The HR Bill, regardless of your political views, has some very exciting components.
We have to go back about 20 years to see our national progression towards reform legislation.
New Health Reform prioritizes quality through scientific measures emphasizing health outcomes and service delivery.
The New Goal of HR legislation uses a scientific approach to measure quality and improve population health and health care service delivery. In the early 90s when we first started about HR, discussions, not unlike today, were centered around access and cost. After years of discussion, In 1996, the health insurance reform act was signed, that ACT was geared primarily improve HC quality through elimination of fradu,abuse, kick backs and monetary civil penalties. Today, HR has a new GOAL – Quality- Yes the bill still talks about access, fraud waste and abuse, BUT .
HR 3590 promises to ensure the quality of care through identification and prioritization of scientific measures of health outcomes. To accomplish this, the bill requires appointment of a national strategy for quality improvement. The AHRQ recently summarized these strategies
Unlike previous health reform initiatives, this bill describes Implementation Activities as the vehicle to operationalize quality improvement. Quality Reporting- `(1) IN GENERAL- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that-- `(A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage; `(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; `(C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and `(D) implement wellness and health promotion activities. Quality Reporting- `(1) IN GENERAL- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that-- `(A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage; `(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; `(C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and `(D) implement wellness and health promotion activities. Whats more Section 2717 defines Implementation Activities as a means to improve health outcomes. And specifically addresses case management, care coordination, discharge planning, evidenced based protocol preventative care and all those elements typically associated with case management.
Generally speaking, Health and Wellness activities are relatively easy to report with hard data, as long as that data is consistent. What can be challenging is how to bridge the gap between ‘quality reporting and quality improvement’. The best way to get from here to there is through implementation of comprehensive case management and care coordination.
In choosing an implementation strategy, consideration must be given to how care for the condition is currently organized and to what factors may prevent compliance There's a logical relationship Focus on the behavioral aspects of clinicians is necessary to achieve meaningful change (Conroy and Shannon, 1995) Understanding previous failure in application of technologies, especially, care management programs suggests, a level of integration a system requires that can facilitate appropriate decision making, relative to the clinical decision process or disease process and not necessarily the REPORTNG OUTCOME .
To demonstrate the interdependent relationship between a target outcome and a targeted process I will use a readmission example, (implementation activity #2) Consider the inter-dependent relationship between targeted process and targeted outcomes. As this example demonstrates a timely transfer of information across settings if aligned well with a quality goal has potential to reduce adverse drug events.
Using a systematic approach you can apply (Medication alerts) Using a mapping technique, Change could impact other areas of care coordination and medication reconciliation (re-admissions)
Care Planning and Care Monitoring is the central function of the Case Manager This is the likely point of target measure to address CM effectiveness. (Implementation Activity #1) Strengthen your case management program and strengthen your Implementation Efforts
How do you strive toward quality case management? . Effective case management systems/programs should be designed to guide case management documentation. Documentation is the key to effective quality driven case management, Case management documentation is so fundemental in fact, that free text documentation was addressed during publication of the EHR. Final Rule, CM documentation should always be Where necessary Describe the and provide Case management documentation should always include NEXT steps This is how you get to the core of case management quality
Effective case management depends on the efficiency care coordination. Implementation activities will likely target efficiencies (design and productivity and application of technologies) as a target measure for care coordination reporting.
To optimize case management reporting, Central location to track CM activities. Must be accessible for purposes of tracking entry related to care planning and monitoring Finally it should be organized logically for the review of multiple entities, This organization style (provides the additional benefit for data extraction based on need)
In addition to standard reporting, to get the most of your system Should guide Coordination activities Information sharing, Theres different ways that can be done. Printing, emailing, faxing and mailing, interfacing, system network styles or designs.
There is a significant amount of literature on the relative costs and casualty of interoperable gaps in care management.
To overcome these dillemas
So know that you know everything about HR BILL, Case Management, and coordination. How to implement a successful implementation activity?
agree That MU is the most beneficial regulation and incentive to sweep HC to date.
Guidance for implementing a fully integrated case management program capable to address, not just case management, but CD, RE-admissions, and prevention.
Getting Started “ In choosing an implementation strategy, consideration must be given to how care for the condition is currently organized and to what factors may prevent compliance. Focus on the behavioral aspects of clinicians is necessary to achieve meaningful change (Conroy and Shannon, 1995)
Develop a work plan that follows a an evidenced based design. Implementation Research approved by the Cochrane Collaboration for its scientific methodology and scope of work; suggests that
Plan for implementation Activity (define objectives and activity plan) Do it (develop your action plan and implement) Check it (evaluation) Act on your results Provide feedback.
Strengthening your case management program
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HR BILLHR BILL 35903590A UNIQUE Implication for Health CareA UNIQUE Implication for Health Care06/20/13 Casey Dills ODonnell 1
06/20/13 Casey Dills ODonnell 2BACK TO THE FUTURE Protects use of individualhealth records (Healthcare Insurance Portability and Accountability:Aug 1996) Ensures storage and use ofelectronic records (Electronic Freedom of Information Act: Oct 1996) Makes it easier to retrievesecure information online (Electronic Freedom of Information Act) Electronically attributes; associates;or links individual records (ARRA: Feb 2009) Enables users to select, sort,and retrieve minimum data (Meaningful Use:July 2010) Enables users to electronically record,modify and retrieve patient data overmultiple encounters. (EHR Technology Final Rule: July 2010)
Health Care Quality Improvement:Quality Measure Prioritization Health Outcomes Multiple Chronic Conditions Coordination/Continuum of Care Efficiency Meaningful Use Clinical Decision Support & related technologies Patient Centered Care effectiveness; safety; appropriateness; Value Based Healthcare Patient Experience and satisfaction
06/20/13 Casey Dills ODonnell 4New Goal of Health Reform Leverage Data Collection Analyze data in a way that informs policy Deliver patient centered care Support progress that utilizes evidence-basedstrategies and promotes best practices Refocus health care system on improvinghealth, intervention, and coordination Select measures and processes that have thegreatest impact on population health AHRQ 2010
06/20/13 Casey Dills ODonnell 5Ensuring the Quality of Care: Section 2717 National Strategy for Quality Improvement Improve Measure of Health Outcomes Develop Quality Measures Develop Reporting Requirement Identify areas for Improvement Potential Emphasize efficiency Improve research (service research) Comparative Clinical Effectiveness
06/20/13 Casey Dills ODonnell 6Improve Health Outcomes: Section 2717New Emphasis in Care Management Implementation Activities Quality Reporting Effective Case Management & Care Coordination Chronic Disease Management Comprehensive Discharge Planning (AvoidableReadmissions) Patient Safety Best Practice and Evidence Based Medicine (ReduceMedical Error) Health and Wellness activities (preventative care)
Aligning Quality with MeasurementLogical RelationshipBehavior of Health Service Delivery&Application of Technology
06/20/13 Casey Dills ODonnell 9Process Measures linked to outcomes Target Outcomes (example for readmissions) Reduction in adverse drug events Reduction in patient medical errors Reduction in unnecessary encounter Reeducation in redundant tests and procedures Achievement of patient goals Improved patient understanding Targeted Processes Timely transfer of information across settings and providers Effective care coordination across settings and providers Timely delivery of care Improved patient understanding Improved patient awareness and emergency back up Improved patient engagement
06/20/13 Casey Dills ODonnell 10Goal Mapping Systematic approach Define the process your trying to improve What is the problem or question I am going to solve or answer Why is this Issue or Topic Important Define how you will know when it is accomplished Intended Outcome Desired Results Determine how this change will impact other service areas andresources Use goal mapping to understand and communicate theimprovement goals throughout the process. What ‘benchmark’ are there to evaluate progress or success and, How am I going to use it to tell about my findings and solutions
Guide to Effective Case Management Strengthen your case management Program Strive for quality in your case management Pursue quality from the design of your carecoordination activities
Care Planning and MonitoringCare Planning Individualized Identifies frequency/need Required for Authorization of ServicesMonitoring Monitor the care and progress of the client Review effectiveness of servicesNew Service(s)Change in service(s)Termination of Service(s)06/20/13 Casey Dills ODonnell 12
Quality Case Management Objective and Nonjudgmental Use only standard medical abbreviations Nature of Contact Detailed description of Contact Brief (if possible) Event focused Relevant Information Actions Taken/Follow Up06/20/13 Casey Dills ODonnell 13
Quality Coordination Process are StandardCare is Individualized Case Manager Roles Coordinate needed services. Communicate with service providersregarding service delivery, andconcerns. Review and revise services, asnecessary06/20/13 Casey Dills ODonnell 14
Case Management Reporting Medical Record (EHR) Requirements Central Location to document and track casemanagement activity Accessible to multiple users Entry for care planning and monitoring activites Available for Review Supervisors Colleagues State/Federal Auditors Clients Legal Reviews06/20/13 Casey Dills ODonnell 15
06/20/13 Casey Dills ODonnell 16Care Management Systems Effectiveness Systems that support clinical decision activity Clinical guidelines; protocols; procedures Standards orders; Triage (critical); clinical pathways Disease Case management Ancillary service management Utilization Review Outcomes and accountability (data) Benchmark Identification (data) Efficiencies System supports Information sharing Facilitates cross site information transfer Report extraction
06/20/13 Casey Dills ODonnell 17THE CHALLENGEHealth Reform 3590 strives to enhance qualityimprovement, and stresses the importance oncare management coordination.The single most challenging opportunity in thequest for improvement in health care, is theharness of integrated coordinated care.
06/20/13 Casey Dills ODonnell 18THE DILLEMAToday most providers lack the information systems necessary tocoordinate patient care. Care Management systems that canimprove the integration of care in real time leverage the markettoward intelligent evidence based support Systems are fragmented Improvement efforts are silo/singular Technologies are disjointed Communications staggered or non existent Resources strained
06/20/13 Casey Dills ODonnell 19THE REMEDIATION Identity common goal utilizing the resourcesand technologies already available. Use an Evidenced-Based design tosuccessfully implement improvement Apply evidenced-based strategies toachieve successful implementationactivities.
06/20/13 Casey Dills ODonnell 20Coordinated Care with a Meaningful Use“The final meaningful use regulations may be the firstdomino to bring about monumental change andtransformation to the U.S. healthcare system”.(Demers, Eric)Meaningful use is the top priority 84%, among healthcareexecutives when considering how the reform bill willimpact their organizations(Health Populi)
06/20/13 Casey Dills ODonnell 21Integrating care management activities Strategies Multidisciplinary TEAM case management CARE COORDINATION Aim to improve the continuum of care throughdischarge planning and transitional caremodeling. Employ a coordinated interdisciplinary approach Coordinate with medical homes and/oraccountable care organizations Apply integrated computer technologies Clinical decision support
06/20/13 Casey Dills ODonnell 22Implementation Activity Workflow is KEY to effective care management. Care Management tools that supportsinterdisciplinary communication. Community resources Patient Education Clinical Decision Support toolsthat assist at the point of care. Data Driven Quality Assessment (SIS/Functional) Quality Assurance and Improvement
06/20/13 Casey Dills ODonnell 23Workflow DevelopmentSample Questions:How do you sort tasks, can you sort by priority?Can you hyperlink between tasks?Can you print health education documents?Can assessment trigger clinical alertsDo triggers take the user to the necessary task?Can completion of an assessment trigger care coordinateddocument?Can your documents be electronically transmitted to other careproviders?
06/20/13 Casey Dills ODonnell 24Enact Implementation Activities using anEvidence-Based design Implementation activities are effective whenapplied to structured quality improvements. Implementation is successful when outcomes areused to benchmark or compared. Regular feedback is critical to implementationsuccess. Assistive support (CDS), alerts and other real timetechnologies aid successful implementation. Organizational setting must be support thestrategy.
06/20/13 Casey Dills ODonnell 25Enact Implementation Activities using anEvidence-Based design Research shows Quality improvement activities facilitate social influencing. Feedback and other comparative measures promote groupand individual competition and facilities social influencethrough perceived intention. Assistive supports used in real time aid in knowledgetranslation, and presents influencing at the level ofinterpersonal cognitive processing. Organizational cultures are a construct to social influence;Whereby the organization’s social structure has the mostability to positively or negatively influence the desiredimplementation.
06/20/13 Casey Dills ODonnell 26Enact Implementation Activities using anEvidence-Based design Research Shows implementation activitiesare not successful when: Implementation is passive. Measures (activity outcome) or guidelines are notaccepted. Implementation activity lacks accountability andownership. Implementation processes are unorganized orrequire competing organizational values.
06/20/13 Casey Dills ODonnell 29Meeting the Challenge We Have Technologies (E.H.R) containing data that representshealth service performance (diagnostic & demographic reporting) Dedicated professionals We need Operationalize a structure that provides a means toefficiently and effectively administer health services ina way that values the delivery of care.