pick an electronic health care company without truly understanding and discussing the critical issues involved.  There are key questions and issues to consider, including:

1. Are the goals of the patient/project clear? A surgeon who treats a 23-year-old healthy individual and a 99-year-old individual with a long list of co-morbidities the same is probably not going to be the first choice.  So too, a technology company that has a one size fits all approach to implementation and their product is not going to provide the results that are needed.  An individual approach to the patient or electronic health records needs of a health care facility is crucial to a good outcome.

2. Does the surgeon/company have the experience and background to be successful? Is the depth of their knowledge at an appropriate level for the situation at hand?  A general surgeon who primarily does laparoscopic cholesectomy might not be the best choice for open laporotomy following trauma.  So too, an electronic medical record company that does not have expertise in an institution’s electronic health records needs may not be able to deliver a successful product.

3. Do they share the same philosophy of care and patient culture? Are they selling an operation or product or actually taking the time to create a “care plan” that has the best chance to succeed and can overcome the barriers and challenges that might arise?

4. Is communication open and available? The most skilled surgeons and technologies often fail if there is not a productive and ongoing dialogue that allows for appropriate follow-up and change in approach as dictated by the progress of the patient or project.

Success on any project — be it a surgical stay or electronic health record — relies and ultimately succeeds or fails on many factors.   However, a holistic and comprehensive care plan that integrates not only technical skill and ability but communication, shared goals, and the ability to reevaluate and participate in creative solutions will benefit each and every patient and project that a health care facility treats, whether they are undergoing surgery for acute appendicitis or having their treatment and discharge plan communicated by an electronic health record.

For more information about vendors in the market, click here to submit your question and information and we’ll be in touch!

December 20, 2010 – 5:04 pm Categories: Health Care Reform, Personal Health Records, Transitions of Care and Home Care, Uncategorized | Post a comment

Developing an Internal Program – Job Descriptions and Hiring

Ed. Note: This is the third in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to view earlier entries and to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

Most organizations are looking for a mix of resources to deliver their transitions of care services. This may be a mix of RN’s, LSWs, LVNs, non-clinical coaches and/or clinical and non-clinical telephonic support.

First, you must identify a team lead. This person will set the tone for the program and be critical in it’s growth and success. Since this is essentially a player/coach role, the person you need must have both the hands-on clinical skills and the ability to lead and development programs.

Who makes the best program lead?

This decision can be tricky. We believe the lead in a readmissions program should be an RN with excellent critical thinking and problem-solving skills. That said, we realize that there are a number of successful, proven models lead by social workers and even non-clinical folks.  In the end, experience and qualifications are the most important considerations.

The reason we tend to lean towards an RN is because medication management, education and reconciliation is paramount in preventing readmissions.  Additionally, you will want to look for a candidate with experience in at least two care settings (if not more) spanning the continuum.  A familiarity with home care, in particular, and making home visits will decrease the ramp time and provide the context for post-discharge care management that can insure a positive patient experience.

Necessary clinical skills

The job description should focus on finding a candidate with excellent clinical reasoning and proven experience and ability:

  • Executing the key pillars in post-discharge care management: medication management and reconciliation, symptom management, insuring a PCP visit, and overall compensation for a patient lack of self management skills.
  • Educating patients with experience using teach-back method
  • Setting patient goals and coaching patients
  • Achieving a positive patient/family rapport in multiple settings – bedside, home, physician office visits, skilled nursing facilities, etc.

The non-clinical requirements

You will need a leader who can champion a new program internally and externally. This requires:

  • Excellent communication skills – Not just with patients and families, but also for promoting this program and its mission to the respective community partners like physician offices, home health, staff nurses, hospital leadership, etc.
  • Familiarity with your system and community – This will, by nature, establish a respect for the program and goals in a collaborative way, avoiding “territory” conflicts and misunderstandings.
  • Oversight of additional personnel (i.e. LVN, telephonic/ call center, etc.) to enable the growth of the program and insure the use of the right resource at the right time.
  • Ability to grow the team and work collaboratively in a team-based approach to post-discharge care management

The expected outcomes

Finally, any good job description should highlight the goals and expected outcomes of the role.  When employees see the purpose in their role and are intrinsically aligned with those goals, you can be confident that they won’t just execute because they have the ability, but also because they have the desire.

While goals will vary from organization to organization, they are best tied back not just to reducing readmissions and specific percentages, but also the core reason you (in Step 1) were motivated to start this program – the financial and quality impact. Was it patient satisfaction? Or poor inpatient nurse to patient ratios?  Either way, a clear description of the role and expectations, combined with a sense of purpose and alignment with the organization’s strategy is a recipe for success.

For more job descriptions or discussion, add a comment and we’ll be in touch!

November 30, 2010 – 3:29 pm Categories: Health Care Reform, Personal Health Records, Transitions of Care and Home Care, Uncategorized | Post a comment

Risk Driven Resource Allocation: Clinical and Telephonic Resources

Ed. Note: This is the second in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to view earlier entries and to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

Hopefully, you’re picking up where we last left off in our series. Perhaps you also picked up on what we think is the thesis of a good transitions of care program:  using the right resources at the right time for the right return on investment.

Surely you caught that. Makes sense, right? So, how do you take that smart idea and implement it in a practical solution?  Here are a few tips:

Figure out what readmissions are costing you today

Which patients are being readmitted and what are the costs of those readmissions?  Work with your financial and data teams to understand the entire scope of readmissions and their impact. It may be patient satisfaction, lost revenue, ineffective nurse/ hospitalist to patient ratios due to high census, potential CMS penalties, elective surgery cancellations or back-up in the emergency room. You get the idea.

Any CFO will recommend that the program cost less than what you lose today. However, we’d argue that most healthcare CFOs recognize that improved patient quality and outcomes as a result of preventing unnecessary readmissions also have a value that isn’t quite so easily measured in dollars and cents. But at least you’d have a place to start making your case internally.

Identify the pilot patient population

The next step is to identify which readmissions have the largest impact. You will certainly want to look at data, but we’d also suggest you talk to the case managers, floor nurses and utilization review teams. They can point you in the right direction quickly.  Either way, there’s a starting point, a subset of patients on which your program will focus. It may be by diagnosis, palliative care recommendations, health status, geography or even financial ability.

Follow the 80/20 rule

Given the program funding, what resources can help you address these patients? We suggest that hospitals focus on risk-driven resource allocation. Within your patient population, you must identify their likelihood of readmission and focus limited resources in the most effective way possible.

They key with any risk-driven resource allocation is the ability to apply it proactively rather than after the fact. No kidding, you’re thinking. But do you know which patients are likely to come back again if they haven’t had any admissions in the last six months?  You don’t want to have a readmission issue to know you have a readmission issue. The goal is to prevent it in the first place.

Identify and assign resources

The lines that divide your patients as high, moderate or low risk of readmission will more than likely vary from your facility to the one down the street.  It comes back to what resources you have and the volume of patients those resources can successfully manage.

You can scale the services you offer patients based on their individual risk for readmission. Focus transition coaches on those patients at highest risk.  Following an evidence-based care plan, their responsibilities may include a mix of bedside visits, medication management, home visits, family coordination, etc.  For lower risk patients, it’s quite possible that non-clinical telephonic check-ins or coaching on key best practices, i.e. insuring the patient attends a post-discharge PCP appointment and obtains their medications, can be used as a low-cost, effective strategy.

The key to this risk-driven approach is that patients receive the level of care and service required to positively impact their outcomes and prevent readmissions, i.e. the right resources at the right time for the right return on investment.

For more information about risk stratification or resource utilization, add a comment and we’ll be in touch!

November 15, 2010 – 2:58 pm Categories: Health Care Reform, Transitions of Care and Home Care, Uncategorized | Comments (1)

Keys to Developing a Transitions of Care Program to Prevent Readmissions

Ed. Note: This is the first in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to be notified when new items are published.

Author: Carrie Kozlowski, OT, MBA

Perhaps the greatest obstacle facing most organizations we talk to is not how to identify the scope of their transitions of care problem (that information is easily obtained), but instead, it’s the daunting task of program development, especially when nursing/care management resources are few and far between.

Yes, Medicare (and a growing list of Health Plans) has kindly helped/forced hospitals and accountable care organizations to make preventable readmissions a priority.  Therefore, you’ve probably discussed or overheard these questions in the halls of your office or on the nursing floors in your hospital:

1)     We’re planning to get a readmissions task force together. Who should own it?

2)     We know we need to do something, but where do we start?

3)     De we really need to follow these patients after they leave the hospital?

4)     How do we identify which patients we should be following?

5)     How will we track what we do, when we do it, and why we did it?

6)     Who has time to do this again?

The answer to reducing preventable readmissions lies in your organization’s ability to create a service line that will enable you to improve care coordination across the care continuum and appropriately resource a patients’ ability or inability to self manage their follow up care. As you know, the service will be critical to patient outcomes, penalty avoidance and quality of life.  It’s crucial that the program is both highly effective and efficient.

You want to use the right resources at the right time for the right return on investment.

As you craft your program, the most important things to identify are:

1)     The appropriate clinical resources to use for identifying high risk patients and follow up interventions requiring clinical reasoning.

2)     The appropriate support resources to keep the clinicians focused on the tasks that best leverage their clinical skills.

3)     A care coordination platform that enables predictive risk stratification, risk-driven resource allocation and shared task lists, while keeping resources focused on the same shared patient-specific goals.

Stay tuned in the following weeks as we break down the keys to successfully achieving these significant pieces:

Step 1: Clinical and Telephonic Resource Allocation

Step 2: Developing an internal program: Job descriptions and hiring

Step 3: Outsourcing: Selecting a vendor

Step 4: Technology: Key decisions in selecting the right partner

Step 5: Growth: Scaling the program to reach more patients

Step 6: Getting the word out: Leverage your success with marketing

We want to hear from you! Please click here to share your comments and feedback with us directly.

November 4, 2010 – 9:45 pm Categories: Health Care Reform, Transitions of Care and Home Care, Uncategorized | Post a comment

Double Dip or Double Trouble or Somewhere in Between?

We’ve talked a good amount about the impending Medicare payment penalties for hospitals that have 30-day readmission rates for CHF, heart attack and pneumonia worse than national averages.  Frankly, these imminent payment changes have caused a great deal of excitement about the CTC approach.  What we didn’t know and that we learned this week from Karen Davis, is that CMS will reward hospitals for achieving benchmark levels of performance in heart attack, heart failure, and pneumonia care, and for preventing surgical infections. Starting in October 2012, hospitals that meet or exceed the designated performance standards will receive enhanced Medicare payments, taken from a pool of money.  Wow!  So will certain hospitals win on both sides of this deal?   Do those hospitals that provide better inpatient care for these conditions also have lower 30-day readmission rates?   Logically, I would think so.  measures will lead to fewer readmissions?  This is a great research topic– anyone game?  I’ll pitch-in.

But, what about those hospitals on the other side of this bet?  Will they lose on both ends too? A study published in the Journal of the Public Library of Sciences this past week sheds some light on this question   Findings from a national, longitudinal study that measured hospital performance on AMI and HF concluded that “locational factors,” often beyond a hospital’s control, have a significant impact on the quality of care they provide.  Specifically, these factors include the endowment of the local economy in terms workforce quality and income level.   The authors go on to assert that these hospitals may be at a disadvantage in a pay-4-performance system.  Accounting for these socioeconomic factors is a point that we belabor on this site.  Will CMS follow-up on these findings?  We have made great progress on creating the data needed for increased quality and cost transparency in our health system but these data must be complemented by the necessary socioeconomic controls.

July 2, 2010 – 5:53 pm Categories: bundled payments, Health Care Reform, Personal Health Records, Transitions of Care and Home Care | Post a comment

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Special World Cup Inspired Post!

In the spirit of international competition exemplified by the ongoing World Cup, we thought we’d first talk a bit about where our health system ranks among those of other western nations– of course with a discerning eye on care coordination as an evaluation criterion.  Is it coincidence that the Commonwealth Fund released findings from its comparative health system review just one day before the United States Round of 16 match against Ghana?  As we all know now, the US lost a nail-biter to Ghana, which means out of a field of 32 nations, the US men’s soccer team finished somewhere between 9th and 16th.  In the Commonwealth Fund study, the United States finished seventh – out of seven countries.   Now, we’re not piling on the US health system.  There’s a reason why we’re in the midst of monumental reform – our system was grossly under performing.   What we thought was interesting is that care coordination found its way into the evaluation criteria.  While we finished second to last according to this measure, we believe we’re on our way to improving this ranking thanks to all the initiatives underway that we’ve talked about here along with the resolve of CMS and other innovators.

So, what about Main Street, USA?  What do we think about our health system?  Well, in the Robert Wood Johnson Foundation’s monthly measure of consumer confidence in our health care system, we saw a bit of a dip.  The RWJF index dropped about 7 points from 101.9 to 95.8 (this is the index that we health care pundits watch as diligently as stock-traders watch the overall consumer confidence index).   But, despite this flagging confidence in May, we did see an up-tick in optimism over health care reform.    Approximately 48% of Americans have a favorable view of health care reform (up 7 percentage points from last month), while 41% had an unfavorable opinion of recent reform.   We’ll revisit these numbers from time to time so how we’re doing both from a comparative perspective (internationally) as well as through self-assessment.

July 2, 2010 – 5:46 pm Categories: Health Care Reform | Post a comment

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Advantage: MA or FFS? Asking Questions that Need Answers

Across the past two weeks, we’ve seen plenty of punditry discussing both the functional and political impact of the scheduled reimbursement cuts for Medicare Advantage (MA) plans authorized in PPACA.   This back and forth between supporters and detractors of MA plans is indeed one of the many follow-on brush fires ignited by the still glowing embers of health care reform.   As much as I’d love to show my political stripes and discuss the electoral impact of cutting popular MA plans in an election year, the meat and potatoes analysis of what MA cuts means for our health system has yet to receive an even-handed assessment.  So, as we’re prone to do in this forum, we’re going to take on this task in the hopes that we give decision-makers something new to think about.

While Secretary of Health and Human Services Secretary Kathleen Sebelius has been reviewing proposals from MA providers, we’ve seen some news regarding the impact of MA Plans on readmission rates that – on the surface – seem to endorse the MA model, and its higher reimbursement levels, over the traditional Medicare Fee-for-service (FFS) system.   Specifically, a study jointly produced by Medassurant and the American Health Insurance Plans (AHIP) demonstrated that readmission rates for MA beneficiaries, when appropriately adjusted for risk, are lower than in traditional Medicare FFS.   This is big news. Or is it? If it is, here’s the logical leap we should take:  We’re getting our money’s worth with MA plans.  Whatever they’re doing with the extra 15% reimbursement they’re getting beyond the FFS plans is doing some good by keeping patients from boomeranging back to the hospital (thus far, no studies have zeroed in on the specific differences in care management practices between MA and FFS that lead to fewer readmissions).

So, even with the inflated reimbursement rates MA plans receive, are they net “winners” when assessing total system costs?  Possibly.  The cost savings achieved by the lower readmission rates of MA beneficiaries may still yield a net savings even when factoring in these plans’ higher reimbursement levels.  I don’t have the answer to this query but both this question and its answer should find itself within the contours of the MA debate.    Assuming that MA plans are net winners based on their lower readmission rates, the next step is to identify what they do that reduces preventable readmissions — and, if the reimbursement cuts will jeopardize these practices.   If so, we may be saving our nose to spite our face in terms of cost-savings.  Again, sadly, I don’t have the answer to this question.  But, most importantly, I haven’t seen the question asked.   From a system-level perspective, with readmission rates as a proxy for performance, the “ideal” situation would be a MA reimbursement reduction that doesn’t impact those items that keep folks from landing back in the hospital.   So in summary, here’s the logic in support of MA plans based on their relatively better performance than FFS with respect to readmissions.  1. MA plans keep folks from going back to the hospital more than FFS, 2. this is partially attributable to those services “funded” by their higher reimbursement, 3. the cost of those readmissions that would’ve occurred outweigh the extra reimbursement, 4. cutting this reimbursement will jeopardize these practices and 5. the system loses.

Now, here’s a new way to evaluate the findings of the joint Medassurant/AHIP study.  The comparative premise is that the study has compared equivalent FFS and MA cohorts (groups), which is why they controlled for health risk between the two pools.  The analysis then assumes that after successfully controlling for risk, these populations are essentially the same and comparative conclusions can then be justly made.   Here’s where there may be a problem.  We know that insurers like to find the best “beneficiaries” to insure – those that are sick less and less prone to expensive care.  This is fair.  The goal is minimize their medical loss ratio (while providing good care) while maximizing profits from premiums.  And, on the flipside, these marketing efforts typically find “more informed” consumers who, in the case of the MA plans, may find little perks such as discounted gym memberships more meaningful.   Those folks who don’t hear about MA plans or who don’t value their differential benefits end up in the FFS offering.  What we’re suggesting here, is that the populations that use MA plans versus FFS may be different in economic terms.  The “socioeconomic status” of these two pools may have differences that could impact their likelihood for going back to the hospital.    Let’s assume that the average income level of folks insured through MA plans is higher than that of those insured by FFS plans.  With our expertise in care team coordination and care plan compliance, we know that patients with more “supporting resources” do better at staying out of the hospital following discharge.   Income, or socioeconomic status, is a great proxy for supporting resources that aid in care plan compliance – such as having the means to pay for transportation to an appointment or pay for the remainder of the gym membership.  So, the results produced by the Medassurant/AHIP study may be confounded by the fact that MA and FFS patients, on average, have different resources on-hand to support compliance to care plans that keep them from being readmitted.   Like before, we don’t know the answer to this question but the important part is that the question hasn’t yet been asked.  And the answer is important.

Lastly, we can’t go a post without mentioning donuts.   The filling of the donut hole definitely needs to be added to this discussion, as its impact may have bearing on the outcome.  What if the drug plan benefit offered through MA plans has contributed to the lower reimbursement rates?  Well, beginning this month, the federal government will begin closing the prescription benefit donut hole.  So, FFS beneficiaries will also begin to consistently receive the drugs they need to stay on track with their care plans.  Will this further diminish the difference in readmission rates between MA and FFS patients.

June 23, 2010 – 5:50 pm Categories: Health Care Reform, Transitions of Care and Home Care | Post a comment

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Crystal Ball is Polished

Our business team is in Vegas this week, at the ANI/HFMA meeting, spreading the Remcare version of coordinated care team religion.  I should probably catch the next flight to join them…. Not at the exhibit but at the tables!   Our last post discussed some topics that broke into the health care headlines this past week.   Of course I’m biased, but we’ve been on quite a run this year in getting out in front of health care reform related topics. (A streak that would probably end if I really did get on that plane to Vegas!)

Much like the predictive power of the Care Team Connect (CTC) readmission risk stratification model (thinly-veiled commercial ends here), we correctly speculated that telemedicine as a tool in supporting care compliance during transitions of care, would quickly gain speed.   On the heels of that post, Wellpoint, which operates 14 health plans nationally, announced a telemedicine program that includes on-line visits with Wellpoint providers that incorporates a secure, live “chat” feature.  As we noted last week, the most important factor for provider participation is that Wellpoint will reimburse providers for these on-line visits.  Along with other initiatives by national plans such as United Health, telemedicine may really get lift in community-based care coordination – and soon! And, by making providers even more productive (in the sense of # of visits/day) these initiatives also serve a very practical purpose.   They help to alleviate the current shortage of primary care providers that will only be exacerbated by the increased patient volume expected from PPACA provisions.

And, if you’ve been a consistent reader of our blog, you know we get very excited about the accountable care organizations (ACOs) chartered through health care reform bill.  Our excitement is only mounting as CMS gets closer to finalizing the rules that will guide how ACOs are put together and rewarded.  (We’re not alone in our excitement surrounding the potential impact of ACOs on preventable readmissions.  In response to a report that further characterizes the California’s struggles with readmission, Anne-Marie Audet, vice president for quality improvement and efficiency at the Commonwealth Fund, pointed to ACOs as a coming-soon solution!)  CMS took an important step last week by publishing a Question and Answer document that outlines broad parameters regarding the organization and makeup of ACOs.   From our perspective, this document only included one curveball that we hope ACOs will quickly learn how to hit (even before they get in the batters box).   The Q&A affirmed the fact beneficiaries will still have the option to receive services from providers not affiliated with their ACOs.  Choice is good; however, it poses a challenge for ACOs.   They are rewarded based on their ability to improve quality while maintaining (or reducing costs) through improved care coordination.  Providers who are not associated with an ACO do not have the same incentives as their ACO colleagues.  So, ACOs will be on the hook for the behavior and performance of non-ACOs providers.  Many good models exist for managing the payment of outside providers – a la the out-of network payments to providers in today’s managed care system.   But, we’re not worried about the payment side.  We’re more concerned about the communication component.  Will a provider that only sees a few patients affiliated with an ACO use that organization’s care coordination tools (such as EHRs, care portals).   I’m guessing that bright minds are working on a solution to this item and, if not, consider this your warning shot.

June 22, 2010 – 5:05 pm Categories: Health Care Reform, Transitions of Care and Home Care | Post a comment

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Your Online Home, House Calls and Donuts (with filling)

As you’ve probably already picked up on, I’d talk about payment reform -  specifically bundling – each week if my editor would let me.  Thanks, Ben.  So, this week we’ll stray from a purely financing-related discussion and piece together some of this past week’s news that will have an impact on care team collaboration.

But, because I can’t resist, for those of you whose interest in still piqued from last week’s discussion, it seems we were one step ahead of The Commonwealth Fund and Health Affairs.   To satiate your bundling appetite, take a look at this report by TCF experts published in Health Affairs, which highlights the urgency for and the impact of payment models that appropriately spread risk across care teams.

And, we’ll stay on this road for a bit longer, though we’ll shift lanes.  The “medical home” concept is a community-based manifestation of the connected care teams that we care so much about at RemCare.  Last week, a Wall Street Journal article took an in-depth look into the progress made by several medical home demonstration projects in Pennsylvania.  These demonstration projects are some of the most mature in the nation and are beginning to yield some great data on the impact and sustainability of this model.  On that latter point – sustainability – what jumped off the page to me is that each practice required an additional 2.5 FTEs to support the medical home program.  And, more importantly, these practices did not think they would have the resources to support this additional staff once grant funding expires –unless the compensation for this model was altered by the state, feds and/or private insurers.  Of course, where my mind goes is right to technology.  What solutions exist that can efficiently support the medical home model and minimize the need for additional staff?   The good folks at The Commonwealth Fund took a different but complimentary approach to resolving this unsustainable staffing requirement.   Shortly after the WSJ article, Health Affairs published an article that highlighted best practices for reducing the staffing burden of the medical home model by sharing resources across practices.

In this forum, we’ve looked at connecting care teams from many different perspectives, including the public sector, private insurers, hospitals, families and community-based providers.  The follow-up appointment between the patient and his/her physician is a staple of successful transitions of care from the hospital to home.  We’ve talked about how the most subtle of triggers, a lack of transportation for example, can set a patient off on a track that may lead to a preventable re-admission.  This is why telemedicine, which in our definition consists of secure on-line communications that offer the equivalent patient experience of an in-person visit, exhibits so much potential.  You can’t miss an on-line appointment because of transportation – maybe for a finicky modem, but not because your ride was sick!  And, physicians are beginning to enforce more financial penalties for missed appointments.  As a student of human behavior, what effect might these penalties have on appointment compliance?  Not what you might think.  Sure, those who don’t miss appointments will certainly not miss their appointments but those who do – those folks who are on fixed incomes – might avoid future appointments for fear of paying the missed appointment penalty.  Am I a cynic?

So, let’s go back to on-line visits.  It appears a strange split is appearing on-line in terms of the way patients and providers communicate.  Patient and provider interactions on social media sites such as Facebook and Twitter continue to grow, with patients seemingly feeling secure enough to discuss sensitive medical matters with their providers through these unsecure (in the HIPAA sense) forums.  At the same time, the growth in secure technology portals that are designed specifically to foster on-line visits continues to lag behind the pace of increased use exhibited by social media.  In fact, patients ironically remain skeptical of these tools.  From my Medem days in the late 1990s, the health care community viewed finding the best way to support an on-line patient experience as the holy grail.  Our growth at Medem was hampered for two reasons – we were too early (primarily) but also insurers were not sure how to compensate the on-line visit.  A decade later, it is still the payment model that gets in the way.  (See, I told you I couldn’t stay away from financing).   In the spirit of not simply pointing out problems, but offering solutions, I suggest the opposite of what Machiavelli advocates for in his  “Art of War:”   Let’s go where they are!   Patients are flocking to Facebook and Twitter – and so are docs.  Why don’t the technology providers that support on-line visits find a way to leverage this user density and plug into the likes of Facebook and Twitter – or at least leverage their brand equity?   Yikes, because of the trust in these brands, consumers seem willing to share sensitive health care information yet still raise eyebrows as secure health records and communication tools for reasons of security.

Finally, I’ve been on a donut kick as of late. (A family camping trip was my excuse for loading up the Wills wagon with saturated fats.)   Last week was a big week for donuts – and, no a Krispy Kreme did not come to town.  The federal government mailed off the first round of $250 checks to those seniors who had entered the “donut hole” in the Medicare Part D subscription drug benefit.  This filling of the hole is significant because one of the many provisions included in PPACA is the ultimate elimination of the donut hole for all Medicare Part D participants by 2020.  Looking at this through the jelly-filled lens of care teams, I’m hoping that a more complete drug benefit may help with care plan compliance and reduce the number of patients who boomerang back to the hospital because of poor medication compliance.  This certainly happens today.  Seniors reach the gap in the drug benefit and they prioritize which medicines they can afford out-of-pocket.  Perhaps they choose poorly and the medicine they no longer purchase causes a relapse in their progress.   If anyone has data on the percentage of re-admissions caused by donut-hole, please send it along!

If nothing else, I hope this post means that I won’t be alone at the Dunkin Donuts counter tomorrow!

June 14, 2010 – 8:12 pm Categories: Health Care Reform, Transitions of Care and Home Care | Post a comment

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