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Ankota: Ushering in the Next Generation of Homecare Blog

The Case for Social Media in Accountable Care

Posted by Will Hicklen on Dec 19, 2012 4:17:00 PM

Social media shows tremendous potential to help better manage Care Transitions and chronic disease, while improving patients lives and reducing hospitalizations. The opportunity here for creativity and innovation that helps patients is unlimited. 

With the rise of Accountable Care and focus on managing Care Transitions to reduce hospitalizations, more care will be planned and coordinated in settings outside of hospitals. That is no secret. Settings will include homes, assisted living facilities (ALFs), skilled nursing, offices of primary care physicians, and more. As the challenges of geography of patients and care givers are met with increasing volume and complexity of services provided, technology that reduces physical barriers and speeds "time to information" will be incredibly valuable. Social media has already proven to knock down these barriers in other industries, and health care is well on its way to similar dramatic change.

In a related paper titled "The Evolving Business Case for Social Media in Healthcare," Chris Hoffman of Triple-Tree writes, "Social media is radically changing the nature of business relationships in every economy and industry - and healthcare is no exception. 'Like' it or not, social media is forcing health plans and healthcare providers to adapt and evolve, changing how they communicate with and engage consumers."

Social Media in Health Care

Triple Tree has detailed an assessment of how this unique communication platform is helping healthcare consumers, care providers and other stakeholders support decision making and simplify complex online interactions. Click on the image above to download the report directly from Triple-Tree, or contact Chris Hoffman directly. 

To learn how Ankota is helping to integrate social media into care coordination models, click on the cool blue banner below and ask us about it.


Ankota Technology to Manage Transitions of Care

Topics: Geriatric Care Management, Care Coordination, thought leadership, transitional care, Will Hicklen, Avoidable Readmissions, ACO, Managing Post Acute Care, Patient Centered Medical Home, ACO Technology

Hospitals Face Severe Penalties for Avoidable Readmissions

Posted by Will Hicklen on Dec 17, 2012 10:30:00 AM

Readmissions stats

CMS has made it very clear that reducing needless hospital readmissions is a priority, with or without healthcare reform. The long anticipated financial penalties took effect in September 2012 and will become increasingly severe for those hospitals that do not improve and meet published benchmarks. Thes first round of penalties is scheduled to double next October and then reach 3% of the hospital's total medicare reimbursements by October 2015.

The problem is significant: 1 in 5 Medicare patients are readmitted within 30 days of discharge, and 30% are readmitted within 60 days -- for conditions that are widely considered avoidable. This translates to a burden on the Medicare system that exceeds $25 BILLION per year

Learn How Ankota Technology Reduces Readmissions

Every hospital in the nation faces these new performance & quality requirements, which are measured by readmission rates for the most prevalent and costly of chronic conditions. Without exception, it is the number one issue facing hospitals today. Further, it is not enough to satisfy CMS's requirements today to avoid penalties because the both the requirements and the penalties continue to escalate. The entire system is being forced to continuously improve and reduce costs, which is a well-developed cornerstone of performance management models long used in other industries. Stiff penalties assure that hospitals take them seriously by taking responsibility for coordinating follow up care that helps patients recover and thrive outside of the hospitals. These settings include the patients' homes, assisted living facilities, and skilled nursing facilities. Clearly, more care will be delivered in homes and other residences and the complexity of that care will continue to increase. This presents a tremendous growth opportunity for the ecosystem of post acute care providers. 

CMS Penalties are Severe resized 600
From the November 26, 2012 New York Times article "Hospitals Face Pressure to Avert Readmissions," In a common example, Barnes-Jewish Hospital in St. Louis, will lose $2 million this year. Dr. John Lynch, the chief medical officer, said Barnes-Jewish could absorb that loss this year, but “over time, if the penalties accumulate, it will probably take resources away from other key patient programs.”

"The readmission penalties will recoup about $300 million this year. But the goal is to pressure hospitals to pay attention to what happens to their patients after they leave. The penalties have captured the attention of hospitals, and many are trying to improve their supervision of discharged patients’ recoveries." This will require new technologies and processes to coordinate care from hospital to home, an area where Ankota is squarely focused. 

A few doctors have long advocated such a model, including Dr. Eric Colemana professor at the University of Colorado Anschutz Medical Campus who has devised proven approaches to reduce hospitalizations. These methods focus on helping elderly patients by caring for them more proactively and encouraging cooperation among primary care physicians, home care, physical therapy providers and those delivering equipment and supplies, for example. This is also the right model to help patients recover at home when events do force a hospitalization.

Even with the development of protocols to better manage care, like those of Dr. Eric Coleman, these protocols generally exist only on paper. There is a fundamental lack of technology in place to connect providers to support these programs of care. Ankota's Healthcare Delivery Management (HDM) platform provides web based, secure technology through which providers are able to manage Care Transitions as well as models like Dr. Coleman's and others.  

Learn How Ankota Technology Reduces Readmissions

Topics: Geriatric Care Management, Care Coordination, transitional care, Will Hicklen, Home Care, Accountable Care Organizations, Avoidable Readmissions, National Association of Geriatric Care Managers, ACO

Does Accountable Care Create Sustainable Innovation?

Posted by Will Hicklen on Dec 14, 2012 9:31:00 AM

Accountable Care Organizations are further along in their understanding of the model, of course, but when I talk to other healthcare providers, there is still a lot of confusion over ACOs and what the model means to them. Providers must appreciate that there are both clinical and business issues to be managed, and there is no question that the train has left the station. In fact, Forbes reported in November that Accountable Care already touches 1 in 10 patients.

ACO touches 1 in 10

The question asked in the title of this post is, "Does Accountable Care Create Sustainable Innovation?" The answer is an unequivocal yes, it does. Here are some of the issues and the rationale why this is rapidly becoming true already. 

Unfortunately, the current system, or more accurately, the one we're moving away from, actually served to depress innovation. Mediocre providers with poor outcomes were paid the same as the better providers with spectacular outcomes. In what other business would you ever accept that? Simply put, there were no rewards for doing things more efficiently or at lower cost, or collaborating with partners better. Or keeping patients out of hospitals. Or helping them to manage chronic conditions better so they would not have to visit the hospital as often. All that has changed, and providers need to raise their awareness of Accountable Care and how they fit in the model. Whether you expect to be an ACO or not, your business will be greatly impacted by ACOs. A significant share of your revenues will be directly driven by ACO involvement. Those providers that drive value to the system, that contribute innovation to the system, will become the most desireable providers to work with and be best positioned to benefit from it. 

ACOs sustainable part of healthcare

Hospitals that Ankota works with are well versed on the concepts and objectives of Accountable Care, even if they themselves are not an ACO. Many of the post acute providers we work with, however, are confused over what exactly the opportunity is for them. Some even perceive ACOs as a threat to their business, but do so in error. There are likely many reasons for the discrepency in perceptions, not the least of which is the more formalized nature of communications in hospital & research environments, the more active lobbies of hospitals (relative to other types of providers, etc), "largeness," lack of business/administrative resources among smaller providers, and so on. In short, hospitals are seemingly organized together, while their counterparts in post acute care remain fragmented across many segments.

Because of this, the "voices" of post acute providers are also highly fragmented, which is a reflection of the historically fragmented business & payment models. For example, an HME organization thinks it is in the business of delivering medical equipment and is paid separately for such, regardless of patient outcomes or contribution to the model. A physical therapy agency may tell you that they provide physical therapy or rehabilitation in the home, and a home health agency might say that they provide nursing services in the home or community. This is even reflected in the associations that are specific to each of these segments of post acute care. Even the associations do not cooperate. These may have been just descriptions under old healthcare delivery models, but in the new era of Accountable Care and intense focus on managing Care Transitions, these are highly secular views that lead to gross inefficiencies and in many instances, poor quality of care. It so stifles innovation by limiting those who can contribute to innovative thinking and delivery of services. This fragmentation adds complexity to an already challenging model, yet provides huge opportunities to better coordinate services using innovative technology. Not surprisingly, that's where Ankota makes its market.

The fact is that each of these providers plays an important role in assuring the success of the patients they serve, and therefore play an important role in assuring the success of the providers with which they interact, which makes up the Accountable Care model, at large. Providers share dependencies among them, which until now have gone largely unmanaged. Managing Care Transitions is a critical element of Accountable Care, and an area ripe for tremendous technologoical innovation. Click the blue button to learn more about how Ankota technology helps to manage Accountable Care and Care Transitions. 

That's right, innovation requires collaboration. 

Contact Ankota for Accountable Care Solutions

If a patient needs to be administered an antibiotic in the home after being discharged from the hospital, there are often multiple providers that have to collaborate to deliver a single, integrated service. The discharging service or primary care physician must develop and communicate a comprehensive care plan. The plan must identify needed providers based on skills and certifications, geographic considerations, availability and quality measures like propensity to be on time and perform quality work. The timing and delivery of services must also consider dependencies such as "the antibiotics must be delivered before the infusion nurse gets there." The bed, IV pole, and infusion pump must be delivered prior to the infususion nurse's arrival, and constraints like timing of services and availability of the patient must be managed with other requirements. It is not uncommon at all to have 3, 4 or even 5 providers providing services in the home for an elderly patient or for a patient who was recently discharged from the hospital. 

With so many providers engaged in delivering services for patients, innovation simply cannot be left to one organization to decide for the rest. Innovation in a vacuum simply does not work. This is one of the reasons why, though it is seldomly discussed, the creation of Accountable Care Organizations will actually fuel innovation. Through payment reform and accountability, it funds the creation of ecosystems of providers where the dependencies among providers becomes obvious to all. The shared rewards system provides incentives for those who improve the process and the cost of delivering care, as well as the outcomes. 

Now that the dependencies, the incentives, and the consequences have been aligned, all providers are provided a voice and a forum in which to express it. Providers now have the opportunity to contribute to innovation with this seat at the table. When all providers in the ecosystem share both the risks and the rewards, incentives are aligned that assure commitment, responsibilty, and dramatically greater innovation. 

Payment models have aleady shifted and will continue to shift, and providers are already being forced to manage dependencies among them. Accountable Care models create new dependencies and exacerbate old ones, which assures that the professional focus of managing Care Transitions will only accelerate. It is here where services must be coordinated among numerous providers, care plans, results and performance are shared. New technologies are required to manage the model.

Fundamentally, Accountable care organizations (ACOs) are a method of integrating local or regional healthcare providers with other members of the health care system and rewarding them for controlling costs and improving quality. In one sense, this sounds like other efforts we've heard about in the past like Health Maintenance Organizations (HMOs) and Physician-Hospital Organiztions (PHOs). However, with alignment in the payment system both public and private, and shared risks, the ACO model promises to be one that more closely resembles a market driven model and rewards innovation. And with 10% of patienst already being cared for under the model, it is rapidly gaining momentum and is here to stay.

Leaarn more about ACOs from Healthcare.gov and in this CMS video 

Topics: Care Coordination, Care Transitions, Accountable Care Organizations, Avoidable Readmissions, ACO, ACO Technology

Ten Myths of Health Care Reform

Posted by Will Hicklen on Dec 11, 2012 8:30:00 AM

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From Deloitte's Center for Health Solutions, comes "Ten Myths of Health Care Reform." Just how well is health care reform understood? Take a look below and you will see. Download the report in its entirety below. 

Myth 1: Most Americans like our current system. They want the current system protected at all costs. In fact, most people see the system as overly coplex and inefficient, and they want it fixed. 

Myth 2: Myth: Most Americans understand the U.S. system and think it’s better than others. Actually, they don't understand it, nor do they understand the systems of other countries. 

Myth 3: There’s not enough money in the U.S. health system. At $9000 per capita, there is a tremendous amount of money in the system, it's just directed poorly and geared mostly towards responding to problems when they occur. Incentives must change, and they are, but the money is there. 

Download Deloitte's 10 Myths of Health Care Reform

Myth 4: Government health care programs—Medicare and Medicaid—are poorly managed and need overhaul. Administrative cost of government run programs, oddly enough, are less expensive than their commercial unsurance counterparts. Overall expenses continue to soar and must be overhauled, but not because of administrative expenses.

Myth 5: There is a shortage of primary care physicians. Well, kind of...if you assume that these services can only be provided by MDs. The reality is that nurse practitioners and physician assistants, nutrionists and other practitioners can provide services more efficiently, are well qualified to do so, and are grossly underutilized.

Myth 6: The major driver of health costs is unhealthy lifestyles, and the Affordable Care Act (ACA) doesn’t address this at all. We'll have to address lifestyle issues, but but the major presumption of ACA relative to lifestyle issues is this: access to health insurance for 32 million newly insured Americans will put a dent in unhealthy lifestyles by taking down a barrier to the system’s providers and programs.

Myth 7: The ACA does nothing to lower costs. Actually it does, between reducing avoidable readmissions and lowering the cost of many services. However, the greatest costs savings will be achieved by the transition from our current "paternalistic" system in which patients are told what to do to one in which patients bear more responsibility for their own decisons. 

Myth 8: Most of the care that’s recommended is necessary. And most of what the system spends is therefore appropriate and unavoidable. Admittedly, most of the care is probably necessary but a substantial amount isn’t, and knowing the differences between the two is essential to better health and lower costs. The ACA assures that needed systems and measures will be in place that assure appropriateness of care for all, regardless of location. 

Myth 9: The health insurance industry is the problem, and its fate uncertain. There are two reasons insurance as an industry will thrive in coming years: (1) employers and consumers value financial security resulting from insurance coverage and they want to keep coverage; (2) enrollment in managed care will increase. Virtually every state is implementing managed Medicaid via private plans. It's not going away, but it will change dramatically. 

Myth 10: : Health reform is about the future of the ACA. The system’s costs at 17.6% of the U.S. gross domestic product (GDP), 25% of the federal budget, 23% of the average state budget, and 19% of household discretionary spending makes this a huge priority...it's a national discussion that must be had, regardless of the ACA.

Download Deloitte's report in its entirety here 

Download Deloitte's 10 Myths of Health Care Reform



Topics: Health Care Reform, Care Coordination, transitional care, Will Hicklen, Avoidable Readmissions

Is Medical Home A Solution to Chronic Disease?

Posted by Will Hicklen on Dec 10, 2012 10:52:00 AM

Deloitte logo

From "The Medical Home: Disruptive Innovation for a New Primary Care Model," Deloitte reports, "Currently, 45 percent of the population has a chronic medical condition. Among the Medicare population the statistics are even worse: 83 percent have at least one chronic condition and almost a quarter have at least five co-morbidities." And, according to CMS data, 3 out of every 4 dollars spent on healthcare is due to chronic diseases." Deoitte's full report can be downloaded using the green button below. 

Deloitte Consulting has long been an advocate of innovative healthcare care delivery models and has published signifcant research and opinions around same. Unfortunately, a great many of the providers that make up healthcare delivery channels--particularly outside of primary care settings--fall outside of Deloitte's business focus. Rather, their business is focused on very large, complex institutions where they can make a living for years on end. As Ankota readers know, many post acute providers are small to mid sized operations, typically regional in focus, and have to approach business operations more pragmatically. However, even Deloitte recognizes that the predominant care delivery models & fee for service payment models are limited at best, particularly when it comes to managing chronic conditions. New models of care must rely increasingly on partnerships with post acute providers for care delivery, where outcomes are better, services are less expensive, and patients are happier.

Innovative health care delivery models that are already upon us--those that drive the highest value and best outcomes--are not limited to traditional, large institutions. Programs of care like Patient Centered Medical Home models, while they may often be driven by payors, hospitals and ACOs, will increasingly rely on post acute providers for delivery of services. Post acute care delivery channels are already established, but are typically disconnected and poorly coordinated with programs like Patient Centered Medical Home. That will change rapidly, and Ankota is positioned to accelerate change by enabling highly cooperative, well coordinated care delivery models through better technology. To learn more about how Ankota's technology is used to establsh vitrual "ecosystems" of providers so that they can better Plan, Coordinate & Deliver care, click here

Technology for Patient Centered Medical Home (PCMH)

Acute and post-acute providers are already coming together in efforts to better manage care, and chronic conditions are especially well suited for this approach. Chronic conditions demand proactive, integrated approaches that are sustained over long periods of time and utilize best practices of care. Protocol based approaches that are delivered outside of hospital settings and more specifically, in the home, have been proven to be much more effective and dramatically less expensive. 

Deloitte reports, "There is widespread recognition that the U.S. health care system falls short in its efforts to effectively manage chronic conditions. Currently, 45 percent of the population has a chronic medical condition. Among the Medicare population the statistics are even worse: 83 percent have at least one chronic condition and almost a quarter have at least five co-morbidities." And, according to CMS data, 3 out of every 4 healthcare dollars spent are due to chronic diseases. Simply waiting for patients to experience enough problems to send them in to the ED is a proven failure.

A good starting point for reducing U.S. health care expenses overall is to implement a long-term strategy to reduce the costs associated with unmanaged chronic conditions. "The Medical Home: Disruptive Innovation for a New Primary Care Model," a paper by the  Deloitte Center for Health Solutions, part of Deloitte LLP, offers a strategic perspective on this potential solution to address the challenge of chronic care management.

Technology for Patient Centered Medical Home (PCMH)

In a medical home model, primary care clinicians and allied professionals provide conventional diagnostic and therapeutic services, as well as coordination of care for patients that require services not available in primary care settings. The goal is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives.

"The Medical Home: Disruptive Innovation for a New Primary Care Model" examines medical home models, their savings potential, and the implications for policymakers and key industry stakeholders. The paper also offers compelling arguments in favor of medical home adoption."

To read the full report, please click here 

Download Deloitte's

Topics: Population Health IT, PCMH, Medical Home, Care Coordination, transitional care, Accountable Care Organizations, Avoidable Readmissions, ACO, Managing Post Acute Care, Patient Centered Medical Home, ACO Technology

Patient Centered Medical Home to Support the Elderly

Posted by Will Hicklen on Dec 4, 2012 12:08:00 PM

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The many great challenges of caring for the elderly also present opportunities, and programs of care like Patient Centered Medical Home (PCMH) may be the vehicles through which patient care is simultaneously improved and costs are reduced. Through better coordinated, more proactive care delivered in the home, and coordinated by primary care, hospitalizations are reduced and patients live more productive and happier lives. Until recently, payment systems have not rewarded these care delivery models, which are almost universally much less expensive than traditional "fee for service" models. 

Steven H. Landers is the Medical Director for the Center for Home Care and Community Rehabilitation for the Cleveland Clinic, and describes how health care reform is providing incentives to assure that more poductive models of care are taking hold. Constant themes include care coordination, oversight, and increased utilization of post accute services such as home health care, rehabilitation, and more. 

Learn About How Ankota Technology is Used to Manage PCMH

Says Landers,  "We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects. In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home."

Dr. Landers' article in the Cleveland Clinic Journal of Medicine can also be read in its entirety on the Journal web site.

MRS. SMITH, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

Learn About How Ankota Technology is Used to Manage PCMH

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”


The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.35 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.6

Learn About How Ankota Technology is Used to Manage PCMH
View this table:

Practical considerations for successful physician-home health collaboration in chronic care management

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The health care reform law also includes the Independence at Home Act, funding a demonstration project in which primary medical care teams will visit patients at home. Beyond the medical home and independence-at-home concepts, the health reform law also promotes “accountable care organizations,” and changes the funding to Medicare Advantage private insurance plans. Both of these initiatives will likely require primary care physicians to redesign how they deliver chronic care to older patients with limited mobility and multiple comorbid illnesses.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (TABLE 1).


Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.7 Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.8 These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

Learn About How Ankota Technology is Used to Manage PCMH

 To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.9

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”10 and can substitute for the revenue lost due to less-frequent office visits.10 In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Learn About How Ankota Technology is Used to Manage PCMH

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.


To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” 1316 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.1720Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.21 Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.


In spite of these opportunities, the Medicare home health benefit rarely permits uninterrupted ongoing home care. Thus, the home health collaboration developed around Mrs. Smith’s heart failure exacerbation is likely to be temporary, and when her condition stabilizes she may no longer meet the criteria for home health services.

This episodic-payment model contrasts with the ongoing needs of the typical high-risk older patient with chronic illness. Changing the home health benefit to allow for ongoing home health care for beneficiaries like Mrs. Smith may be an opportunity for patient-centered reform. Although ongoing home health care for a given patient may not be possible, the medical home model offers the opportunity for ongoing physician-home health collaboration because at any time a physician’s practice is likely to have patients requiring these services. The independence-at-home model does provide for uninterrupted ongoing in-home physician and mid-level care for some patients, but it may require changing primary care physicians, and this may be undesirable to some patients. If a viable financing model is established for medical homes and independence-at-home practices, they may choose to contract with home health agencies to provide ongoing telephone or telemetric care management between (or outside of) episodes of eligibility for traditional home health care. All of these potential arrangements would need legal review and would need to be structured to avoid violation of the letter and spirit of laws prohibiting self-referrals and kickbacks.

Learn About How Ankota Technology is Used to Manage PCMH


In the case of Mrs. Smith, Dr. Jones has the option of making a follow-up home visit, or even ongoing home visits.

Granted, home visits may be impractical due to the time involved and the impact of that downtime on the physician’s medical practice and responsibilities to other patients. However, larger practices may employ a specific physician, nurse practitioner, or physician’s assistant to provide in-home care to patients in need.

Some communities have house-call practices to which Dr. Jones could refer Mrs. Smith for in-home physician care, and, where available, this may be a preferred care model— somewhat analogous to how a primary care physician might collaborate with a hospitalist for inpatient care of a specific patient.22 These homecare physician practices will likely become more prevalent if the independence-at-home Medicare demonstration project is successful.

In the future, even if Mrs. Smith needed more intensive inpatient care, an emerging concept called “hospital at home” may be able to provide this acute care in her home.23,24 These in-home physician services are increasingly supported by new mobile diagnostic technologies.25

However, adding or changing physicians may not be possible or desirable for Mrs. Smith and could lead to further fragmentation of care. In the future, teleconferencing may provide options for “virtual visits” that would partially solve this problem.

Whether the physician care is provided in the office, in the home, or as a virtual visit, much of the care Mrs. Smith needs can and should be done by nonphysician home health care providers in partnership with informal caregivers.


Dr. Jones decided to refer Mrs. Smith for home health nursing and maintained close telephone contact with her and the home health nurse during the first 2 weeks. Mrs. Smith responded well to the changes in medication and diet, her leg swelling decreased, and she was feeling more like her usual self. At a follow-up office visit 3 months later, Mrs. Smith hugged Dr. Jones and thanked her profusely for helping her get better at home.


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Topics: PCMH, Care Coordination, Will Hicklen, Home Care, Care Transitions, National Association of Geriatric Care Managers, Patient Centered Medical Home

Transitional Care Improves Patient Outcomes

Posted by Will Hicklen on Dec 3, 2012 4:59:00 PM

Fierce Healthcare Care Transitions

reprinted from Fierce Healthcare

September 18, 2012 by By  

Adding to the growing body of evidence of the benefits of transitional care, a review of medical literature in the Annals of Internal Medicine found that some hospital-led interventions can improve outcomes for adult stroke and myocardial infarction patients.

Researchers looked at 44 studies and found that transitional care reduced length of stay for stroke patients, although they were less confident that it reduced mortality for myocardial infarction patients. Researchers also noted they couldn't conclude whether interventions such as patient and family education programs and community-based support affected outcomes, with insufficient evidence, they wrote. Nevertheless, few of the studies reported adverse events as a result of transitional care.

Inadequate care coordination, including poor care transitions, resulted in $25 billion to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions, according to Health Affairs.

In addition to varied electronics systems across organizations and failure to notify other providers of discharge, there also is a lack of incentives to promote care transitions. In fact, critics of the current fee-for-service system suggest providers are gaming the system; for instance, some nursing homes unnecessarily transfer patients to hospitals to reap reimbursements, Health Affairs noted.

With the Institute of Medicine and the National Quality Forum setting care transitions as a national priority, the concept of continuity of care has made its way up to Capitol Hill.

Reps. Earl Blumenauer (D-Ore.), Thomas Petri (R-Wis.), Allyson Schwartz (D-Pa.) and Jan Schakowsky (D-Ill.) on Friday introduced the Medicare Transitional Care Act of 2012 to fund providers and beneficiaries with specific payments for coordination activities. Supported by the National Transitions of Care Coalition (NTOCC), the legislation aims to improve transitions from hospital to home, skilling nursing facility or another care setting for Medicare beneficiaries at risk for readmissions.

"The Affordable Care Act made significant progress in improving the coordination of care in our healthcare system, but still gaps remain to promoting the type of team-based, coordinated care that is critical to quality transitions of care," NTOCC Executive Director Cheri Lattimer said yesterday in a statement.

For more information:
- read the Annals of Internal Medicine study
- here's the Health Affairs policy brief
- read the NTOCC statement
- see Blumenauer's statement

Related Articles:
Looming readmission penalties force hospitals to improve transitions
Cut frequent flier readmissions with care management
Transitional care life coaches, clinics save hospitals thousands
Conference highlights 7 transitional care interventions
Cut readmissions with discharge 'passports,' communication

Read more: Transitional care improves patient outcomes - FierceHealthcare http://www.fiercehealthcare.com/story/transitional-care-improves-patient-outcomes/2012-09-18#ixzz2E1oFO46V 
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Karen Cheung Larivee bio Care Transitions

Topics: Care Coordination, transitional care, Will Hicklen, Care Transitions, Accountable Care Organizations, Avoidable Readmissions, ACO, Patient Centered Medical Home

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