Improving care quality and patient outcomes continue to be prominent goals in our healthcare system. However, cost control is also an important goal, catalyzed in part by CMS' announcement that it intends to shift 50 percent of Medicare payments from fee-for-service to fee-for-value models by 2018.
Heightened standards for quality and coordination of care are central to value-based payment models. Over time, hospitals' financial performance will increasingly depend on their ability to meet these standards.
The introduction of tougher quality metrics and greater financial risk puts care teams under greater pressure. To preserve the organic drive to improve care quality, many hospitals and health systems are launching care redesign initiatives to improve workflows and strengthen clinical decision-making.
This content is sponsored by xG Health Solutions
Additionally, more healthcare providers are realizing the importance of robust care management teams, as these multidisciplinary groups increase the care coordination across the continuum and serve as "first responders" when high-risk patients need intervention. Care managers help ensure the most complex patients — who are also the highest utilizers of healthcare services and the most expensive — are monitored and cared for in a proactive manner.
Developing an effective care redesign process requires standardization, cultural buy-in, solid leadership and a strong commitment to education of clinicians and non–clinical caregivers.
Many organizations find they need help in redesigning care processes and developing their care management teams. xG Health Solutions, a national healthcare improvement company launched in 2013 by Danville, Pa.-based Geisinger Health System, has developed a suite of tools and solutions to assist providers in the process of care redesign and care management,
A Proven Approach
At their core, care redesign programs should ensure buy-in from key stakeholders — including physicians, nurses, care managers, pharmacists and ancillary personnel — to ensure adherence to best practices, reduce variation in care and drive accountability for outcomes, according to Meg Horgan, RN, MSN, senior vice president of partner resources at xG Health.
Effective care redesign programs have five key components:
- Document what constitutes appropriate care
- Establish evidence-based or consensus-based best practices
- Reliably deliver those best practices, primarily by embedding them in the everyday workflow in the EHR
- Engage patients and families in the care process
- Monitor compliance with agreed upon best practices
Glenn D. Steele, Jr., MD, PhD, chairman of the board at xG Health, conceptualized ProvenCare in 2006 while serving as president and CEO of Geisinger Health System. ProvenCare is a multicomponent program that facilitates the delivery of reliable, evidence-based care for a population of patients. It redesigns workflow to incorporate best practices, often within the EHR to enable real-time decision support. The model has been shown to reduce mortality, complications, length of stay and readmissions, while as increasing efficiency and profitability.
"Any organization that is looking for a process or methodology to improve the reliable delivery of best practices would benefit from ProvenCare," says Ms. Horgan. "If they lack standardization, have inconsistent quality or outcomes or don't leverage their EHR to support workflow — implementing ProvenCare could accelerate solving these problems."
ProvenCare is a flexible template easily adapted to the individual needs and preferences of a provider organization. Although xG Health provides recommended evidence-based best practices, providers can modify them to enhance acceptance and integration from all members of the care team.
One critically important component of the ProvenCare methodology is regular monitoring of individual clinicians' compliance with the agreed-upon best practices.
Care Management
Care management is an integral component of and complement to effective care redesign. Working in tandem with physicians, care management personnel are leading a transformation in healthcare delivery, according to Sarika Aggarwal, MD, CMO and senior vice president of population health at xG Health. "Care managers support primary care physicians by focusing on highly complex or high-risk patients that would benefit from additional education, care coordination and management of goals."
As providers transition to value-based care, the need for all healthcare workers to operate at the "top of their license" to most efficiently manage patient care is greater than ever. Nurse care managers and other members of the care management team — such as community health workers, social workers and health coaches — must be prepared to proactively identify high-risk patients and intervene at the first sign of health problems.
"Embedded care managers become an accepted part of the care team and can facilitate more timely interactions with physicians and staff when they receive important patient information," says Steven B. Pierdon, MD, senior medical director of xG Health.
xG Health Solutions created xGCare, a care management software platform, to streamline the key components of an efficient care management model. xGCare supports the care management team by consistently delivering best practices for patients with complex needs, multiple conditions, chronic conditions and during transitions of care.
xGCare comes with multiple features to enhance care management, such as evidence-based patient assessments for 35 conditions and rules that automate the production of patient-specific action plans. xGCare produces streamlined workflows, stratifies patients based on risk, provides data analytics-driven decision support and organizes tasks for care managers, including identifying patients in need of alerts and reminders.
The platform also enables supervisors to monitor the performance of individual care managers, including their caseload distribution and productivity. xGCare organizes a care manager's workflow and priorities for the day, updating these in real time based on patients' risk. "A care management platform needs to not only guide a care manager on the question, 'What is the right thing to do?' but also to know when that intervention or outreach is due," says Dr. Aggarwal.
Data analytics that enable the care management team to deliver the right care to the right patient at the right time is an integral feature of a care management platform. To determine each patient's risk, xG Health runs each client's membership and claims data through risk stratification software to obtain prospective risk scores. These scores are then combined with certain condition- and time-related metrics to produce a list of patients requiring care management.
Once the highest-risk patients are identified for care management, real-time alerts and decision support guide the care managers through care pathways. Patients are typically flagged for different care management programs, such as complex case management, disease management, gaps in care and others, says Dr. Aggarwal.
"For example, weight gain in a heart failure patient will lead to an automated care plan," says Dr. Aggarwal. "The care plan will help the nurse increase the diuretic medication, which is part of the provider-directed heart failure management plan. This can help prevent an emergency room visit."
The Importance of Education in Care Management and Care Redesign
Any change to clinical pathways and workflows requires physicians, nurses and non-clinical staff to make adjustments in their daily practices. This typically requires a greater focus on education and team member support.
To address this need, xG Health created xGLearn, an educational platform that guides the implementation of ProvenCare, xGCare and the training of effective care managers. xGLearn combines collaborative technology with distance learning to help providers and health plans quickly develop effective care management teams. xGLearn includes expert-narrated modules, self-guided activities, individual and small group coaching sessions, social learning and pre- and post-evaluations. Students also have live interactions with experienced Geisinger and xG Health clinicians, who teach the care team to think collaboratively and develop critical decision-making skills.
xGLearn modules are accessible around the clock on a variety of electronic devices, allowing education to fit into each individual's busy schedule.
"Organizations can review these processes at their own pace, 24/7 on the Internet," says Ms. Horgan. "This allows students to view any particular stage of the process multiple times, and allows the project leader to review [next stages] in advance and prepare the team."
Conclusion
Developing a robust care management program and undertaking care redesign requires subject matter expertise, experience, system wide buy-in and strong leadership. The increasing pressure for providers to assume more risk and accountability for patients' health is driving them to take the plunge.
Now, with solutions like ProvenCare for care redesign, xGCare for care management and xGLearn to provide training, healthcare organizations can embark on their journeys toward value-based care with confidence and support.