Healthcare Intelligence Network

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."

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.