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.

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

schoy@thecamdengroup.com

www.thecamdengroup.com

###

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.

Join us at this upcoming event in Scottsdale, Arizona, February 28 through March 2, 2010.  Our Senior Vice President, Brian Silverstein M.D., and our Senior Medical officer, Eric Nielsen, M.D., will be presenting on Sunday at 2:30 p.m.  They’ll be talking about value-based payment – from clinical integration to accountable care.   

Here’s a link to where you can register:  http://www.healthcarestrategy.com/conferences/2010/PSS2010.asp