Accountable care organizations are the future of health care. A five-step plan will prepare your organization for upcoming changes.
Click here for the full article written by Brian J. Silverstein, M.D. and Michael J. Randall. It first appeared on July 12, 2010 in HHN Magazine online site.
Federal and state government incentives for physicians and hospitals to install and meet “meaningful use” requirements for information technology (“IT”) have created an unrelenting push to implement electronic medical records. While meeting government guidelines is important, senior management leaders need to remember that to make healthcare systems more effective and efficient, these strategies must deliver better tools for caregivers. Any of the strategies being employed to improve the quality of healthcare and reduce costs require the ability to manage, interpret, and coordinate information in real-time. The tenets of pay-for-performance programs, medical home models, clinical integration (“CI”), and accountable care organizations (“ACOs”) are based on improving care delivery through coordination of the entire continuum of care. Here are the top ten questions senior leadership should discuss in preparation for this “new world.”
1. Why should we consider CI or becoming an ACO? CI has demonstrated results in improving quality and reducing costs – key goals to achieve in the path toward accountable care. Organizations that meet the Federal Trade Commission’s (“FTC”) definition of CI achieve efficiencies by monitoring and controlling quality, service, and costs, selectively choosing physician participants, and making a significant investment of monetary or human capital in infrastructure. An additional benefit for organized groups of independent physicians that become clinically integrated is that if these groups meet FTC guidelines, they will be allowed to jointly contract with payers. In many markets, a majority of physicians are not in an employed group model; the CI structure allows them to provide better patient care as well as be rewarded by increasing the quality, service, and cost effectiveness of the care. Ultimately, CI is an early stepping stone to becoming an ACO.
2. What are the keys to a successful information strategy for CI and ACOs? Regardless of the organizational model (e.g., large multi-specialty group, IPA, PHO, or integrated delivery system), the information system should lead to higher quality, effective, and efficient patient care. The system must provide the right information, at the right time, in the right form and be supported by an infrastructure to assure its security, maintenance, and use. Providers must be able to make timely, personalized decisions for the individual patient at the point of care. These decisions must be based on current, comprehensive information and patient history.
3. How will this information strategy improve the quality of healthcare, reduce costs, and provide the ability to manage, interpret, and coordinate information in real-time? Real advantages and productivity gains are realized only if the caregivers have access to real-time information at the bedside, exam table, or through secure email exchanges between providers, staff, and patients. Physicians and caregivers should easily be able to collect, visualize, and interpret information and compare it to network protocols, guidelines, and databases when it counts – that is, at the time of decisions. The information strategy must avoid locking information into inaccessible “islands.”
4. Does the proposed strategy facilitate working toward the goals of quality, service, and cost reductions implicit in the new payment incentives? Payment incentives rely on the ability of an organization to demonstrate and document care processes and the achievement of performance targets, including clinical and patient satisfaction metrics. Some of these requirements can be met with relatively simple IT solutions, but more sophisticated and comprehensive systems are needed to drive improvements throughout the continuum of care. The IT strategy must focus resources on assisting the caregiver in knowing not only what to do, but when to do it (i.e., real time alerts). It must also indicate if their performance is getting better or worse.
5. How can we incorporate independent physicians and small medical groups in CI? Using CI tools, even small to mid-sized physician groups, in partnership with an IPA, PHO, hospital, or integrated delivery system, can use information technology to begin to impact the health status of their patients, meet the requirements of payers, and identify process improvement opportunities.
6. Does the technical infrastructure of this information strategy meet the requirements set by the FTC? The technical infrastructure for CI must address two key components to meet the FTC definitions: “the use of common information technology to ensure exchange of all relevant patient data” and “the development and adoption of clinical protocols.” The exchange of all relevant patient data requires a platform that can integrate data from multiple community sources (e.g., hospitals, physician offices, labs,) and store this data in a central data repository. This immediate availability of trusted data is the key to patient care collaboration, the identification of diseases and corresponding care protocols, and performance monitoring at the provider, practice, and network levels. The assembly of patient data from multiple sources requires careful consideration to ensure accuracy and completeness.
7. Does this strategy facilitate the integration of existing systems across the provider and service continuum? Integration of existing systems across the provider and service continuum must be considered when designing a CI infrastructure. Regional health information exchanges, hospital enterprise systems, electronic medical records, ancillary provider portals, and patient portals can all potentially be leveraged as part of the overall solution. These solutions must be evaluated carefully as they alone will not guarantee that CI has, or will be, achieved. Regardless of the solution chosen, at least one should be available to virtually every physician. As the tools become more comprehensive, the ability to drive results increases dramatically.
8. Do the information tools meet the criteria and requirements in order to be successful in CI and accountable care? To meet the functional needs related to the exchange of patient data, the technical support for CI must meet the following:
■ Provides immediately available clinical results to be viewed across service providers
■ Provides access to the established clinical guidelines
■ Provides a secure mechanism for provider communication
■ Allows providers to assign patient access to referring or consulting providers
■ Provides access to protocol adherence and measure quality outcomes at the provider, practice, and network level
■ Allows electronic prescribing
■ Enables clinical decision support based on network determined guidelines including point of care alerts
■ Tracks physician performance against benchmarks and their peers
9. What are the resources required and timelines for implementing an information strategy for CI and ACOs?
There are various methods to approaching the development of a successful long-term information strategy for CI and ACOs. An evaluation of a build vs. buy scenario will determine the best approach with the greatest potential for success and, in many cases, a combination of the two will be the final solution. Factors that may play into the decision include current internal resources, expertise, and internal systems, current vendor applications already in contract, vendor experience and satisfaction, desired timing of implementation, and cost. There are pros and cons to each approach which can be generalized, but individual organizations should pay careful attention to the internal IT culture and history of IT implementations before choosing an approach.
10. How will we know when the changes in information strategy have led to the desired outcomes for quality and efficiency, and how should we continue to support these ideas and capabilities? The only way to be aware of successes or failures is to measure them! When information is organized into a structured system, the focus must be on meeting the needs of physicians, providers, and patients’ care while decreasing errors, gaps, delays, and variation in practice. What are the users’ satisfaction levels with the content, its ease of use, and its relevance to meeting their needs? The strategy should create a highly flexible integrated system with tools that help each patient/member become healthier, leading to a healthier population while focusing on impacting cost, efficiency, and quality. As with all work, it is never complete and will lead to the next iteration as the bar is raised.
For more information on clinical integration and accountable care organizations, please contact Jim Smith at 800.360.0603 x6108 or jsmith@thecamdengroup.com or Claire Heideman at 312-775-1703 or cheideman@thecamdengroup.com.
Bundled payment is one of several CMS pilot projects for payment reform designed to achieve clinical and financial integration between physicians and hospitals, leading to enhanced quality and reduced costs. The process of care redesign associated with managing effectively within a global payment (Part A and Part B) can be an early stepping stone to developing more comprehensive models of care integration, such as an accountable care organization (“ACO”)…
Click here for the complete article written by Senior Vice President Mark Dubow, MBA and Senior Advisor Robert Minkin, MBA which was published by CA Healthcare News in their June 2010 issue.
The Camden Group Announces Affiliation with Long Time Client GRIPA
Los Angeles, California, May, 26, 2010— The Camden Group, a national healthcare business advisory firm, today announced that it is now affiliated with Greater Rochester Independent Practice Association (GRIPA), a leading physician hospital organization (PHO).
The Camden Group sought the affiliation with GRIPA given the increased demand from healthcare clients to find ways to facilitate improved coordination of care and achieve greater integration in order to deliver greater value to healthcare consumers. With its 812-physician membership, two community hospitals, and a medical management and IT staff, GRIPA is one of the first in the nation to achieve a favorable advisory opinion from the FTC on their plan for clinical integration. Camden clients will now have direct access, including site visits, to GRIPA in order to learn and understand ways to deliver accountable care.
“We are thrilled to have this unique opportunity to be affiliated with such a groundbreaking organization – one that we have worked with for several years,” said Steve Valentine, president of The Camden Group. “Healthcare is changing, and it’s moving in a very clear direction. GRIPA embodies the future of healthcare and achieves the core objectives defining this new age in accountable healthcare – greater clinical quality, improved cost effectiveness, and superior patient experience.”
In addition to The Camden Group’s affiliation with GRIPA, the firm announced earlier this year its hiring of GRIPA’S former CEO, James Smith, FACHE, as senior vice president. Smith is heading up The Camden Group’s advisory services in clinical integration and the development of accountable care organizations. Eric Nielsen, M.D., the current CMO of GRIPA, also recently joined The Camden Group as Medical Director for the firm.
“This collaboration brings great exposure and expertise for both our organizations,” said Gregg Coughlin, president of GRIPA. “Healthcare is revolutionizing at an incredible pace, given the anticipated impact of healthcare reform. Together, we’re dedicated to innovating the industry to make healthcare work better – for everyone.”
This latest news follows the recent announcement by The Camden Group that it has added Robert A. Minkin, former CEO of Exempla Saint Joseph Hospital, to serve as senior advisor to the firm. Minkin is a leading national expert on bundled payments. Under Minkin’s leadership as president and CEO, Exempla Saint Joseph won the bid to participate in a three-year CMS Acute Care Episode (“ACE”) demonstration project to “bundle” payments to hospitals and physicians. Exempla Saint Joseph is one of four hospitals with cardiac programs to participate in the pilot demonstration.
About The Camden Group
The Camden Group provides a vast array of consulting services on areas ranging from hospital operations improvement, strategic, financial and business planning, and physician group advisory services. Since its founding in 1970, The Camden Group has advised more than 1,000 hospitals, medical groups, outpatient facilities, and other healthcare organizations nationwide. For more information, please visit www.thecamdengroup.com.
Contact:
Sarita Choy, Marketing/Communications Coordinator
The Camden Group
310.320.3990
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Robert A. Minkin, former CEO of Exempla Saint Joseph Hospital, to serve as senior advisor to consulting firm
Los Angeles, California, May 18, 2010—The Camden Group, one of the nation’s leading healthcare business advisory firms, today announced that it is adding Robert A. Minkin, former CEO of Denver-based Exempla Saint Joseph Hospital, to its growing team of healthcare industry experts. In recent months, The Camden Group has been steadily expanding its senior leadership team to better serve its clients, particularly in light of changes anticipated with healthcare reform. Minkin will focus on assisting hospitals and health systems explore and undertake the bundled payment model for their service lines to demonstrate greater value while managing costs.
Under Minkin’s leadership as president and CEO, Exempla Saint Joseph won the bid to participate in a three-year CMS Acute Care Episode (“ACE”) demonstration project to “bundle” payments to hospitals and physicians. Exempla Saint Joseph is one of four hospitals with cardiac programs to participate in the pilot demonstration.
“Bob Minkin is one of only a handful of people who really understands how to implement bundled payments to create value for an organization and its patients,” said Steve Valentine, president of The Camden Group. “His firsthand experience and unparalleled expertise will help guide our clients to succeed in this new era for healthcare.”
This recent news follows The Camden Group’s announcement earlier this year that James R. Smith, FACHE, the former CEO of Greater Rochester Independent Physicians Association (“GRIPA”) and Regional President of Excellus BlueCross BlueShield for the Central New York region, joined the firm to lead its new office in Rochester, New York. As senior vice president, Smith heads up the firm’s advisory services related to clinical integration and developing accountable care organizations. GRIPA was one of the first in the nation to receive a favorable advisory opinion from the FTC on their clinical integration program.
“The Camden Group is very well-respected and has a long history of success with their clients,” said Minkin. “I am thrilled to have this opportunity to help provide innovative solutions to the challenges hospitals and health systems are currently facing. The healthcare industry is rapidly changing, and there are many opportunities for visionary organizations to succeed. The Camden Group can help those organizations get there. ”
Prior to Exempla Saint Joseph Hospital, Minkin served as the chief operating officer and executive vice president for St. Joseph Hospital, a 448-bed tertiary care medical center in Orange, California. He also served as CEO for Desert Hospital in Palm Springs, California for eight years. Additionally, Minkin has held senior positions at other healthcare facilities, including Riverside Community Hospital, Riverside, California; Memorial Hospitals Association, Modesto, California; Pacific Medical Center, San Francisco, California; and Community Hospital of Santa Rosa, Santa Rosa, California.
About The Camden Group
With offices in California, Illinois, and New York, The Camden Group is one of the nation’s leading healthcare business advisory firms. The firm provides a broad array of healthcare consulting services in areas ranging from strategic and business planning and financial advisory and compliance, to hospital operations improvement, hospital/physician alignment, clinical integration, and developing accountable care organizations. Since its founding in 1970, The Camden Group has advised more than 1,000 hospitals, medical groups, outpatient facilities, and other healthcare organizations nationwide. For more information, visit us online at www.TheCamdenGroup.com.
Contact:
Sarita Choy, Marketing/Communications Coordinator
The Camden Group
310.320.3990
Through our strategic alliance with Labor Management Institute (“LMI”), we are co-sponsoring LMI’s 2010 International Conference on Workforce Management. The theme of this year’s conference is “Creative Strategies for Maximizing Your Resources.” Several members of our team will be speaking at this event, including Frank Flosman, MBA, Bonnie Barndt-Maglio, PhD, RN, Patricia Hines PhD, RN, and Steve Valentine, MPA. The conference will be held June 9-10, 2010 at the Green Valley Ranch Resort & Spa in Las Vegas, Nevada. For more information, please download the brochure or visit www.lminstitute.com. We hope to see you there!
Now that healthcare legislation has been passed, the industry shift towards accountable care accelerates. Healthcare costs are expected to continue to rise even as reimbursement rates decline. As a result of these challenges and in response to the demand for increased quality and enhanced patient experience, accountable care organizations (“ACOs”) and clinically integrated organizations are being formed across the country. Payers, including government, employers, and health plans, are taking notice of this trend and considering either beginning or expanding their participation with such organizations. The following are five reasons why hospitals, physicians, and payers should support and develop clinically integrated and “accountable” delivery systems or ACOs:
I. Increasing healthcare costs.
Healthcare costs continue to increase and erode the ability to balance state and national budgets, as well as weaken the country’s position in the world market. The Kaiser Family Foundation estimates that Medicare alone, currently 3.6 percent of the United States Gross Domestic Product (“GDP”), will grow to 4.2 percent of GDP by 2018 and to 6.4 percent of GDP by 2030. The Commonwealth Fund National Scorecard on U.S. Health System Performance 2008 shows that U.S. healthcare spending per capita and as a percentage of GDP is respectively more than twice and 50 percent higher than the next industrialized nation. Concurrently, physicians’ and hospitals’ per unit of service revenue increases are not meeting providers’ increased costs, and employers and payers are seeing utilization and technology use sky rocket, driving double digit premium and per member medical cost increases. Simultaneously international quality studies have shown the U.S. population is a poor performer in many areas of community health. This expensive healthcare system is not performing to the level expected nor creating the value needed.
International Comparison of Spending on Health 1980-2005
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II. New incentive systems and models promote quality and cost savings.
New models of shared risk have emerged under different names. Some pay-for-performance (“P4P”) models compensate physicians for clinical care improvements that require some degree of collaboration with hospitals (e.g., Bridges to Excellence®, Medicare’s Physician Group Practice Demonstration). Other P4P programs reward hospitals for improvements that may require physicians to collaborate (e.g., The Leap Frog Group, Medicare’s Hospital Quality Incentive Demonstration). There are also other models led by physician groups or hospitals in which all parties have jointly assumed risk through global capitation or fixed-payment “guarantees” for elective procedures and a ninety-day follow-up period [e.g., HealthCare Partners (“HCP”) or Geisinger Health System respectively].
Some are using clinical integration to evolve a network creating accountability and performance through new community-based models, organized structures, processes, and management [e.g., Greater Rochester Independent Practice Association (“GRIPA”) and Advocate Health]. C. Schoen et al suggest that these options may achieve promising long-term savings as depicted in the next graphic.
Total National Health Expenditures 2008-2017
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III. New IT and connectivity solutions allow for creation of structures and processes through integrated delivery systems.
Health and healthcare delivery are re-organizing ‒ enabled by a myriad of new IT and connectivity solutions. GRIPA Connect™ is an example of a set of solutions used to create an electronically connected provider network. Installation of these electronically connected provider solutions enabled GRIPA to meet the FTC clinical integration requirements, and created an organization, structures, processes, real-time reporting, and action-oriented culture usually found only in employed physician models. Technology is now available to allow independent practitioners and hospitals form the connections needed to clinically integrate and collaborate in accountable care. The following illustrates a CI model and the connections and real-time activity reporting now being used within the network.
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A dependable, accessible infrastructure of shared experts and analysts, as well as a set of reports with active management and support by skilled staff can create real physician and network alignment and positive quality, service, and cost saving results.
IV. New ways to create structure and process result in quality and cost performance improvement.
Due to the advancements in technology, clinically integrated organizations and ACOs are able to monitor, report, and act upon data — in nearly real-time, which facilitates the use of evidence-based guidelines and, for payers, the first opportunity to integrate value-based benefit plans, enabling a new path to metric-driven accountability. This can be the basis on which to eventually build an aligned partnership of members, providers, and payers focused on the health and wellness of the individual and population, and focused on the best healthcare value (i.e., advanced care quality and cost performance improvement).
The FTC and Medicare have promoted clinical integration and ACOs through a series of regulatory actions and pilots programs during the past decade. Structures and processes, such as real-time alerts, tracking, and the efficacy of electronic interchange, along with setting guidelines and the ability to exchange immediate feedback, have been demonstrated successfully by GRIPA, Advocate Health, and others. Lessons on how to build and operate these organizations have been learned and are now being adopted by others. The tools developed, along with committed physicians and leadership focused on change, support the structures and processes, which enable real-time analysis, action, and adjustment. The work required is the active focus on care and service coupled with continuous process improvement, which then becomes part of the culture of the network. The “glue” is the incentives developed to continuously raise the bar while rewarding the efforts of members, employers, and providers.
V. Healthcare is local ‒ these organizations are constructed at ground level and built, operated, and focused to align payers, members, and providers.
Payers – governmental, commercial and self-funded employers ‒ have an opportunity to adopt and benefit from the development of innovative technology and structural and process change. As physicians, hospitals, and other providers learn and use these new connections and systems the power of the connected components in a continuum of care becomes apparent. When there is transparency and communication in near real-time, timeliness, efficiency, and accuracy of care is improved. These changes will transform the health delivery system and ultimately raise the trust and accountability between participants, physicians, providers, and payers. The key benefits for payers will initially be quality-based, but as the iterative improvement process continues, and the culture of improvement and transparency is embraced, investments will pay off in reduction of waste, forgone inappropriate tests and procedures, and truly evidence-based care to the benefit of member, payer, and provider. Systems and networks that have been early adopters of these measures have demonstrated positive results and continue to develop ways to improve.
Members benefit from improved health and quality of life, the motivation to strive for wellness, and personal out-of-pocket savings. Everyone benefits through a system of care based on scientific evidence, adoption of best practices, high standards of quality of care and service, and enhanced communications between patient and provider.
Physicians and hospitals gain enhanced linkage and alignment with each other, which facilitates implementation of quality improvement initiatives and provides “branding” consistency to patients and payers. United branding helps present a collaborative entity working to improve the health of the population it serves. The expansion of physician leadership in clinical care redesign improves revenue yield (e.g., P4P, global payments), facilitates clinical resource reduction, creates a sustainable form of gain-sharing, and provides a vehicle to increase market share and patient preference.
For more information on developing accountable and clinically integrated organizations, please contact James Smith at jsmith@thecamdengroup.com or 800.360.0603 x6108.
By Frank G. Flosman, MBA
Many healthcare providers are discovering that while they were able to weather the rough economic climate of 2009, 2010 has brought additional financial pressures. These pressures are likely to continue unabated given public and private outcries for healthcare cost containment.
In order to meet the challenges of a permanently changed healthcare environment, provider organizations must improve operational efficiencies and structures to address both near-term financial management and long-term service and quality requirements. Here are the top ten ways to achieve sustained operational improvements in a challenging healthcare environment.
1. Strategically focus on high-return improvements first. Identify those cost reduction and efficiency opportunities that are likely to yield the most significant results and then pursue these initiatives in a manner that supports service, quality, and customer satisfaction.
2. Balance short-term needs and long-term goals. Achieving cost improvements simply through across-the-board reductions may limit an organization’s ability to adapt to future service requirements, as well as miss an opportunity to streamline structures and processes. Cost improvements should be based on achieving efficiencies through aligning processes, service integration, structures, and resource utilization with best practices and the organization’s culture and mission.
3. Improve organizational knowledge and capabilities to ensure sustainability of operational improvements. Initial and ongoing communication, education, and training should be integral to any improvement initiative. A communication plan should be developed at project inception; improvement rationale and objectives should be disseminated to all stakeholders; methods and metrics used to assess and monitor performance should be transparent; and orientation and ongoing training related to improved processes, management metrics and tools, and redesigned roles should be acculturated.
4. Use metrics to identify the overall likelihood and scale of operational improvements, followed by the use of best practice knowledge and experience to determine how to achieve required performance levels. Tools, such as benchmarks, are essential for addressing and achieving operational improvements. However, achievable performance goals and the specific opportunities related to these targets can only be determined following a comparison of current processes and structures against best practices. This will result in achieving improvements that meet and exceed the organization’s needs (i.e. “push the envelope”) while considering the facility’s unique operating environment (i.e., improvement should not compromise long-term service requirements).
5. Draw from multiple best practices and improvement techniques to develop an operational improvement approach that meets specific organizational needs. Improvement initiatives should apply a variety of best practice methodologies, tools, and philosophies in a manner that considers, respects, and utilizes an organization’s unique operating environment. This includes an organization’s specific culture, mission, organizational memory, resource availability, competitive landscape, current practices, and stakeholder expectations. Relying on a single methodology or tool may not allow for the flexibility needed to adapt to the ever-changing healthcare provider landscape.
6. Develop and institute accountability structures and practices. Many organizations can identify both the need for improvement and at least the rough scale of likely opportunities. However, very few organizations have the capabilities and tools to realize and sustain significant operational gains. Management tools should be implemented, performance metrics established, and accountability structures and expectations should be set. Most importantly, all these processes and structures should be fully and consistently utilized and fully embraced by leadership.
7. Gain efficiencies from aligning resources and processes across the care continuum. Increasingly, hospitals will find that they have limited ability to achieve significant efficiencies by focusing improvement efforts solely on internal processes. This situation will be exacerbated in the future by likely requirements to better integrate service components across the care continuum. Including clinical integration components in any operational improvement initiative is one of the best ways to address near-term cost and efficiency improvement needs while preparing for probable healthcare payment methodology changes.
8. Pursue new relationships with referral sources and related service providers that will facilitate successful improvement efforts. A hospital’s ability to achieve significant operational improvements without addressing issues of stakeholder participation and behavior may be limited, or, more likely, very difficult. This point is especially important given that the need to improve integration of clinical services may well transition from a major driver of efficiencies and effective utilization of scarce resources to a financial and perhaps even regulatory requirement. New relationships with referral sources and related service providers will need to be developed and nurtured.
9. Own the information, process, and outcomes. Whether or not external assistance for either operational assessments and/or improvement implementations is utilized, hospital management must take full credit and responsibility for both the initiative and its outcomes. Such accountability will convey the gravity of an organization’s need to improve, as well as give legitimacy to the need for all management staff to take charge and be held to performance standards and outcomes.
10. Don’t wait. Delaying operational improvement initiatives will only exacerbate current financial challenges and put an organization further behind the curve in preparing for whatever changes may come. Hospitals and healthcare systems need to strive to improve operational efficiencies and structures now to address both financial management and service and quality requirements.
For more information on how to improve your hospital’s operations, please contact Frank Flosman at 312.775.1714 or fflosman@thecamdengroup.com.
Mark J. Dubow, MBA, MSPH and Brian J. Silverstein, M.D. will be presenting the seminar, “Bold Strategies: Thriving During and After a Recession,” at the ACHE 2010 Congress on Healthcare Leadership on Wednesday March 24, 2010. In this session, attendees will understand why a bold strategy, though counterintuitive, may be the best strategy during and immediately after a recession. Attendees will also discover the tools and techniques to identify, prioritize, select, and implement the right bold strategies to get desired results. Join us there!
In addition, we have written several articles on the topic of bold strategies that were published by Healthleaders Media that might be of interest.
By Michael J. Randall, MHA and Patricia A. Hines, Ph.D, RN
While the nature of the healthcare reform debate changed in recent weeks, the direction in which healthcare delivery systems need to move remains clear. Healthcare spending is out of control, and despite efforts, quality remains variable and somewhat elusive. A variety of new payment mechanisms (e.g., Bundled Payment, Acute Care Episodes, Medicare Physician Group Practice Demonstration, and Bridges to Excellence®),are currently being piloted by Medicare and others. One mechanism that integrated delivery systems are using to change culture, align incentives, and improve care delivery processes and clinical outcomes is clinical integration. Clinically integrated organizations implement robust infrastructures and mechanisms (e.g., provider and patient portals, real time reporting and alerting, electronic health records, care management, clinical measures and protocols) to improve quality and reduce cost through collaboration with physicians.
In clinically integrated organizations, the traditional functions of utilization management and case management evolve to more seamless and coordinated care, with a focus on the multiple venues of care, health maintenance, the patient’s role in care, and the management of chronic diseases. Here are the top 10 initiatives to assure that your care management function is fostering clinical integration and assuring success in new payment models.
1. Advanced Practice Roles. Clinical care managers with a specialty in primary care and general medical surgical care will take a larger comprehensive role in coordinating care across inpatient and outpatient settings, especially for patients with chronic illness and co-morbid conditions. Given that nurses must meet National Committee of Quality Assurance (“NCQA”) and MedPAC standards of care, including coordinating and integrating care standards, nurse practitioners can play an important role as primary care providers in clinical integration. It is estimated that 83,000 nurse practitioners are currently providing primary care services, with significant responsibilities in managing chronic conditions and promoting use of primary care services). These individuals will serve as a conduit for linking wellness, the management of chronic diseases in the outpatient setting, inpatient care delivery, and post-acute services.
2. Communication. Silos within the hospital and across the system must be removed and care needs must be organized around the patient. Care managers are an important linchpin in assuring communication with and among hospitalists, “SNFists”, and other physicians in coordinating care both in and out of the hospital. Care managers in organizations that are clinically integrated will assume additional responsibilities, including negotiating with health plans, collaborating across multiple disciplines and care settings for optimal outcomes, and engaging community resources for care delivery.
3. Clinical and Quality Transparency and Pay-for-Performance. Performance will have a significant impact not only on payment for services rendered, but also on any incentives the hospital and physicians may earn for demonstration of quality and cost reduction. Care managers in clinically integrated organizations must play a leadership role in identifying risks and developing performance improvement initiatives that are multi-disciplinary and lead to measurable results.
4. Strong Medical Staff Relationships. Nurturing strong physician relationships will be an essential skill set for care managers as they assist in the care coordination across specialists and care settings. While care managers will fill the essential coordinator role in clinical integration across clinical specialties to realize operational and strategic goals, patient satisfaction, and optimized revenue, physicians must be engaged and own the process. Care managers are in a key position to partner with the medical staff, create a platform for seamless care coordination, and provide them with the tools and support they need to be successful.
5. Human Capital Changes and Challenges. The trend for increasing utilization of hospital-based physician specialists (i.e. hospitalists, intensivists, laborists, and surgicalists) will continue, which is a challenge from a coordination of care perspective, but also offers some opportunities. By working closely with these specialists, organizations can more easily influence the appropriate utilization of services through the use of care protocols and efficient care processes. Care must be delivered in the appropriate setting, and systems that will ensure a smooth hand-off must be built to manage the transition for the patient.
6. Knowledge Management and Standardization. Clinical care protocols based on best practices have been sporadically utilized in the acute care settings for diagnoses that reflect the majority of admissions. In many organizations, adoption of these protocols is voluntary, resulting in variability in care practices. Metrics such as length-of-stay (“LOS”), ancillary utilization, and cost per case may not correlate to quality outcomes, hindering medical staff discussions of shared knowledge management and the necessity for clinical standardization. Care managers will leverage the information from electronic medical records (“EMRs”), data warehouses, and disease registries to provide information on quality and cost, and manage key populations of patients.
7. Plan of Care. As hospital LOS declines, patients are being sent home earlier in their treatment and with continued care requirements. Existing discharge practices are often fragmented, have ineffective handoff strategies to ensure continuity of care, and frequently lack an immediate contact or appointment with the primary care provider. The patient may have a limited understanding of his/herdischarge plan for continued care and lack of medication compliance, which results in frequent readmissions. Healthcare reform will provide incentives for patients and their families to take a more active role as partners in their care delivery and decision-making. As health systems develop clinical integration strategies and become more at risk for the outcomes of the patient population under their care, care managers will work closely with patients to define treatment goals and write compliance contracts to facilitate adherence to treatment plans and follow-up care. Handoff communication is essential to ensure a complete and accurate transition of information from caregivers to the patient, family, and other care givers. Key data elements should include a discharge report that notes patients’ functional status, medical history, baseline information, learning needs, care plans, medication reconciliation, and services provided while admitted.
8. Effective Discharge Planning. Reimbursement will be affected by the utilization of post-acute venues and the management of chronic readmissions. One model for more effective discharge planning is called the “Care Transitions Intervention” model, where a nurse-coach is responsible for helping patient’s transition back into the community and self manage their recovery. The coach visits the patient once in the hospital, once at home within 48 hours of discharge, and then calls the patient three more times to check on how care treatment is progressing. The coach focuses on four pillars: medication self management, a patient-centered record, primary care and specialist physician follow up, and the patient’s knowledge of adverse symptoms of his/her condition. Care managers will fill an essential role in the communication handoff and ensuring that the plan of care is understood and implemented.
9. Information Technology. Care managers, physicians, patients, and others will have immediate access to advanced technology devices, such as mobile, tablets, and PC portals that will provide real time access and alerts and facilitate care coordination from home to home. EMR access will allow information exchange between sites of care and members of the care team. Telemedicine will become more widely adopted especially in the management of chronic disease, such as congestive heart failure.Telemedicine enables real-time data on a patient’s functional status while at home to be relayed to a healthcare professional who reviews results immediately and implements interventions before a patient deteriorates to a status that requires hospitalization. The data may be quantitative, such as daily weights and blood pressure, or qualitative, such as symptoms a patient may be experiencing. The results can be sent to a nurse or physician through a computer, PDA, or Smartphone. Care managers will evaluate the data in time and collaborate with the healthcare team to adjust the patient’s treatment plan.
10. Performance Scorecards. To thrive in tomorrow’s payment model, hospitals and physicians will need to demonstrate value through improved outcomes and cost management to receive incentive payments. These include: 1) clinical process and outcomes (e.g., nurse sensitive indicators, core measures, management of hospital acquired infections); 2.) patient and caregiver perception of care (e.g., satisfaction rates, patient attrition) and 3) utilization and costs (e.g., bed-days, readmissions, one-day length-of-stay). An important tool for elevating performance is the use of scorecards or dashboards. Organizations should invest in advanced analytic and modeling capabilities to better understand the association between care processes, outcomes, and practice variability. Measurement, monitoring, and continuous improvement will be pervasive in clinically integrated organizations. Scorecards should exist at all levels of the organization, from executive and department directors to staff and physicians. All members of the organization must be aligned and strive for a common set of objectives, each armed with information that is within their span of control and influence.
Clinical Integration Care Management Team
For more information on the roles of care managers in a clinically integrated organization, please contact Michael Randall at mrandall@thecamdengroup.com or Patricia Hines at 310.320.3990 or phines@thecamdengroup.com.