Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
This document provides a summary of evidence on the impact of patient-centered medical homes (PCMHs) and primary care innovations on cost and quality from 2013-2014. It finds that PCMH interventions are associated with modest improvements in quality of care and reductions in utilization and costs. It also discusses challenges in evaluating PCMHs and outlines opportunities to further integrate primary care with other specialties and engage consumers. The future of the PCMH relies on continued financial support, training interprofessional teams, harnessing technology, and partnering with patients and communities.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The document summarizes a presentation by Paul Grundy on extracting value from the patient centered medical home model. It discusses:
1) How the patient centered medical home model creates partnerships across the healthcare system to drive primary care redesign, offer population health management, and move away from an episodic, fee-for-service model.
2) Studies that show improvements in costs, quality, access, and utilization from implementing the patient centered medical home model, including reduced hospital and ER use.
3) How payment models are shifting towards value-based purchasing tied to quality, utilization, and patient satisfaction outcomes rather than volume of services.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
Patients and their loved ones often hold critical knowledge that informs diagnosis. This toolkit from the Institute of Medicine offers patients, families and clinicians guidance on how they can collaborate to improve diagnosis.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
This document provides a summary of evidence on the impact of patient-centered medical homes (PCMHs) and primary care innovations on cost and quality from 2013-2014. It finds that PCMH interventions are associated with modest improvements in quality of care and reductions in utilization and costs. It also discusses challenges in evaluating PCMHs and outlines opportunities to further integrate primary care with other specialties and engage consumers. The future of the PCMH relies on continued financial support, training interprofessional teams, harnessing technology, and partnering with patients and communities.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The document summarizes a presentation by Paul Grundy on extracting value from the patient centered medical home model. It discusses:
1) How the patient centered medical home model creates partnerships across the healthcare system to drive primary care redesign, offer population health management, and move away from an episodic, fee-for-service model.
2) Studies that show improvements in costs, quality, access, and utilization from implementing the patient centered medical home model, including reduced hospital and ER use.
3) How payment models are shifting towards value-based purchasing tied to quality, utilization, and patient satisfaction outcomes rather than volume of services.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
Creating a standard of care for patient and family engagementChristine Winters
Nationally-recognized governance expert Beth Daley Ullem addresses the state of patient engagement in heathcare and provides a vision for establishing a minimum standard of care for patient engagement programs.
The Beryl Institute 2013 State of the Patient Experience Benchmarking StudyEngagingPatients
This document summarizes the key findings of a survey of over 1,000 US hospitals regarding their efforts to improve the patient experience. It finds that while patient experience remains a top priority, hospitals feel somewhat less positive about their progress than two years ago. Most hospitals now have a formal definition and structure for patient experience. Leadership support and HCAHPS scores are the top factors driving patient experience work. Hospitals continue focusing on communication, noise reduction, and discharge processes to improve patient experience.
The document discusses the nursing shortage and its implications for quality of care for the elderly population. It notes that the nursing shortage is projected to worsen significantly by 2020 and beyond as the elderly population doubles. Higher nurse-to-patient ratios are linked to negative health outcomes for patients like infections, pneumonia, and medical errors. As patients age, they have more complex medical needs, so the nursing shortage diminishes quality of care through issues like inadequate pain management, medication errors, and increased falls and potential for abuse in hospitals. Some solutions discussed are state mandated nurse staffing ratios and basing staffing levels on patient acuity levels.
Patient engagement is evolving to include a composite of practices that impact patient behaviors and health. Contemporary models of patient engagement include the HIMSS 5 phases of patient engagement and the Regional Primary Care Coalition's 6 dimensions of patient engagement. Meaningful Use Phase 3 identifies key priorities around patient access to health records and secure messaging. Barriers to patient engagement include defining engagement and integrating diverse engagement tools and technologies.
An aging population combined with the decline in the number of primary care providers places unique demands on the provision of health care. Adult-gerontology nurse practitioners provide primary care to adults and the elderly, serve in administrative roles in health care organizations, and evaluate and implement health care policy and programs.
Topics:
What’s the difference between the adult-gerontology nurse practitioner and the family nurse practitioner role?
What should I consider when choosing my nurse practitioner career path?
Focus on the adult-gerontology nurse practitioner specialization
Master’s level vs. doctoral level nursing degrees: Which is right for me?
What is a "super specialization?"
Patient-Centered Strategies for HCAHPS ImprovementEngagingPatients
This document discusses strategies for improving patient experience scores on the HCAHPS survey through patient-centered care. It notes that HCAHPS performance is becoming increasingly important for hospital reimbursement. The document recommends partnering with patients, creating a healing physical environment, making data meaningful to staff, focusing on care transitions beyond the hospital, and prioritizing compassionate care. Planetree is introduced as an organization that advocates for these patient-centered approaches and certifies hospitals that meet standards for patient-centered culture and environments.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
This infographic from The Beryl Institute presents key findings from its study, the "State of Patient Experience 2015: A Global Perspective on the Patient Experience Movement," which engaged over 1,500 respondents in 50 countries, sharing challenges and opportunities in addressing the patient experience across all healthcare settings.
Changing scenario needs an ever changing rational approach to healthcare terms and services.Where "tools"[your knowledge,interpretations,etc] helps you to make the picture better.
Closing the Loop: Strategies to Extend Care in the EDEngagingPatients
This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
2016 Connected Care and the Patient ExperienceSurescripts
Annual survey of 1,000 Americans reveals increased dissatisfaction with data availability and innovation, even though the technology exists today for a safer, more convenient and connected healthcare experience.
Delivering value based_care_with_e_health_services.5Greg Bauer
The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
This document discusses processes that have been implemented at a rural hospital with 1200 births per year to improve obstetric patient safety and outcomes. Some of the key processes discussed include establishing a team approach involving all hospital personnel, conducting regular simulations to improve communication and adherence to protocols, implementing mentorship programs for nurses and managers, standardizing communication using SBAR, leveraging electronic medical records and data to monitor quality and outcomes, and promoting a culture of accountability and professionalism. The goal of these initiatives is to reduce errors, minimize harm, and improve outcomes through multidisciplinary collaboration and a systems-based approach. While changing healthcare culture and achieving measurable outcomes can be challenging, continuous monitoring and refinement of processes may help advance safety and quality of
Polls show overwhelming evidence that patients WANT to be involved in their medical records and health data, so they can partner with their clinicians for better health. Survey results from Society for Participatory Medicine 2014 and 2015 surveys.
This document discusses patient support programs offered by pharmaceutical companies in 2014. It notes that the patient journey has become more complex, with patients needing to navigate multiple stakeholders and sources of information. It also notes that while pharmaceutical companies traditionally followed a linear promotional model, the patient journey is less linear. The document then analyzes over 200 pharmaceutical websites and identifies 65 patient support programs. It finds that support commonly includes nurse hotlines, educational events, and assistance navigating insurance. However, data tracking remains basic. It concludes that digital health is advancing beyond information seeking to care management, and pharmaceutical companies will need to partner more and help patients navigate the complex system.
Tikisha Walwyn has over 10 years of experience in behavioral health care advocacy and utilization review. She has worked for several companies including United Health Care, Beacon Health Strategies, and Cedar Crest Hospital, managing Medicaid plans and other programs. Her experience includes assessing patient needs, determining appropriate levels of care, managing treatment plans, and assisting with quality improvement initiatives.
As the baby boomer population gets older and 32 million Americans gain access to healthcare under the Affordable Healthcare Act, the demand for nurses has significantly increased. Healthcare jobs are among the fastest growing jobs in America, with a predicted increase of 526,800 registered nurses by 2022. The demand for nurses is quickly growing and it has been chronicled through the years. While this is good news for anyone looking to start a career in healthcare, nurses are suffering from heavier workloads, and that can directly affect patient care.
Population Health Management White Paper, Spring 2015Edward Pierce
Population health management (PHM) aims to improve health outcomes for groups of individuals through coordinated care and patient engagement. Key components of PHM include leadership from primary care physicians to develop customized care plans for each patient. Data analysis is used to identify at-risk patients and care gaps, while automation and technology help disseminate information to patients. Referral networks and payment structures incentivize physicians to focus on outcomes over volume. Hospitals are developing PHM strategies starting with their own employees to coordinate benefits, replicate the model, and expand it community-wide to improve affordability.
From Patients to ePatients Driving a new paradigm for online clinical collabo...ddbennett
CareTech eHealth Innovation Series
From Patients to ePatients Driving a new paradigm for online clinical collaboration and health management
David Bennett, SVP, Interactive Solutions
StayWell Custom Communications
Anthony Chipelo, Director, Portal Strategies
CareTech Solutions
Creating a standard of care for patient and family engagementChristine Winters
Nationally-recognized governance expert Beth Daley Ullem addresses the state of patient engagement in heathcare and provides a vision for establishing a minimum standard of care for patient engagement programs.
The Beryl Institute 2013 State of the Patient Experience Benchmarking StudyEngagingPatients
This document summarizes the key findings of a survey of over 1,000 US hospitals regarding their efforts to improve the patient experience. It finds that while patient experience remains a top priority, hospitals feel somewhat less positive about their progress than two years ago. Most hospitals now have a formal definition and structure for patient experience. Leadership support and HCAHPS scores are the top factors driving patient experience work. Hospitals continue focusing on communication, noise reduction, and discharge processes to improve patient experience.
The document discusses the nursing shortage and its implications for quality of care for the elderly population. It notes that the nursing shortage is projected to worsen significantly by 2020 and beyond as the elderly population doubles. Higher nurse-to-patient ratios are linked to negative health outcomes for patients like infections, pneumonia, and medical errors. As patients age, they have more complex medical needs, so the nursing shortage diminishes quality of care through issues like inadequate pain management, medication errors, and increased falls and potential for abuse in hospitals. Some solutions discussed are state mandated nurse staffing ratios and basing staffing levels on patient acuity levels.
Patient engagement is evolving to include a composite of practices that impact patient behaviors and health. Contemporary models of patient engagement include the HIMSS 5 phases of patient engagement and the Regional Primary Care Coalition's 6 dimensions of patient engagement. Meaningful Use Phase 3 identifies key priorities around patient access to health records and secure messaging. Barriers to patient engagement include defining engagement and integrating diverse engagement tools and technologies.
An aging population combined with the decline in the number of primary care providers places unique demands on the provision of health care. Adult-gerontology nurse practitioners provide primary care to adults and the elderly, serve in administrative roles in health care organizations, and evaluate and implement health care policy and programs.
Topics:
What’s the difference between the adult-gerontology nurse practitioner and the family nurse practitioner role?
What should I consider when choosing my nurse practitioner career path?
Focus on the adult-gerontology nurse practitioner specialization
Master’s level vs. doctoral level nursing degrees: Which is right for me?
What is a "super specialization?"
Patient-Centered Strategies for HCAHPS ImprovementEngagingPatients
This document discusses strategies for improving patient experience scores on the HCAHPS survey through patient-centered care. It notes that HCAHPS performance is becoming increasingly important for hospital reimbursement. The document recommends partnering with patients, creating a healing physical environment, making data meaningful to staff, focusing on care transitions beyond the hospital, and prioritizing compassionate care. Planetree is introduced as an organization that advocates for these patient-centered approaches and certifies hospitals that meet standards for patient-centered culture and environments.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
This infographic from The Beryl Institute presents key findings from its study, the "State of Patient Experience 2015: A Global Perspective on the Patient Experience Movement," which engaged over 1,500 respondents in 50 countries, sharing challenges and opportunities in addressing the patient experience across all healthcare settings.
Changing scenario needs an ever changing rational approach to healthcare terms and services.Where "tools"[your knowledge,interpretations,etc] helps you to make the picture better.
Closing the Loop: Strategies to Extend Care in the EDEngagingPatients
This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
2016 Connected Care and the Patient ExperienceSurescripts
Annual survey of 1,000 Americans reveals increased dissatisfaction with data availability and innovation, even though the technology exists today for a safer, more convenient and connected healthcare experience.
Delivering value based_care_with_e_health_services.5Greg Bauer
The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
This document discusses processes that have been implemented at a rural hospital with 1200 births per year to improve obstetric patient safety and outcomes. Some of the key processes discussed include establishing a team approach involving all hospital personnel, conducting regular simulations to improve communication and adherence to protocols, implementing mentorship programs for nurses and managers, standardizing communication using SBAR, leveraging electronic medical records and data to monitor quality and outcomes, and promoting a culture of accountability and professionalism. The goal of these initiatives is to reduce errors, minimize harm, and improve outcomes through multidisciplinary collaboration and a systems-based approach. While changing healthcare culture and achieving measurable outcomes can be challenging, continuous monitoring and refinement of processes may help advance safety and quality of
Polls show overwhelming evidence that patients WANT to be involved in their medical records and health data, so they can partner with their clinicians for better health. Survey results from Society for Participatory Medicine 2014 and 2015 surveys.
This document discusses patient support programs offered by pharmaceutical companies in 2014. It notes that the patient journey has become more complex, with patients needing to navigate multiple stakeholders and sources of information. It also notes that while pharmaceutical companies traditionally followed a linear promotional model, the patient journey is less linear. The document then analyzes over 200 pharmaceutical websites and identifies 65 patient support programs. It finds that support commonly includes nurse hotlines, educational events, and assistance navigating insurance. However, data tracking remains basic. It concludes that digital health is advancing beyond information seeking to care management, and pharmaceutical companies will need to partner more and help patients navigate the complex system.
Tikisha Walwyn has over 10 years of experience in behavioral health care advocacy and utilization review. She has worked for several companies including United Health Care, Beacon Health Strategies, and Cedar Crest Hospital, managing Medicaid plans and other programs. Her experience includes assessing patient needs, determining appropriate levels of care, managing treatment plans, and assisting with quality improvement initiatives.
As the baby boomer population gets older and 32 million Americans gain access to healthcare under the Affordable Healthcare Act, the demand for nurses has significantly increased. Healthcare jobs are among the fastest growing jobs in America, with a predicted increase of 526,800 registered nurses by 2022. The demand for nurses is quickly growing and it has been chronicled through the years. While this is good news for anyone looking to start a career in healthcare, nurses are suffering from heavier workloads, and that can directly affect patient care.
Population Health Management White Paper, Spring 2015Edward Pierce
Population health management (PHM) aims to improve health outcomes for groups of individuals through coordinated care and patient engagement. Key components of PHM include leadership from primary care physicians to develop customized care plans for each patient. Data analysis is used to identify at-risk patients and care gaps, while automation and technology help disseminate information to patients. Referral networks and payment structures incentivize physicians to focus on outcomes over volume. Hospitals are developing PHM strategies starting with their own employees to coordinate benefits, replicate the model, and expand it community-wide to improve affordability.
From Patients to ePatients Driving a new paradigm for online clinical collabo...ddbennett
CareTech eHealth Innovation Series
From Patients to ePatients Driving a new paradigm for online clinical collaboration and health management
David Bennett, SVP, Interactive Solutions
StayWell Custom Communications
Anthony Chipelo, Director, Portal Strategies
CareTech Solutions
The document discusses CMS's Chronic Care Management program, which pays providers to coordinate care for Medicare patients with multiple chronic conditions. Key points:
- The CCM program pays providers $42 per patient per month to perform 20 minutes of care management and coordination activities outside of office visits.
- To qualify for CCM, patients must have Medicare fee-for-service and two or more chronic conditions expected to last over a year.
- Eligible providers must obtain patient consent and provide 24/7 access, care management, care coordination, and electronic care plans shared with other providers.
- The program aims to improve outcomes and lower costs for patients with multiple chronic conditions by encouraging coordinated chronic care management between visits
Three key trends are forcing a change in today's health models: 1) Rising chronic diseases among both young and old are driving up health costs and creating future liabilities. 2) Technology is enabling mass customization of healthcare similar to other industries. 3) Broader factors like behavior, socioeconomics, and genetics are recognized as influencing health beyond medical care. To address these issues, health will be customized around six vectors: incentives, regulations, funding, patient communication, information technology, and workforce models to personalize diagnosis, care and cure for individuals.
This document summarizes discussions from a series of panel discussions on the future of post-acute healthcare. Key concerns discussed include the need for better coordination and pathways between acute and post-acute care to reduce hospital readmissions, ensuring clinical staff in skilled nursing facilities have sufficient skills and training, understanding new models like Accountable Care Organizations, managing increased utilization of managed care plans with lower reimbursement rates, and navigating changes to state Medicaid systems. Potential solutions focus on developing partnerships across settings, sharing clinical information, participating in advocacy, and using technology and analytics to improve coordination and decision making.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
How is Digitalization Helping in Healthcare Management.pdfbasilmph
Healthcare management may interest someone who wants to contribute significantly to
healthcare without having direct patient contact. A person can play a significant role in the medical field without working in an operating room, delivering medication, or directly caring for patients.
35NURSING ECONOMIC$/January-February 2011/Vol. 29/No. 1
T
HE WORLD OF ARISTOTLE AND
Ptolemy believed that Earth
was positioned at the cen-
ter of the universe. Thanks
to Galileo and Copernicus’s studies
in the 16th century, we know this
is not true and that the sun is the
center of our universe. Pers -
pectives of health care have
undergone similar, radical changes
in perception. For centuries we
had a hospital-centric view; an
illness-based model, where the majority of care was
provided in hospitals, when we were ill. In the last
few decades, that model has migrated to a more con-
tinuum of care view; a wellness/health maintenance
model, where emphasis of care is outside the hospital
in other venues such as outpatient, ambulatory/clin-
ic, and home care (see Figure 1).
But as we all know, this is still not where we need
to be to support the highest quality care at the right
cost. Despite a focus on moving care out of the hospi-
tals, one only needs to think about the process of
medication reconciliation between care venues to
realize the lack of seamless integration of care deliv-
ery and the challenges of supporting interoperability
across the continuum. Hence, here I am proposing the
patient centric view, where the patient actively partic-
ipates in his or her care and we look at delivering care
from a patient’s point of view. This allows us to break
down some of the barriers we have struggled with on
our journeys to promote higher quality care through
the use of health information technology (HIT). Now
we need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital. Considering a
patient-centric point of view when implementing and
optimizing the use of HIT provides new perspectives
on the meaning of “integrated” health care.
Patient-Centric Care
It might seem odd that a health care organization
needs to be reminded to involve the patient in his or
her care. After all, this approach would certainly be
supported from a patient’s perspective. And, of
course, the health care industry has compelling rea-
sons to incorporate a strong customer and service
focus in order to improve patient satisfaction and
impact patient loyalty. But as health care systems
Patient as Center of the Health Care Universe:
A Closer Look at Patient-Centered Care
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-
Information Services, Aurora Health Care, Milwaukee, WI; a
HIMSS Board Member; Co-Chair of the Alliance for Nursing
Informatics; a member of the federal HIT Standards Committee;
and is a Nursing Economic$ Editorial Board Member. Comments
and suggestions can be sent to [email protected]
EXECUTIVE SUMMARY
We need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital.
Considering a patient-centric point of view when
implementing and optimizing the use of health infor-
mation technology (HIT) provides new perspect.
35NURSING ECONOMIC$/January-February 2011/Vol. 29/No. 1
T
HE WORLD OF ARISTOTLE AND
Ptolemy believed that Earth
was positioned at the cen-
ter of the universe. Thanks
to Galileo and Copernicus’s studies
in the 16th century, we know this
is not true and that the sun is the
center of our universe. Pers -
pectives of health care have
undergone similar, radical changes
in perception. For centuries we
had a hospital-centric view; an
illness-based model, where the majority of care was
provided in hospitals, when we were ill. In the last
few decades, that model has migrated to a more con-
tinuum of care view; a wellness/health maintenance
model, where emphasis of care is outside the hospital
in other venues such as outpatient, ambulatory/clin-
ic, and home care (see Figure 1).
But as we all know, this is still not where we need
to be to support the highest quality care at the right
cost. Despite a focus on moving care out of the hospi-
tals, one only needs to think about the process of
medication reconciliation between care venues to
realize the lack of seamless integration of care deliv-
ery and the challenges of supporting interoperability
across the continuum. Hence, here I am proposing the
patient centric view, where the patient actively partic-
ipates in his or her care and we look at delivering care
from a patient’s point of view. This allows us to break
down some of the barriers we have struggled with on
our journeys to promote higher quality care through
the use of health information technology (HIT). Now
we need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital. Considering a
patient-centric point of view when implementing and
optimizing the use of HIT provides new perspectives
on the meaning of “integrated” health care.
Patient-Centric Care
It might seem odd that a health care organization
needs to be reminded to involve the patient in his or
her care. After all, this approach would certainly be
supported from a patient’s perspective. And, of
course, the health care industry has compelling rea-
sons to incorporate a strong customer and service
focus in order to improve patient satisfaction and
impact patient loyalty. But as health care systems
Patient as Center of the Health Care Universe:
A Closer Look at Patient-Centered Care
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-
Information Services, Aurora Health Care, Milwaukee, WI; a
HIMSS Board Member; Co-Chair of the Alliance for Nursing
Informatics; a member of the federal HIT Standards Committee;
and is a Nursing Economic$ Editorial Board Member. Comments
and suggestions can be sent to [email protected]
EXECUTIVE SUMMARY
We need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital.
Considering a patient-centric point of view when
implementing and optimizing the use of health infor-
mation technology (HIT) provides new perspect ...
1. Pharmacists are well-positioned to help healthcare organizations transition to a patient-centered medical home model focused on quality, efficiency, and outcomes over fee-for-service.
2. CHI Franciscan Health implemented a polypharmacy initiative and patient-centered medical home model with pharmacists playing a key role in identifying high-risk patients, optimizing complex medication regimens, and building trust with providers.
3. Starting small by saying yes to all opportunities, prioritizing clinics with the most need and building trust, the pharmacists were able to expand their roles and impact more patients with limited resources.
This document discusses the patient-centered medical home (PCMH) model and its benefits. It provides examples of organizations that have implemented PCMH initiatives to improve care coordination, access, costs and outcomes. Key points include:
- PCMH aims to strengthen primary care through care coordination, enhanced access, quality improvement and payment reform.
- Studies show PCMH can reduce costs by decreasing ER visits and hospital days while improving outcomes.
- Several large employers, the Department of Defense, and state governments have adopted PCMH models for the populations they insure.
- Successful PCMH models integrate primary care, specialists, hospitals, and community resources through use of health IT, data sharing and care
Approximately 12 million adults experience a diagnostic error each year due to factors like poor identification, incomplete communication, and limited resources. Healthcare organizations struggle to address these challenges because of the growing amount of data and regulations. Without consolidated, clean data, achieving interoperability and high-quality patient-centered care is difficult. Healthcare organizations must focus on accurately identifying patients and providers, understanding care teams, establishing data governance, and reducing unnecessary expenditures in order to improve outcomes and meet evolving quality standards.
Team based care model for better productivityJessica Parker
The document discusses the benefits of a team-based care model over the traditional physician-only model. In the team-based model, clinical assistants help with data gathering and documentation to share the workload with physicians. This model has been shown to improve healthcare delivery and help address workforce shortages. Effective teams require all members, including specialty medical billers and coders, working together with physicians, PAs, NPs and other providers. As information grows, no single practitioner can handle it all, making specialized team-based care a necessity.
This document discusses 5 elements of a successful patient engagement strategy:
1. Define your organization's vision for patient engagement.
2. Create a culture of engagement within the practice.
3. Employ the right technology and services like patient portals.
4. Empower patients to become collaborators in their care.
5. Continuously evaluate progress and be ready to adapt the strategy.
True patient engagement involves patients managing their own health, a practice culture that prioritizes engagement, and collaboration between patients and providers.
Team based care model for better productivity Jessica Parker
In an old-fashioned practice model, the physician is solely responsible for most, if not all of the work undertaking of his facility, which also involves charge entry, to medical billing and coding till the time of claims reimbursements.
PCPCC on the Patient-Centered Medical Homedebronkart
The document discusses transforming primary care practices into patient-centered medical homes (PCMHs) through collaboration between large employers, employer coalitions, and primary care providers. The key points are:
1) Establishing long-term patient-doctor relationships and comprehensive primary care focused on patients' needs can improve health outcomes and reduce costs.
2) The current healthcare system fails to support primary care adequately through funding and incentives.
3) Transforming primary care practices into PCMHs through collaborative efforts between employers and providers can help fix these issues by improving care coordination and shifting reimbursements to support comprehensive care.
Why Emplyers care about Pimary care 2008Paul Grundy
Employers have struggled with rising healthcare costs and uneven quality of care. Investing in primary care may help address these issues, as primary care is associated with reduced costs and better health outcomes. However, primary care faces a crisis in the US with a declining primary care workforce. Employers are well positioned to help strengthen primary care through initiatives that support primary care practices, payment reform, and advocating for policies that value primary care. By rebuilding the primary care system, employers can work towards stabilizing costs and improving employee productivity.
Patient-centered medical home initiatives in several states have shown promising results in improving access to care, quality, and cost control for Medicaid patients. Oklahoma saw a $29 per patient annual reduction in Medicaid costs from 2008-2010 alongside increased use of preventive care. Colorado expanded Medicaid access from 20% to 96% of pediatricians at lower costs. Vermont saw 21-22% decreases in inpatient care use and costs from 2008-2010 alongside 31-36% drops in ER use and related costs. Washington state's acute care spending was 18% below average with 35% fewer inpatient stays per beneficiary. Overall, these initiatives demonstrate that the patient-centered medical home model can positively impact Medicaid programs.
A New Era For Nursing: How non-traditional roles are reshaping nursing careersKelly Services
Nontraditional nursing roles have emerged due to technological growth, healthcare reform, and demand for preventative and community-based care. Areas such as patient safety, quality improvement, health informatics, behavioral health, and care coordination have become important domains for nursing. The roles of occupational health nurses, case managers, HEDIS nurses, quality assurance nurses, and nurse educators are growing due to a focus on wellness, chronic disease management, and reducing healthcare costs. These nontraditional nursing roles offer salaries comparable to registered nurses and are projected to be in high demand over the next decade, especially in large cities such as Houston, Chicago, and Los Angeles.
How do we see the healthcare's digital future and its impact on our lives?Jane Vita
"Healthcare is undergoing major changes spurred on by, but not limited to, technology.
Digitalisation is changing the way we think about health, what taking care of it really entails, our personal role in healthcare systems and the way we interact with technology in the context of health.
In many ways, we are entering a post-institutional age of increased personal responsibility, which presents healthcare service providers and other players in the field with major opportunities and great risks. Technology has the potential to empower people and help them become more active in the management of their and their families’ health. This will change the relationship of the patient and the caregiver in profound ways." Mirkka Länsisalo
A co-creation with Mirkka Läansisalo and Sala Heinänen, at Futurice.
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Medical Students Who Want to Become PCPs Are Reconsidering Their Options
1. www.medicaltranscriptionservicecompany.com 918-221-7809
Medical Students WhoWant to Become PCPs
Are Reconsidering Their Options
PCPs can hire medical transcription services to ensure accurate medical
documentation. It is vital that PCPs find more time to focus on patient care.
The key to optimum patient care is having a good patient doctor relationship. A solid
physician-patient relationship can go a long way in helping patients stay healthy and obtain
the best patient care. Interviewing patient, processing their concerns and talking them through
evaluation are the important aspects of one’scommunicative role as physician. However,
pressing demands – related to administrative duties as well as patient care – lead to physician
burnout. This burnout rate is maximum among primary care physicians or PCPs, a new study
by In Crowd points out. 79% of PCPs surveyed said they experienced burnout symptoms,
compared to 68% among all the physicians surveyed. Among the specialists surveyed,
leaving out PCPs, the burnout rate was 57%. Physicians can reduce their documentation
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burden by utilizing EHR-integrated medical transcription services. It is important to also
identify other ways by which physicians can reduce their workload.
Crisis in Primary Care Physician
With an aging general population, the Association of American Medical Colleges projects a
severe physician shortage, particularly in the primary care field by the year 2032. The
shortfall range for 2032 is projected to be between 47,000 and 122,000 physicians. Similarly,
it is predicted that there will be a national shortage of more than 44,000 primary care
physicians (PCPs) by 2035 due to rampant physician burnout, and a workforce saddled
with two hours of required documentation for every hour of patient care.Many medical
aspirants want to become primary care physicians but many are turning away from this field.
Around 80 percent of internal medicine residents including nearly two-thirds of those who
specifically chose primary care tracks, do not plan to pursue a career in primary care. This is
because primary care physicians are forced to spend 18 hours of work a day to complete their
various duties. Earlier, the duty of the PCPs was to connect with patients and build a doctor-
patient relationship but today with the EHR system doctor patient interaction has become
transactional and has no meaning to quality patient care.
Primary care residences of academic medical centers do very little to promote incentive
careers in primary care. Outpatient training is often an afterthought, and dysfunctional
experiences in the clinic have a negative impact on trainees’ impressions of primary care.
Data from hospitals shows that residents have a high percentage of Medicaid patients in their
panels than their preceptors do. Such clinical practices are impossible as well as
overwhelming for physicians and unfair to patients who have complex needs. Most primary
care programs demand many more than the mandated 12 months of inpatient training and
primary care residents struggle to fully integrate into their clinics, to build confidence with
outpatient medicine, and to create longitudinal relationships with patients.
As the demographics and cultural values of the U.S are changing, traditional primary care is
finding it challenging to define its value proposition. Office visits to primary care
doctors have decreased considerably between 2012 and 2016. For their immediate health
needs, patients are choosing urgent care centres, smartphone apps, telemedicine, and
workplace and retail clinics that are often staffed by nurse practitioners and physician
assistants. The young generation are choosing solutions that avoid physicians – they go for
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direct-to-consumer diagnoses and prescriptions for various conditions such as hair loss and
also for skin care solutions.
There are many patients that have complete behavioural needs with many disorders, often
complicated by trauma, lack of housing, and so on. Caring for a fragile population like this
requires collaboration of social workers, doctors, community health workers, nurses and
others. Organizations like City block Health are placing the community health worker at the
center of the care team and not the primary care physician as it works to address the social
determinants that are driving health outcomes.With a variety of expertise required for such a
care modelthe primary care physician may no longer be the soleprovider and there will less
burden on them.
The training for primary care physicians must be changed and the future PCP should be
ensured that it is a profession with reasonable demands. They should be given training
programs that are high functioningwith goals like prevention, efficient resource utilization,
and population health. With the right support, primary care physicians can focus on making
primary care valuable for both patientsand physicians. For optimum care and health
outcomes, streamlined medical documentation is a must, which PCPs can ensure with the
support of reliable medical transcription company. When the documentation burden is also
minimized, PCPs can work to strengthen their relationship with their patients and earn their
trust and confidence.