Healthcare Intelligence Network

While neither colocation of team members nor an electronic health record is a prerequisite for a successful integrated care team, explains Dr. Jan Berger, chief medical officer of Silverlink Communications Inc., there are four essential factors that contribute to the confidence and comfort levels of both patients and team members. Dr. Berger will share practical examples on how the integrated care team can work together to support patients in adhering to care plans, including a model of care that places the pharmacist on the care team and another that incorporates technology, during "Achieving Medication and Care Plan Adherence Through an Integrated Care Team," a 45-minute webinar on March 17, 2010.

Even though more than a third of the elderly are online, they're not necessarily using the Internet to seek health assistance, explains Marcia Wade, M.D., F.C.C.P., M.M.M., senior medical director at Aetna Medicare. That's why Aetna delivers its health risk assessment for the elderly in an alternate format while making available other Web-based tools to web-savvy boomer beneficiaries. Dr. Wade also describes Aetna's user-friendly strategy for heading off high-risk complications among its elderly and how this contributes to an overall reduction in hospital readmissions. Dr. Wade explained what to assess in the elderly population, how to match interventions based on risk score and the impact of this type of initiative during "Assessing and Predicting Health Risk in the Elderly," a 45-minute webinar on February 10, 2010.

A year into the Colorado multi-payor medical home pilot whose practices provide care to 30,000 patients, Julie Schilz, B.S.N., M.B.A., prescribes a single tool that can help transform practices, improve quality and deliver evidence-based care. It's NOT an EHR, says the manager of the Improving Performance in Practice and Patient-Centered Medical Home (PCMH) initiatives for the Colorado Clinical Guidelines Collaborative, who lists this tool's four key functionalities. Also in this interview, Schilz describes the influence of other reimbursement models on the Colorado pilot and identifies two opportunities for NCQA to enhance its PCMH recognition process. Schilz shared Colorado's experience to date in creating this multi-payor initiative --- from the development of the program to the challenges of working with multiple payors --- during the January 20, 2010 webinar, "Multi-Payor Medical Home Programs: Addressing Funding and Organizational Challenges."

The dismal economy of 2009 has been a bright spot for health coaching and other health improvement programs, notes Dr. Jim Reynolds, chief medical officer for Health Fitness Corporation. Dr. Reynolds also compares early results from a Massachusetts' smoking cessation program for Medicaid beneficiaries with outcomes in commercial populations, and describes what Year 1 of a coaching program for improved medication adherence might yield in the way of behavior change and cost impacts. Dr. Reynolds and Dr. Elizabeth Rula, clinical research manager at the Center for Health Research at Healthways Inc., shared how their organizations respond to the challenges of evaluating and reporting on health coaching ROI during the January 13, 2010 webinar, "Health Coaching Evaluation: Measuring the ROI on Healthcare Utilization and Costs."

The pharmacist has a natural and important role in patient medication reconciliation and review, explains Dr. Beth Chester, senior director of clinical pharmacy services and quality, Kaiser Permanente Colorado. She describes the dramatic impact that a pilot pharmacist intervention had on emergency department visits and mortality rates among patients just discharged from skilled nursing facilities (SNFs) once the health plan's pharmacists stepped in to monitor medication therapy in this population. Dr. Chester detailed the roles of the physician practice's staff and the pharmacist in medication management, the use of technology and how financial incentives and reimbursement can play a role in improving medication compliance during the January 6, 2010 webinar, "Medication Therapy Management in the Patient-Centered Medical Home."

Social and demographic factors such as chaos in the home or functional status can complicate care coordination for patients as much as clinical factors, explains Jeff Schiff, M.D., M.B.A., medical director of Minnesota Health Care Programs for the Minnesota Department of Human Services. He identifies two key social/demographic factors getting close attention in Minnesota's new primary care reimbursement model and explains how the engagement of patient and family at the clinical level is paying off in improved patient safety, satisfaction and health outcomes. Dr. Schiff examined the risk factors that need to be considered in a risk-adjusted medical home reimbursement strategy during the December 16, 2009 webinar, "Risk Adjustment in the Medical Home: Building an Effective Reimbursement Strategy."

Case managers and advanced practice nurses in Aetna's Transitional Care pilot have also successfully partnered to reduce readmissions. Dr. Randall Krakauer, national medical director, Medicare at Aetna, describes the key focus and the complementary roles that reduced 90-day readmissions by 25 percent. Dr. Krakauer also weighs in on the pros and cons of bundled payments, and why incentives alone will not significantly impact avoidable readmissions. Dr. Krakauer and Dianne Feeney, BSN, MS, associate director of quality initiatives for the Maryland Health Services Cost Review Commission (HSCRC), examined how to structure programs to reduce avoidable hospital readmissions, including the alignment of financial incentives, during the December 2, 2009 webinar, "Aligning Reimbursement To Reduce Avoidable Hospital Readmissions."

Maryland's Hospital Preventable Readmissions program rewards efforts that reduce hospital readmissions while improving care quality and decreasing cost. Dianne Feeney, associate director of quality initiatives for the Maryland Health Services Cost Review Commission (HSCRC), describes HSCRC's response to hospitals that claim they can't afford the empty beds that result from programs like these, as well as processes to help ensure that higher-risk patients are not refused admittance to hospitals. She also explains how partnerships with "siloed settings" --- nursing homes and home health providers --- can reduce common errors that occur during patient handoffs. Feeney and Dr. Randall Krakauer, national medical director, Medicare at Aetna, examined how to structure programs to reduce avoidable hospital readmissions, including the alignment of financial incentives, during the December 2, 2009 webinar, "Aligning Reimbursement To Reduce Avoidable Hospital Readmissions."

Priority Health members play an active role in keeping themselves out of the hospital, explains Mary Cooley, manager of case and disease management at Priority Health. She describes the four-point strategy that is reducing readmissions at Priority Health, the challenges that still exist and the essential tool that Priority supplies to help providers identify and close care gaps. Cooley provided more details on the strategies that Priority Health is using to reduce avoidable hospital readmissions during "Reducing Avoidable Hospital Readmissions: A Case Study from Priority Health," a 45-minute webinar.

Case managers are the backbone of the Geisinger Health Plan (GHP) Health Navigator(SM) program, a medical home partnership between primary care providers and GHP that has reduced 30-day hospital readmissions by 15 to 20 percent. Providing benchmarks for case manager caseloads and contact frequency, tools to support the case management effort, the key to smooth placement of case managers in the medical home and tips for better management of patients discharged to nursing facilities are Diane Littlewood, R.N., and Joann Sciandra, R.N., who are both regional managers of case management for health services at Geisinger Health Plan. Littlewood and Sciandra provided more detail on the key components of a winning case management program during "Effective Case Management in the Medical Home," a 45-minute webinar. The webinar is part of HIN's continuing "Medical Home Open House webinar series."