Infographic: The Health Care Reform Bill

Infographic: The Health Care Reform Bill

With the close of oral arguments surrounding the constitutionality of the Patient Protection and Affordable Care Act and individual mandate, healthcare leaders remain hanging in the balance.  Do they march forward with new care models to improve patient quality/safety, enhance patient experience, reduce readmissions and re-engineer transitions?

As noted in a recent HealthLeaders Media article, Michael Dowling, president and CEO of North Shore-Long Island Jewish Health System, responded that his organization has been working toward bundled payments, greater transparency, and preventive medicine, and away from fee-for-service “for years before the law.”

(Most importantly), “Innovators will continue to move forward, no matter what happens with the Supreme Court,” he says.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

*Graphic courtesy of Marco Giannini

Does Collaborative Continuous Quality Improvement + Technology Innovation = Improved Hospital Value-Based Purchasing Scores?

Poised at the nexus of Supreme Court oral arguments for health care reform constitutionality and the close of the Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) nine month performance period (July 2011-March 2012), hospitals eagerly anticipate news regarding their FY2013 Medicare reimbursement.  Beginning October 2012, CMS will reduce base operating diagnosis-related group (DRG) payment to all hospitals reimbursed under the inpatient prospective payment system (IPPS) model by 1 percent, with the amount gradually increasing to 2 percent by FY 2017.  Monies withheld will be used to create an incentive fund for future hospital performance based payment relative to identified domains of quality measures. Final determination of payment from the 1 percent withholding will be calculated as a linear function based on all participating entities, meaning that organizations must demonstrate continuous quality improvement in order not to fall behind their peers.

As outlined in the FY 2013HVBP final rule, an overall performance score will be calculated by assessing achievement and improvement for an institution’s Clinical Process of Care Measures and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey feedback.  In determining the final score, CMS will weigh the HCAHPS results at 30 percent and the Clinical Care Core Measures results at 70 percent.

For each of the 17 measures (12 identified for FY2013 shown below) included under the Clinical Process of Care Measures, CMS will use hospital data to calculate a performance score ranging from 0 to 10. A hospital earns an achievement score based on how well it did relative to a lower threshold and upper benchmark (generally 1.0 or 100%) calculated from all hospitals’ previous baseline scores, and an improvement score based on whether it beat its own performance during the baseline period. CMS uses the higher of these two scores for its official tally. In theory, a hospital could receive all 10 points if it beats the achievement benchmark, or 0 if it fails to meet the achievement threshold or better its own previous score.

Measure ID	Clinical Process of Care Measure Description	Threshold
AMI-7a	Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival	0.6548
AMI-8a	Primary PCI Received Within 90 Minutes of Hospital Arrival	0.9186
HF-1	Discharge Instructions	0.9077
PN-3b	Blood Cultures Performed in the Emergency Department Prior to Antibiotic Received in Hospital	0.9643
PN-6	Initial Antibiotic Selection for CAP in Immunocompetent Patient	0.9277
SCIP-Inf-1	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision	0.9735
SCIP-Inf-2	Prophylactic Antibiotic Selection for Surgical Patients	0.9766
SCIP-Inf-3	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time	0.9507
SCIP-Inf-4	Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose	0.9428
SCIP-VTE1	Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered	0.95
SCIP-VTE2	Surgery Patients Receiving VTP w/I 24Hours Prior to Surgery to 24 Hours After Surgery	0.9307
SCIP-Card-2	Surgery Patients on a Beta Blocker Prior to Arrival Receiving a BB During the Perioperative Period	0.9399

Scoring remains relatively the same for the eight measures based on the HCAHPS patient surveys. Hospitals, however, also can earn up to 20 consistency points based on how well their single lowest score stacks up to the competition. Hospitals will receive a percentage grade based on how many points they scored out of the possible total.  CMS will post all scores on its Hospital Compare site and use the final performance score to determine the value-based incentive payment.

Domain	Question	Min	50th %	Benchmk
Nursing	Nurse courtesy and respect	38.98	75.18	84.7
Communication	Nurse listens carefully
	Nurse explanations are clear
Doctor	Doctor courtesy and respect	51.51	79.42	88.95
Communication	Doctor listens carefully
	Doctor explanations are clear
Staff	Did you need help in getting to bathroom?	30.25	61.82	77.69
Responsiveness	Staff helped with bathroom needs
	Call button answered
Pain	Did you need medicine for pain?	34.76	68.75	77.9
Management	Pain well controlled
	Staff helped patient with pain
Medication	Were you given any new meds?	29.27	59.28	70.42
Instructions	Staff explained medicine
	Staff clearly described side effects
Discharge	Did you go to a home or another facility?	50.47	81.93	89.09
Information	Staff discussed help needed post discharge?
	Written symptom/health info provided
Cleanliness and Quietness	Area around room quiet at night	36.88	62.8	77.64
Hospital	Room and bathroom kept clean
Overall Rating	Hospital rating question	29.32	66.02	82.52

While CMS’ Hospital Value-Based Purchasing Final Rule refers to Medicare patients only, private payers are quickly advancing towards a quality based reimbursement model as well.  As the bar continues to be raised in pursuit of improved quality and better value, how will your organization prepare for this challenge?  With less time to address the much more speculative HCHAPHS scores, does this provide the greatest area for improvement?  Since many enterprising organizations are currently engaged in this process, will innovative technology coupled with collaborative continuous quality improvement keep your institution in the race?

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

*Graphic courtesy of Triple Tree Research

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Are Collaborative Care Planning Teams and Technology the Key to Reducing Readmissions?

Are Collaborative Care Planning Teams and Technology the Key to Reducing Readmissions?

Tick tock goes the clock – in six short months the Centers for Medicare & Medicaid Services (CMS) will begin withholding 1% of Medicare inpatient payments for avoidable readmissions within 30 days.  Peaking at 3% in 2014, this penalty has the potential to be a major financial hit to some hospitals already facing lower reimbursements. According to PriceWaterhouse Coopers Health Research Institute’s, “The Price of Excess: Identifying Waste in Healthcare”, preventable hospital readmissions are a significant avoidable cost in the U.S. health care system, costing an estimated $25 billion annually. Further noted by authors Stephen Jenks, MD MPH, Mark Williams, MD and Eric Coleman, MD MPH, poor discharge procedures and inadequate follow-up care lead to nearly one in five Medicare discharged patients being readmitted within 30 days.  And across all insured patients, the preventable readmission rate is 11 percent, while the rate for Medicare patients is 13.3 percent.

While Jenks et al. noted that the highest rates of preventable readmission diagnoses are heart failure, COPD, psychoses, intestinal problems, and various types of surgery (cardiac, joint replacement, or bariatric procedures), the National Priorities Partnership estimates that total hospital readmissions could be reduced by up to 12% by improving proce­dures for admitting and dis­charging patients, providing better follow-up care and utilizing health information technology. With many readmissions costing between $6,000 and $10,000 each, a number of innovative solutions aimed at helping reduce avoidable incidents could be implemented:

During the Inpatient Stay

–          Collaborative Care Planning (CCP) – similar to morning management huddles, convene a multi-disciplinary discharge planning team to start working with the patient prior to transition to develop a care plan in laymen’s terms that effectively addresses appropriate care, medication instructions, future physician appointments, transportation and other psychosocial needs.

• Include health plan, home health, skilled and long-term providers in discussion via innovative technology or other means
• Request primary care physician acknowledgement of care plan before patient transition
  • Schedule first follow-up visit to occur within five days
• Clinical Pharmacist member of CCP team meets with patient to discuss medication, preventable errors and presents 30 day supply
• Require patient to ‘consent’ to care plan and sign-off prior to transition
  • Additional literature has highlighted the fact that most patients have one primary care giver – look for ways to integrate this individual into your discussions and follow-up
• Similar to the VA’s blue button, integrate the care plan with current EHR technology and make available online, in addition to paper format, via a patient portal

Following Discharge

–          CCP team member follows-up with patient within 48 hours

–          Schedule follow-up visit by CCP team member for high risk patients to review progress, monitor safety of home and manage medication adherence

• Akin to the Health Alliance Plan’s HealthTrack, enroll patient in disease management program
  • Assign Care Navigator/Coordinator/Health Coach
• Provide patient education materials in paper and online format, including interactive symptom checker driven by evidence based tool that delivers directives based on a decision tree
• Implement telehealth, IVR and/or wireless monitoring to remind patients to take meds, follow preventative measures, attend PCP visits and provide early warnings of worsening health conditions
• Educate patients regarding early warning signs and appropriate next steps

–          Explore means of sharing data with all participating parties in order to avoid duplicative visits, tests and other unnecessary resource consumption

–          Standardized discharge summary is sent to primary care physician, payer, clinicians, care givers

–          Post-mortem review of readmitted patients

If significant reductions in readmissions are to be achieved, a true system approach must be implemented with appropriate payment reform to bind payers, providers, physicians, pharma and specialty organizations to this important initiative.  Reengineering current processes to include collaborative care teams and progressive information technology could be the key for improving transitions, reducing readmissions and delivering safe, quality, patient-centered care.

 

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Innovating Your Way to a Patient-Centric Emergency Department

As noted in a recent article by Hospital & Health Network’s Senior Editor, Haydn Bush, “When a patient with a sore throat, earache or other minor ailment heads to the emergency department for a cure, there are a raft of consequences every hospital is familiar with: longer waits for patients with more serious conditions, higher costs for the patient and the hospital, and the challenge of treating a patient in a less-than-ideal care setting.”  With the onset of National Patient Safety Awareness Week, it is an ideal time to review innovative strategies for implementing Be Aware for Safe Care (the 2012 NPSF theme), proper selection of care setting, reduction of wait time and expense and, ultimately, a more positive patient experience.

Since hospitals are required by the Emergency Medical Treatment and Active Labor Act (EMTALA) to take care of all patients that arrive in their ED, it is counter-intuitive to think that their best course of action might be to refer patients elsewhere.  It is in this vein that leaders at Presbyterian Healthcare Services of New Mexico have been piloting a program to screen patients for more serious problems prior to scheduling a primary care appointment for them.  Having met with the Centers for Medicaid & Medicare, local advocacy groups and ED physicians, this group’s initiative has led to decreased ED utilization and return visits from patients who had been navigated to primary care settings previously.

Additional tactics for preventing unnecessary ED visits include staffing and procedural changes within the ED department itself. Nurse Practitioner and Physician Assistants, along with a triage coordinator, have been successful at handling fast track patients with lower acuity.  Care coordination teams are also popping up at various facilities in order to ensure that patients presenting with chronic repeat problems receive care from a variety of disciplines – psychosocial, nursing, physical/occupational therapy, dietary and others.  Follow-up telephonic visits are conducted in efforts to confirm that patients are adhering to their care plan.  If one were to add a relationship management program that encompassed interactive voice response and mobile alerts, it would be intriguing to measure the enhanced outcomes.

According to Neighborhood Health Plans’ Multi-Dimensional Approach to Reducing Preventable Emergency Room Use, there are a number of additional steps that can be implemented post-visit to prevent future ones.  First, NHP distributes patient education materials in the form of the Healthwise Handbook to all members who have visited the ED for ambulatory-sensitive conditions in the past quarter.  In addition, members have access to the handbook online, which includes an interactive symptom checker.  By clicking on a body part and answering a series of questions generated by an evidence-based tool, patients can receive care recommendations such as seek urgent care, call a primary care physician or go to the emergency room.

NHP also sends quarterly reports to all physician groups in its network to indicate: (1) which of their patients have used emergency rooms; (2) which patients have used EDs frequently (i.e., more than five times in the past year); (3) the diagnoses of patients using emergency rooms and whether they used EDs for ambulatory-sensitive conditions;(4) times of day during which patients have used emergency rooms; and (5) health outcomes following ED visits. NHP sends reports to individual physicians and posts them on its secure Web portal so that physicians can sort and analyze the data.  Such impactful changes are to be lauded; however, just imagine the change that a multidisciplinary payer – provider team working in tandem with the chronic needs population could achieve.

While these examples are nothing less than noteworthy, the most potentially innovative change could be found in Intermountain Healthcare’s recent telehealth launch, which allows individuals to access primary care physicians or specialists from private computers at the hospital via a video chat feature located on the IHC website.  Individuals presenting at the ED, only to learn that their symptoms are more appropriate for primary care, now have the option to speak with a physician in a safe environment for a reasonable fee in an acceptable amount of time. Sounds like a win-win to me.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Population Health Management: Revolutionizing Health Care Service Delivery

As noted in the recent HealthLeaders Media article, ACOs Population Health Management Share a Common Thread, “(as) the reimbursement environment transitions from volume-based to a value-based one focusing on quality care and efficiency, providers will be held accountable and could lose out financially if the health of their patients doesn’t improve.“  In an attempt to be ahead of the curve, one such group, Monarch HealthCare, is doing just that.  As a participant in the Brookings-Dartmouth ACO Pilot Program, this large physician-led independent practice association (IPA) felt well suited to pursue the concept of patients first.  And in the Commonwealth Fund’s January 2012 Case Study, Toward Accountable Care, the authors provide a comprehensive overview of the group’s journey towards this goal.

Located in the northern, southern and Orange county coastal California regions, this seventeen year old organization contracts with 2,200 independent private practice physicians to serve nearly 180,000 patients.  With a license to take global risk under its own Medicare Advantage plan, Monarch specializes in providing managed care to seniors.  Spurred by a perceived competitive threat from Kaiser Permanente’s move into Orange county, Monarch decided to leverage its extensive managed and preventive care experience in order to develop an accountable care organization.  Extolling their “I CARE” values, standing for “Innovation, Communication, Accountability, Respect, and Excellence.”, Monarch partnered with Anthem in order to provide care coordination and care navi­gation support for 25,000 Anthem preferred provider organization (PPO) members in Orange County.

In order to bear risk and successfully share in potential savings, Monarch had to develop sophisticated tools and infrastructure to manage both the quality and costs of care for this popula­tion of patients.  Specifically, they engaged in the following:

ACO Structure

• Governance & Leadership – two complementary governance structures are involved in overseeing and driving the progress of Monarch’s single payer/provider ACO model. These include an internal Executive Steering Committee, which meets weekly, and an external Monarch-Anthem Partners Joint ACO Steering Committee, which meets monthly. The Joint ACO steering committee is also supported by the Attribution, Clinical Operations, Contracting, Cost of Care, HIT/Sys Ops, Marketing/Sales/Comms, Medical Management, Performance Metrics and Product Development/Benefit Design subcommittees.  In addition, the SVP for Accountable Care position was created to execute ACO strategy.
• Payment – for the first year, the two groups have agreed on a care management fee and simple shared-savings model. They also have noted that for the ACO to be successful, they will eventually need to shift to a risk-bearing model and aim to phase in a global capitation model over the course of the five-year contract.

HIT Infrastructure

• Health Information Exchange (HIE) – when it is launched, this Web-based platform will pro­vide internal connectivity between systems that are already in place at Monarch and between Monarch’s electronic systems and those of other institutions.
• NextGen – includes an EHR system, prac­tice management system, internal HIE system and patient portal. The EHR is linked with laboratories, pharmacies, imaging services, and appointment reminder tools.  And the patient portal will provide patients with secure access to phy­sicians via e-mail and enable them to request appointments or medication refills and see test results.
• PracticeConnect – a web-based tool that deploys information to all independent practice providers and enables clinical information-sharing, patient status inquiry and messaging.  With chronic care registries and claims submission/authorization/referral features, a variety of important metrics can also be monitored and reported.

Population Management Strategies

• Case Management – Monarch keeps a tight rein on care transitions for their elderly population by using the following “five pillars” as guidelines: 1) reconcile medications, 2) set a follow-up appointment, 3) educate patients about warning signs, 4) use effective patient–physician communica­tion, and 5) use a personal health record.  Key players in providing case management include inpatient case managers, ambulatory case managers in a centralized office, employed hospitalists and nurse practitioners on site at hospitals and skilled nursing facilities, social workers, patients’ primary and specialty care physicians,  inpatient medical directors and ambulatory care medical directors .
• Disease Management and Registries – primary care providers and disease man­agement coaches help asthmatic and diabetic patients write self-care man­agement plans, with a case manager being assigned to each patient. The plans include recommendations for patients on routine care, sick-day planning, symptom recognition, and early intervention to prevent unneces­sary emergency department visits.
• “Touch Teams” – an advanced nurse practitioner, case manager, social worker, and pharmacist—coordinate patients’ transition from hospital to home and make home visits. Monarch also hired two full-time social workers to integrate behavioral health clinical services and other community-based services into the overall plan of care for each high-risk patient.
• Personal Health Records and Advance Directives – these two paper-based tools are used to improve care transitions. The personal health record includes sections on medi­cal history, medications, recent hospitalizations, emergency or urgent care visits and preventive maintenance.  The Physicians Orders for Life Sustaining Treatment is recorded on paper, as well as online, for future reference.
• Urgent Care and ‘Alternative’ Providers – in order to reduce hospital re-admissions and emergency department visits, Monarch has employed hospitalists, skilled nursing physicians and nurse practitioners for better care transitions and, if appropriate, encouraged members to utilize urgent care facilities.

Performance Improvement

• Readmission Rounds – medical director or assistant medical director, hospitalists, and case managers con­duct a root cause analysis of every readmission that occurs within 30 days of discharge to determine where the system broke down and how to improve care pro­cesses.
• Integrated Care Teams – a new initiative aimed at bringing together all of the people involved in managing a population of patients. These teams will focus on patients aligned with spe­cific physician practices, according to geography.  With local integration, Monarch hopes to facilitate more effective communication and alignment across specialties, geographic locations, and episodes of care.
• Reducing Waste – by pulling relevant data from the network using nearly 20 complementary data systems, as well as actu­arial services to compare utilization with peer organiza­tions, Monarch identified system-wide inefficiencies in duplicative or otherwise unnecessary tests, inadequate communication of information, excessive inpatient bed days, unnecessary utilization of specialists and over­-utilization of emergency services.
• Quality Gate and Efficiency Scorecard – the qual­ity gate is the minimum performance threshold that must be achieved by participating providers in order to receive a bonus. The draft efficiency scorecard iden­tifies aggregate utilization and costs associated with efficiency measures. Once the ACO passes the quality gate, the efficiency scorecard will be used to determine the savings that will be shared between Monarch and Anthem.

Through strong executive leadership, trust and transparency in partnerships, use of care navigators, physician champions and economies of scale, Monarch HealthCare has the potential to revolutionize healthcare service delivery with its population management strategies.  In light of Monarch’s recent acquisition by OptumHealth, a subsidiary of UnitedHealth Group, it will be intriguing to see if they remain the course.  The proof, no doubt, will be in the pudding.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

*image courtesy of the Public Health Agency of Canada