HealthSounds

While shared savings could be several years in the future for fledgling accountable care organizations, there are shortcuts for physician practices in ACOs to generate population health revenue immediately, explains Tim Gronniger, senior vice president of development and strategy for Caravan Health. In this HealthSounds episode, Gronniger outlines the rationale for using three Medicare billing codes--the annual wellness visit (AWV), chronic care management and advanced care planning--to create revenue that offsets ACO infrastructure costs.

As 2017 draws to a close, the recent CVS Health-Aetna merger continues to dominate the healthcare conversation. David Buchanan, president, Buchanan Strategies, weighed in on the non-traditional partnership during Trends Shaping the Healthcare Industry in 2018: A Strategic Planning Session, a December 2017 webinar now available for replay. In this HealthSounds episode, Buchanan predicts the future of mega mergers in healthcare, the impact of the CVS-Aetna alliance on brand awareness, and the real ‘bonanza’ of the $69 billion partnership beyond bringing healthcare closer to home for many consumers.

As patients of Lehigh Valley Health Network (LVHN) began to utilize the features of its newly minted portal, LVHN and its physician providers soon recognized the added benefits of this interactive tool. In this HealthSounds episode, LVHN’s Lindsay Altimare outlines seven ways the LVHN portal, the fastest growing portal on the Epic® platform, improves efficiency and quality for her organization.

How do you engage community residents in their health when many are distrustful of and feel disrespected by the healthcare system? Encourage them to both direct and participate in the initiative, advises Charmaine Ruddock, project director of Bronx Health REACH. In this HealthSounds episode, Ms. Ruddock shares what Bronx Health REACH learned early on in its coalition-building from community focus groups, and how this local feedback informed program development for a community traditionally ranked last in New York in terms of health outcomes and health factors.

How can care teams encourage patients to open up about sensitive social determinant of health (SDOH) factors? By employing motivational interviewing to establish a respectful partnership, advises Cindy Buckels, TAV Health director of population health. In this HealthSounds episode, Ms. Buckels explains why motivational interviewing is more effective than the usual Chunk-Check-Change approach in transforming patient ambivalence and effecting the kind of behavior change that improves health.

How receptive are clinicians to being coached in patient engagement techniques? At PinnacleHealth, provider reaction to rollout of patient engagement coaching has followed a standard bell curve, notes Kathryn Shradley, PinnacleHealth’s director of population health. In this HealthSounds episode, Ms. Shradley outlines the framework underscoring the engagement coach’s supportive and educational role while at providers’ elbows as well as ways the health system earned clinicians’ support for the initiative.

For patients with cancer, palliative care should begin at diagnosis to help them shoulder the disease’s emotional, physical and financial burdens, explains Laura Ostrowsky, director of case management at Memorial Sloan Kettering Cancer Center (MSKCC). However, for multiple reasons, referrals to hospice frequently happen too late for MSKCC patients to derive full benefit from that service. In this episode of HealthSounds, Ms. Ostrowsky shares some key questions for integrated case managers to ask providers to improve timeliness of hospice referrals, patient and family satisfaction with hospice service, and awareness of end-of-life care. The strategy is one way MSKCC uses integrated case management to validate its worth in a value-based system: providing the best care in a quality-effective manner.

In this podcast, Paige Moore, director of patient experience at UnityPoint Health, describes the rationale and rollout for the four behaviors, which are based on patient and visitor feedback and comments.

In this podcast, Dr. Amanda Parsons, MBA, vice president of community and population health at Montefiore Health System, explains the various screening approaches taken by the physicians, and how that multi-site strategy figures into the health system’s overall plans for SDOH interventions.

In this podcast, Susan Craft of the Henry Ford Health System (HFHS), one of four collaborative founders, outlines a few SNF participation and reporting mandates that run the gamut from meeting attendance to LACE readmission risk scores.

Among the myths surrounding care transitions management is the belief the intervention can be effectively executed pre-discharge or by phone only, explains Jennifer Drago, executive vice president of population health for Sun Health. In this audio interview, Ms. Drago dispels this myth, outlining requirements for a professionally designed, evidence-based transitions of care program, and why inclusion of dedicated staff and home visits will enhance clinical outcomes and possibly save lives.

Among other data, detail tables in a physician practice’s Quality Use and Resource Reports (QRURs) pinpoint specialist referral networks for Medicare beneficiaries, explains William Holding, consultant, PDA, Inc., which can help physician practices determine their highest value referral pathways. In this audio interview, Holding explains the benefits of tapping CMS-generated QRUR reports to enhance performance under Merit-Based Incentive Payment Systems (MIPS), one of two payment paths for physician reimbursement under MACRA.

Working to bridge the gap between hospital discharge and permanent supportive housing for homeless patients, the California-based Chronic Care Plus program found that 40 percent of client needs are related to social determinants, explains Paul Leon, CEO of the Illumination Foundation, a Chronic Care Plus joint venture partner. In this audio interview, Leon explains the need to not only house patients but also to connect them to a plethora of social services, including mental health appointments.

Identifying social determinants of health (SDH) requires providers to probe beyond the scope of clinical data. But how can health teams ensure that patients and health plan members provide valid data during SDH assessments? In this audio interview, Dr. Randall Williams, chief executive officer, Pharos Innovations, describes three scenarios to build trust and encourage individuals to share sensitive information during SDH interactions.

The engagement of patients, particularly those with multiple chronic conditions, continues to challenge healthcare providers. However, as Steven Valentine, vice president of advisory consulting services for Premier Inc., explains in this podcast, clinicians actually have a host of tools at their fingertips to engage patients—tools they must employ in order to succeed in value-based healthcare.

Prior to enrollment in MACRA’s Merit-Based Incentive Payment System (MIPS), physician practices should request their confidential Quality Use and Resource Report (QRUR) from the Centers for Medicare and Medicaid Services (CMS) for crucial performance feedback, advises Barry Allison, chief information officer, the Center for Primary Care. In this podcast, Allison explains how to obtain a QRUR report, the origins of QRUR quality and cost data, and the benefits of leveraging QRUR feedback to improve the quality and efficiency of care delivered to attributed Medicare fee-for-service beneficiaries and ultimately prosper under MACRA’s multi-pronged approach.

After UT Southwestern Accountable Care Network (UTSACN) discovered its home health spend was more than twice the national average, it applied data analytics to create a preferred home health network of 20 agencies (down from 1,200) that has saved more than $6 million in home health utilization in the first quarter of 2016 alone. In this podcast, Cathy Bryan, director of care coordination at UTSACN, describes the provider reeducation process supporting the launch of this narrow network that has improved accountability, data sharing and communications related to home health utilization.

Under its partnership with CMS to improve quality of care in long-term care (LTC) facilities by reducing avoidable hospitalizations, the University of Pittsburgh Medical Center RAVEN project embeds clinical staff within eighteen nursing facilities. Here, April Kane, co-director of the RAVEN project, explains how the on-site presence of enhanced care and coordination providers (ECCPs) elevates the facility’s clinical capabilities, from goal development to advanced care planning.

Even when employing sophisticated predictive analytics to zero in on population health risk, healthcare organizations shouldn’t discount providers’ intuition, advises Luke Hansen, MD, vice president and chief medical officer, population health for AMITA Health. With a future plan to adopt a risk prediction tool, AMITA currently creates chronic illness registries to track its high-cost patients. Listen as Dr. Hansen discusses the tradeoffs of mathematically intense risk predictors versus physicians’ guts.

By focusing chiefly on moving high-risk patients down to the low-risk band, population health management programs are in danger of missing the “natural inertia” driving low-risk patients right back into that high-risk stratum, cautions Dr. Adrian Zai, clinical director of population informatics at Massachusetts General Hospital (MGH). Dr. Zai describes why MGH, ranked the number one hospital in the nation by U.S. News & World Report,® advocates a multi-pronged approach addressing both low-risk and rising risk patients—a strategy that has improved MGH care quality and provider performance while reducing high-cost healthcare utilization.

Rather than threatening to drop Medicare volumes or open a concierge practice, small and solo physician practices daunted by MACRA technology requirements should sit tight and avail themselves of current and promised education and training from CMS to support the transition, advises Eric Levin, director of strategic services, McKesson. In this audio interview, Levin describes what’s at risk for practices that don’t engage in at least one physician reporting program and four benefits of tapping into MACRA technical assistance from CMS.

Increasingly in motivational interviewing (MI) research, change talk—anything a patient or client says that counts as an argument for change—is a reliable sign they’re ready to make a change, notes Mia Croyle with the University of Wisconsin School of Medicine and Public Health. Here, Ms. Croyle shares some of the latest thinking regarding change talk: how motivational interviewing practitioners might interpret change talk in interactions with clients, particularly those with behavioral health diagnoses, as well as how to elicit more change talk during an MI session.

Whether an ACO is assessing readiness for CMS’s Next Generation ACO model or is already a Medicare Shared Savings Program (MSSP) participant, face-to-face education of non-executive providers living the day-to-day ACO reality is critical to that accountable care organization’s viability, advises Travis Ansel, senior manager of strategic services for Healthcare Strategy Group. Even within experienced MSSP ACOs, providers often don’t understand MSSP quality goals, the relationship of their actions to cost management or MSSP data requirements, noted Ansel. In this broadcast, Ansel describes the two biggest barriers to success across all ACO models, and offers two tips to organizations wishing to prosper in the value-based care reimbursement world.

While it does not immediately eliminate fee for service, a retrospective upside-only payment model is helping to transform the spirit of the payor-provider relationship, notes Lili Brillstein, director of the Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) Episodes of Care (EOC) initiative where this methodology has been implemented. Listen as Ms. Brillstein describes how Horizon’s application of retrospective methodology across all episodes expands the program’s reach and opportunities while fostering a no-risk environment conducive to collaboration.

Community Care of North Carolina’s Transitional Care program was awarded the Hearst Health Prize this month not only for demonstrating how effective transitional care is for its 1.5 million Medicaid beneficiaries, but also for continually evaluating and modifying the intervention based on its findings. In this broadcast, Carlos Jackson, CCNC’s director of program evaluation, shares one of CCNC’s more interesting findings, identifying the priority population for the intervention, and explains why the care transition management mindset must expand beyond reducing hospital readmissions.

An accurate medication list is square one for clinical pharmacists working to reconcile prescriptions and reduce readmissions among Novant Health’s highest-risk patients, explains Rebecca Bean, director of population health pharmacy for Novant Health. But maintaining a valid list can be problematic when the inventory is accessed by multiple healthcare providers. Ms. Bean describes the challenges of maintaining an accurate medication list and suggests strategies for ensuring medication list integrity in this audio interview.

Beyond facilitating business decisions and improving quality of care and patient experience, data analytics help Collaborative Health Systems (CHS) to close gaps in preventive care within its 24 accountable care organizations (ACOs), explains Elena Tkachev, CHS director of ACO analytics. One key preventive metric for the largest U.S. sponsor of Medicare Shared Savings Programs (MSSPs) is the Medicare Annual Wellness Visit (AWV), which CHS has set as a core goal. In this audio interview, Ms. Tkachev describes the rationale behind this goal, how data analytics drives AWVs, and the dramatic correlation between AWVs and patient attribution.

When Bon Secours adapted Geisinger's case management model six years ago and embedded nurse navigators within physician practices, there was reluctance and even resistance from some solo cowboy physician practitioners, recalls Robert Fortini, PNP, chief clinical officer for Bon Secours Medical Group. Today, providers are fiercely protective of the cadre of 70 nurse navigators, who do the heavy lifting of chronic care management. In this audio interview, Fortini offers some lessons learned for organizations considering the embedded case management approach, including budgetary planning, calculations, and icing-on-the-cake outcomes for patients and hospitals.