Growing up in California I learned to surf as a teenager.  Little did I know that during my “senior years,” I would be riding some of the best waves on the planet.  As providence would have it, I was blessed to live on the North Shore of Kauai for a decade while in my 50s.  During those years on the Island, I surfed two- to three-hour sessions about 12 times a month.  That equates to 2,880 hours on my surf board, passing over (or under) approximately 720,000 waves.  I estimate that I rode more than 10,000 waves, more than anyone deserves. 

Needless to say, I became good at it.  That much time dedicated to any sport (with the exception of golf), should produce good results. Commitment was the key to my success in riding any one of those 10,000 waves. There is a point when you are paddling to catch a wave that you have to give it all you’ve got to catch it, but once you’ve caught the wave there is one final decision to make. I call this the point of commitment. 

A few weeks ago I was enjoying the winter surf on Kauai.  The surf was overhead (6 to 8 feet), and I was perched on top of a wave that I had barely caught.  Looking down from standing position on the board I could see the trough of the wave and the reef below — I was at the point of commitment.  I moved forward on the board, shifting my weight, and drove the nose of the board down the face of the wave.  Once I committed to that move, I was “ALL IN,” and there was no turning back.

As CEO, the lessons learned about commitment in my personal life have influenced the culture here at TCS.  We are committed to every one of our client-partners.  Here is an example – I recently received an email regarding Wendy Day, a senior implementation specialist at TCS:

“Wendy and I did the analysis and developed the needed letters and reports (of which there were many).  She demonstrated time and time again an unfaltering commitment to excellence and customer support.  I want anyone who reads this note to know how lucky you are to have her on your team!”

Wendy was “ALL IN” in the same way all of us at TCS are here for you. Whether catching a wave in the ocean or operationalizing the latest technology wave, TCS is all about commitment. Are you ready to catch a wave? Call us, we would love to chat.

Reform has always been a sign that society is evolving and changes need to be made to meet the needs of the population, and it is no secret that healthcare is in the middle of its own reformation.  Public and private demands, market forces and several legislative bills are pushing the system to improve patient care and expand coverage. With the current paradigm shift facing the healthcare industry a variety of resources are being published which can help professionals understand changes and explain some of terms that are becoming common place.

President Obama signed into law the final version of the Patient Protection and Affordable Care Act (PPACA) on March 30, 2010. PPACA is a primary example of legislation that is causing major change within the healthcare industry. The law is currently awaiting a final verdict from the U.S. Supreme Court which should be delivered sometime in June.  

Thomson Reuters recently published a white paper titled, Vocabulary of Healthcare Reform which states, “One of the major goals of the PPACA is to ensure nearly universal health coverage. This means finding ways to provide coverage for the approximately 45 million people in the U.S. who are currently uninsured.” Although the fate of the PPACA is still undecided, we can be rest assured that the reformation will continue to progress.

The Thomson Reuter’s white paper is an excellent resource that examines the many aspects of healthcare reform facing our country as well as key terms that are going to become a part of the vernacular within the industry. Some key points of the paper include:

• Healthcare Reform Goals
• Payment and Insurance Reform
• Healthcare Innovation and Technology Reform
• Organizational and Operational Reform

The publication is just one example of resources that are being published to assist healthcare providers as the transformation takes place. In addition to examining the various types of reform being pushed in the healthcare industry, the white paper also features a glossary of key terms and supporting graphics to explain what is being discussed. Resources such as this are a great asset to members of the healthcare community and should be utilized often to ease the transition as healthcare reform progresses.

For a complete copy of the Thomson Reuter’s white paper, please go here.

Traditional case management interventions often have used face-to-face, telephonic, and written communication links to support patients and others who need healthcare support. With the rise of new communication strategies that are affordable and the buzz about social media, case managers are beginning to think about expanding how they connect with their patients to improve patient engagement levels and clinical outcomes.

TCS Healthcare, through Acuity Advance Care™ (ACUITY), offers an array of options to enhance the ways that clinicians can reach out and stay in touch with their patients. Examples include letters or information packets that can be automatically queued for mailing without any manual processing, and HIPAA-compliant electronic communications, such as email and text messaging. In fact, care management software platforms like ACUITY are opening up many new doors in terms of automating workflows and coordinating patients with many co-morbidities.

As referenced in the Research Update Column, the bi-annual survey of care management trends reinforces this point as well. The survey, which was completed by 670 case managers and others, predicts increased reliance over the next two years on communication media such as email, text messaging, personal health records, smartphone applications, remote monitoring connections, and other new communication options. Interestingly, the survey results show a slight decrease in the reliance by case managers on telephone calls, letters, and face-to-face interactions in the future.¹

Of course, the recent negative press that Facebook has received regarding its privacy policies -- which often are not optimized for patient protection -- is a warning that case managers must be informed communicators no matter what the medium.

The nice thing about running these enhanced communication links through a system like ACUITY is that everything is documented, allowing for easy tracking, retrieval and reporting of information. This also helps with regulatory, business and clinical compliance requirements.

¹ Survey results to be published in June 2010, see www.tcshealthcare.com for details. Survey co-sponsored by ABQAURP, CMSA and TCS.

The advent of health IT (HIT) systems has transformed the health care industry. Leveraging technology to improve medical management intervention strategies should remain a high priority in terms of both improving patient outcomes and reducing medical costs. These applications are ever-evolving tools that support care management. Clearly, HIT applications are changing the practice of care management in profound ways.

According to the Department of Health and Human Services (HHS), "Health information technology (health IT) makes it possible for health care providers to better manage patient care through secure use and sharing of health information."  By utilizing available HIT, providers are better able to diagnose health problems sooner, reduce errors and coordinate the care they give.

Keeping the patient, family, caregivers, and the entire health care team in different settings aware of all the care coordination needs of a patient is a major challenge. Health care barriers need to be broken down and all providers need to work together as a collaborative team for the good of the patient. This requires commitment, communication, and teamwork.

Interestingly, health information technology fulfills an important role in supporting this communication, teamwork, and all aspects of patient transitions of care. With so many aspects of care coordination to think about, case managers need to have a care management system that helps them assess, plan, implement, track, facilitate, and document key aspects of a patient’s care.

It is increasingly important that the right information be available at the right time to the right people to support health management and patient care. For the sake of being forward-thinking, data content and the quality of the data are going to be an integral part of the interconnected health care system of the future.  Having the proper health history and detailed care plan available are essential to managing the ongoing care of a patient. In addition to improving the quality of care and reducing costs, the utilization of health IT also supports and improves medication management and self-management of chronic diseases.  Many factors come into play when thinking about the ideal process for transitioning a patient from one care setting to another. Communication between patients, providers, and hospitals is key to having an organized health care system, and capitalizing on HIT is an excellent way to improve communication.

HIT use allows caregivers to communicate quickly with hospitals, providers, and most importantly, with patients and their families.  Incorporating HIT into the care continuum allows health care providers to offer a safer and more comprehensive system to treat patients, keep accurate records, improve outcomes, and educate patients and caregivers about their health and treatment plans.  

Originally published in CMSA Today.

At this time of year, we see numerous articles and blogs discussing health care trends and predictions for the upcoming months. 2012 is no exception. These trends include a range of topics, but a big issue on most case managers’ minds is how “medical management” and “technology” will work together to improve care management processes. Leveraging technology to support and enhance medical management solutions is essential to optimize clinical and financial outcomes for patients, providers and payers.

In reality, looking ahead one year at a time often is not enough to make accurate predictions. In fact, software developers need to look even further into the future to identify emerging trends and needs in order to anticipate and design future innovations. But that isn’t always easy in this industry, because things change so quickly. “Key” predictions for this year may not turn out to be correct or they may be irrelevant in a year or two. There is no “crystal ball” that we can simply rely on with 100% certainty.

However, here are a few key observations, okay “predictions” if you will, that are impacting the U.S. health care system in general and case management in particular:

• Promoting Patient-Centered Initiatives. The patient-centered model is “here to stay,” at least for the foreseeable future. Accountable care organizations, patient-centered medical home, and guided care programs have shown cost reduction through reduced admissions, increased quality, and high satisfaction rates. These initiatives provide and rely on more direct physician involvement and leadership. This team collaboration means we need to develop better communication channels and transparency of information for all members of the care team.

• Enhancing Patient Engagement Strategies. Since the patient, family members and caregivers are at the heart of the emerging patient-centered model, we also need to improve communications between them and the care team. Easy tools need to be developed that encourage patient education, engagement, and self-management. Millions of patients use the internet to review test results, schedule appointments, get health information, and email their physicians. This trend will continue to grow, so we have to find better ways to continually improve the experience.

• Expanding Communication Channels. The rise in social media interactions to support patient health is another communication trend that is rapidly expanding. It will not affect our elderly population in any great numbers now, since they don’t routinely use social media, but it will become increasingly more engrained in the way we communicate with younger patients and their families. Similarly, text messaging, email, online video chat, VOIP-based telephone systems, and other communication channels will increase our ability to stay connected with family, caregivers, providers and others.

• Empowering Remote and Wireless Monitoring. We are seeing more care coordination being done at provider sites and in-home visits through wireless connections using laptops, tablets and smartphones. This is creating increased concerns for the IT departments regarding privacy and security. Remote home monitoring is less expensive to provide now and easier to set up and manage, so it is going to be used more in the coming years. The data from these devices needs to be seamlessly integrated into the medical management software, so care managers can be alerted immediately if potentially dangerous situations arise.

• Expanding Care Coordination Interventions. We are already aware of other key care coordination processes that are essential, i.e., transition of care, medication reconciliation and management, and patient safety. Tracking and analysis of readmissions is another key area. Medical management systems need to include tools to easily manage, document, and report outcomes for these processes. Systems should currently have these capabilities, but they need to be improved upon, as we learn more about which care interventions drive the most successful outcomes.

• Relying on Efficiency and Real-time Feedback Loops. Efficiency and cost reduction remains a key objective for all programs. Real-time dashboard reporting and data analytics are essential to determine actionable areas for improved quality and cost savings. Business process management is another essential component. Systems need to be easily configured, based on unique business logic, to drive automated, streamlined workflows that improve efficiency, increase productivity, and reduce costs.

• Creating Practical Technologies with Elegant Designs. With Steve Job’s recent passing, we are reminded of the importance of merging technology with elegant designs. Job’s vision for combining iPhones with thousands of health applications that can be easily downloaded from iTunes, or integrating the myriad of EMR/EHR apps that can now run on iPads, signal much more of what is to come. Technology that is ready out of the box, practical and functional!

These are just some of the trends that software developers, case managers and others should keep in mind when developing strategies for future enhancements and implementing care management programs. Therefore, it is important that you provide your thoughts and perspectives to your technology vendors regarding what you feel is needed. This will help us both move forward together to stay ahead of the trends and create innovative IT and medical management enhancements.

Health care is an ever-changing industry, therefore, IT applications and clinical processes need to keep pace. By looking forward, we can do a better job with our tasks today and anticipate what is coming tomorrow.

Originally published on CMSA’s website

As we venture into a new era of information and storage options, one question keeps arising… What are the risks?

Sure, endless information stored “somewhere else” sounds great, but who is making sure this data is secure?  Making sure no one else can view, copy, or download your private data.  And what are some options in regards to this?  An article in Healthcare Informatics Magazine discusses this topic in depth, and sheds some light on the situation.

Please follow the link below to an article in the “Healthcare Informatics Magazine”.

http://www.healthcare-informatics.com/article/security-cloud

Recently, the National Transitions of Care Coalition (NTOCC), a non-profit founded by CMSA posted a Transitions of Care checklist which aids in identifying areas providers do not currently assess but may want to begin including in patient records moving forward. The main goal of the checklist is to increase communication between providers, care settings, and caregivers of patient care plans, assessment and other clinical information.

The checklist which can be found here is one of several free professional tools that NTOCC offers to help health care professionals.  The list includes the following Overarching Concepts:

• Engagement

• Collaboration

• Strengths-based assessment

• Assessment as an ongoing process 

In addition to the Overarching Concepts, the checklist also includes Common Elements for Assessment and Intervention:

• Physiological functioning

• Psychosocial functioning

• Cultural factors

• Health literacy and linguistic factors

• Financial factors

• Spiritual and religious functioning

• Physical and environmental safety

• Family and community support

• Assessment of medical issues

• Continuity/Coordination of Care Communication

This is one of several free professional tools for case managers offered by NTOCC.  Please visit NTOCC’s website to view all of the resources that they have to offer.

In order to offer effective medical management programs, case managers need to be aware of key health care trends and try to stay “one step ahead” of them. Clearly, the expanding symbiotic interface between technology and care management workflow processes is a prime example.

It is imperative in most health care settings that nurses understand how technology solutions can improve patient care. On the other hand, we also need to be cognizant of those situations where technology is not meeting baseline expectations or could even be a detriment.

There are five key IT attributes that case managers should keep in mind when assessing the efficacy of information technology (IT) applications:

• Integration: Are you working in an environment where technology is beginning or has already created an integrated IT platform? The elimination of “silos” and “paper” systems is an essential part of the equation.

• Interoperability: Does your health IT system interface with other critical systems? For example, data from electronic health care records including medical charts, claims, pharmacy data, lab data, health risk assessments and other data should be linked or viewed through one portal to optimize the flow of information.

• Automated Workflows: Does your IT system promote dynamic, rules-based workflows resulting in automated tasks such as “To-Do” lists, letter generation for patients or populations, etc.?

• Evidence-based Decision Making: Does your IT application utilize pre-defined, evidence-based care plans that can be auto-populated with linked problems, goals, interventions and expected outcomes?

• Enhanced Communication Links: Does your IT system allow you to communicate with patients, providers and other collaborators (and document those communications) through emerging platforms such as the Web, remote monitoring, texting, encrypted emails, and social networking?

In this new age of technology transformation, monitoring technology trends is more important than ever.

This blog was originally published in CMSA's February 2010 monthly newsletter. To view this post go here.

The concept of “external review” is familiar to most case managers.  The ability for a patient or their provider to appeal an adverse medical necessity or benefit determination has been around for years.  However, a new national framework for such appeals is being established through the Patient Protection and Affordable Care Act (PPACA). 

Last June, the U.S. Department of Health and Human Services (HHS) and U.S. Department of Labor (DOL) issued a revised technical release updating the new federal “external review” requirements.   Simply put, hhealth plans issuing new policies and offering “non-grandfathered” coverage must provide individuals an expanded reconsideration and appeals process when an adverse determination is made. After several draft regulations were published and a six-month delay, key provisions of the new federal law go into effect January, 2012.  

The relationship between case management and external review is an important one.  "The right to an external appeal is considered one of the most important consumer protections that you can have," said Steve Larsen, director of HHS’ Center for Consumer Information and Insurance Oversight. "Consumers do not want insurance companies making medical decisions for them or for their families." As a result, case managers play a vital role in helping patients navigate and find balance between their medical care needs and service reimbursement.  

Unfortunately, identifying which set of appeal rules apply is not always easy.  Under existing requirements and PPACA, several sources of external review requirements might apply to a given situation, including:

• Section 2719 of PPACA

• U.S. Department of Labor regulations adopted in 2002

• The Uniform Health Carrier Review Model Act issues by the National Association of Insurance Commissioners (NAIC)

• Most states have adopted an independent or external review regulation already (see comments below)

• URAC and NCQA’s accreditation standards for external review and independent review organizations

 The federal government notes that in some cases state-based external review requirements may be sufficient to meet and/or exceed the new federal requirements.  Currently, HHS is determining which states meet or exceed the new federal requirements. 

 All of these potential variations can be overwhelming for patients, providers, and for all of us working in case management.  However, this is where technology comes in.  Several software applications are being configured to help automate some of these key external review decision points.  When done correctly, key workflows and regulatory requirements can be integrated and streamlined, which in turn will allow providers and case managers to continue focusing on the patient.   

 I encourage you to take the time now to review the requirements to determine how they might affect your workflow processes.  You may be surprised to find that you are lucky and they won’t affect you at all.  However, if you do have  to make changes to meet the requirements, at least you will have time to make them before they are needed.  It’s always best to be prepared and plan ahead.      

 In the meantime, regulators still need to sort out all of the nuances associated with PPACA’s new reforms.  Even if some of the reforms are repealed or scaled back in the future, IT systems and applications will continue to empower case managers and providers to do more for their patients.   We are living in exciting times indeed.   Challenging - but exciting!!

 This blog was originally published in CMSA's December 2011 eNewsletter. To view this post go here.

It is amazing to observe how quickly technology is changing the practice of case management. A review of the TCS website at www.tcshealthcare.com provides an illustrative example of how TCS is making its mark in the care management field through technology-based applications and clinical workflow support.

In these fast-changing times, another important thing to consider is stability and consistency. I, along with my wife Esther Pock, founded TCS over 25 years ago. We are a family-owned business that has been dedicated to supporting patients, clinicians and various types of health organizations for decades. Our hope is that we will continue to deliver the same quality-based services over the next 25 years!

Without a doubt, TCS will continue its mission of delivering the most appropriate technology enhancements to the care management field. In addition, TCS’ clinical team of experts will identify and share with clients a myriad of best-practices supporting UM, CM, DM and Wellness Programs. This makes us not only a technology expert but a full-service “solutions” company.

In addition, TCS will continue pursuing many of our altruistic endeavors which include:

• Technology Access. Partnering with CMSA to offer CMSA members, Acuity AnyWare, a hosted application for independent case managers and smaller organizations that is affordable with no long term commitments.

• Educational Support.  Financially supporting CMSA’s new nonprofit foundation to ensure that underfunded or public service case managers have an opportunity to attend CMSA’s national conference.

• Research. Sponsoring the second annual health information technology survey, examining care management software trends and making the results available to all stakeholders at no charge (you can download a complimentary copy of the 2008 Survey results from our website).

If you are not familiar with us, the TCS team encourages you to become part of our growing community. Also, any feedback on our newsletter would be greatly appreciated. Please email us at info@tcshealthcare.com or call me at (530) 886-1700. ext 206.

I’ve been surfing since I was 15 years old, and ten of those years were spent on the North Shore of Kauai. One thing I’ve learned is, “when in doubt, don’t go out.” This sport requires a great deal of patience, and to catch your wave you must spend considerable time in the lineup studying the rhythm of the ocean and the other surfers. Moving too quickly can result in a wipeout, but when it’s your time to go you must be totally committed. As in surfing, the medical management (MM) industry requires patience and study, and often can lead to a wild ride.

Among other influences, the Patient Protection and Affordable Care Act (PPACA) includes dozens of references to case management, chronic disease management and other medical management programs in the statutory language. As a result, we can expect literally wave upon wave of new regulation to be proposed and implemented over the next several years to operationalize these new programs.

It’s reassuring to know that TCS is ready to “catch the wave” no matter how turbulent the ocean becomes. This is for many reasons, including the fact that we have over 25 years of medical management software experience, and we understand how emerging trends could have an impact on the industry.

In addition, we are constantly enhancing Acuity Advanced Care™, our signature medical management system, to keep ahead of the curl. In fact, the 2010 Health IT Survey rated ACUITY’s ability to perform the following significantly higher than industry averages:

• Automatically generate care plans for patients;

• Stratify health data;

• Use data to schedule or execute follow-up tasks; and

• Use of Case Management Adherence Guidelines (CMAG).

These health IT qualities were less frequently reported by users of competing medical management systems.

Our core philosophy is to stay focused on medical management. Through our understanding of best practices, technological advancements and our creative problem-solving abilities, we provide our clients with the tools that allow them to serve their customers and patients efficiently and effectively.

And that isn’t all. TCS’ past successes have emboldened us to keep catching wave after wave and not wipe out. To learn more about how TCS plans to stay an industry leader, visit our website, shoot us an email, or just give us a call. We’d love to hear from you.

With all of the market forces at play and major reform efforts underway, both at the federal and state levels, it’s important to understand how these trends are impacting the practice of case management.  Clearly, one trend is the need to promote and move to integrated “care” solutions.  The move to enhanced clinical and administrative workflows often is dependent upon linking existing activities and interventions through emerging ideas, technologies, business platforms, and evidence-based clinical pathways.  This column highlights some of the ongoing challenges and opportunities to promote a more seamless environment for case managers and the patients they support. 

Delivery System Integration 

The bi-furcation of the insurance function from the provider delivery system is common throughout the United States.  Almost everyone agrees that the delivery and financing of patient care is fragmented, and attempts to better coordinate care often face legal, market and institutional barriers. 

However, efforts are underway to figure out how to increase the payment, efficiency and connectivity of healthcare.  The formation of accountable care organizations (ACOs) is one example of an emerging concept that is being discussed.   ACOs are viewed as a mechanism to allow physicians, hospitals, case managers and other clinical caregivers to address some of the perceived delivery and coordination challenges in the current healthcare delivery model – while at the same time allowing clinicians to assume some of the financial and business risks associated with patient care.  CMSA also has addressed the issue of fragmentation in some detail with its support of effective transitions of care (see March 2011 column).

Information Technology Integration 

Healthcare system fragmentation also is perpetuated by information technology (TI) platforms.  In most cases, IT systems need to improve interoperability and other data interfaces to optimize the ability to better serve providers, patients and payers.  We addressed the need to connect disparate IT systems deployed in the U.S. healthcare system in a CMSA column published earlier this year (see January 2011 column).  While much work still needs to be done in this area, there a few care management software systems that are fairly effective in integrating various sources of data in a way that case managers and others can act upon. 

Consistent Regulation 

Inconsistent regulation also can hurt the ability of case managers and others to work in an integrated and seamless manner.  A microcosm of this tension is highlighted by efforts to implement the Patient Protection and Affordable Care Act (PPACA) as both the federal government and the states develop the exchange-based marketplace that will offer qualified health plans to individuals and the small groups.  It will be interesting to see if the regulators implementing PPACA can establish a more level playing field than the current regulatory system, with a primary goal of preventing adverse risk selection from one insurance pool to the next.  Another example is the over-lapping and sometimes inconsistent regulation covering utilization management, case management and external review activities.  

Program Integration 

Sometimes there is enough integration of the clinical, business and IT workflows to do something special with chronically-ill populations.  Through an integrated and coordinated platform, case managers can do wonderful things as they identify, track, and improve targeted patients, who often suffer from a wide-range of co-morbidities and social problems.  There are a number of care management organizations and health plans that have the right mixture of activities in place to do something special.  In such cases, integrated care management programs often produce improved clinical and financial outcomes. 

Meaningful Integration 

Clearly, one size does not fit all.  But the power of integration is becoming even more important in this ever-expanding world of complexity.  Facebook links us virtually, cell phones and texting keep us connected no matter where we are, ATMs make accessing cash easy, and iTunes makes downloading music a snap.   It is going to be exciting to see how case managers adapt and change in this technology-dependent age. Although we will have many “tech” challenges ahead, case managers (and their patients) should not fear change.  Good things are going to happen.  Integration must become a fundamental value.

                     Originally published in the CMSA's Member eNewsletter (October 2011)

At TCS, we are happy to announce that we have completed the project to incorporate ICD-10 codes into our suite of products.  They are available to you now, or whenever you have the time and resources to go through the upgrade process and do thorough testing so that you are ready for production.

Before we began implementation, we did a lot of research to understand what ICD-10 is and what its impact would be to our software.  We called on our internal experts in workflow and coding to give you a straight-forward yet powerful solution to the implementation of ICD-10.

Our products, beginning with our core product ACUITY Advanced Care™, can accommodate both ICD-9 and ICD-10 codes simultaneously.  Code sets are easily identified and you can search on either or both sets of codes.

In order to accomplish this, we had to make changes to the database structure.  This is the reason you have to “migrate”.  Automated steps take your data from your current version to the ICD-10 version.  No data is lost or mislaid.

Because the database changed, there is an impact on reports and letters.  Sometimes this impact is minimal, sometimes not.  We have updated all standard reports and letters to report on both or either ICD code sets.  But you may have developed your own reports and letters.  These have to be reviewed individually to determine if a change is needed and a decision made about what the change should be.  We found that some reports / letters could be changed to display either type of code without having to change the report / letter format.  Some reports required more thought.  A few reports were left as is, so they will display only ICD-9 information, and new ICD-10 reports were developed.

We did lots of testing, going through screen by screen, field by field to verify that everything worked as we expected.  You won’t have to be this detailed in your testing, but you’ll want to set aside some time to go through your standard work flows and make sure that you’re seeing what you expect.

If you would like assistance from TCS for the upgrade to the ICD-10 release, please contact us and get on our upgrade schedule. 

October 1, 2013 still seems a long way off, but we want to help all of you be as prepared as possible on that date to meet the requirements of the ICD-10 initiative.

One of the hot topics in today’s healthcare trade press and blogs is the Accountable Care Organization (ACO). ACOs are essentially a model for healthcare reform. Under the recent Patient Protection and Affordable Care Act, ACOs are listed as a model for cost-cutting and improved care under the Medicare Program. At press time, the new ACO regulations are due to be published by the federal government at any moment.

What Are ACOs?

ACOs are intended to deliver quality healthcare services more efficiently and improve the patient experience through a Medicare “shared savings program.” The buzz about ACOs is significant in many circles and several pilot programs are being established, despite the lack of an existing business model. ACOs will initially be organized as regionally-based healthcare delivery systems that integrate primary care, multi-specialty group practices and/or hospitals to carry-out several traditional health plan functions.

ACOs are going to hold a strong position in today’s healthcare landscape because they will be responsible for monitoring the overall health status of their assigned patients, as well as providing care. ACOs will be incentivized to keep people out of the hospital and thus encourage more selective use of quality treatments. Under the new plan, ACOs and participating providers receive a portion of the savings. ACOs will likely be responsible for providing a “continuum of care” by becoming a vehicle for paying teams of healthcare providers to treat the “whole” patient, rather than requiring patients to pay for care one service at a time.

How do ACOs relate to TCS?

The Center for Medicare and Medicaid Services (CMS), the federal agency in charge of the ACO program, will likely require ACOs to integrate key clinical and operational processes. This likely will include data reporting, case management programs, and quality assurance monitoring. As a result, TCS’ suite of products and services are perfectly positioned to help ACOs meet and exceed most of the federal requirements once they are finalized.

TCS is a leading provider of software and clinical solutions that support and improve population health management strategies for health plans, insurers, providers, third-party administrators, medical management companies, and others. Its solutions are a perfect fit to support ACOs.

For example, Acuity Advanced Care™, TCS’ flagship software application, is a comprehensive and integrated care management software system supporting case management, disease management, prevention/wellness, and utilization management programs and interventions. TCS also offers an array of other solutions that will be useful for ACOs, including evidence-based care programs that include clinical assessments and outcome-based care plans, as well as a population stratification and automation tool that turns patient healthcare information into automated, actionable events.

Needless to say, TCS products are an excellent choice for fledgling ACOs and other groups looking for a simple, comprehensive, user-friendly medical management solution. After 25 years in the business, TCS has both the experience of an established industry leader and the vision of a forward- thinking, innovative company.

To learn more about TCS and why it is one of the top medical management system companies in the country, give us a call.

I’m still reflecting on “take-aways” from the 21st Annual CMSA Conference. Each year there are some sessions that really stay with me. This year it was one by Dr. Tom Wilson, PhD, entitled “Health Care Effectiveness Review – Measurement and Performance”. It sounded like a good outcomes session, so I decided to attend. But it was much more than that!

What Dr. Wilson described is a new, exciting way to transform the overwhelming, intimidating process of developing a research study and publishing its results into a simple method that any of us can feel comfortable doing. We have probably all had some successful program, project, new initiative, or maybe a study that showed lowered costs or increased productivity that we felt others would be interested in learning about. However, we didn’t publish it because it didn’t seem like it was “formal” enough. Likewise, we are interested in knowing what successes (or failures) others are having, but they aren’t published, so that information doesn’t get shared. So what can we do about this?

Those of us working in case management have an obligation to demonstrate the clinical and financial efficacy of how we intervene with patients and their providers and to share this information with others. One challenge we must address is that our choice of services is broad and dynamic, so any “return on investment” (ROI) analysis or report might not adequately document how case managers are positively impacting the targeted population.

Similar challenges and problems have confronted other areas of medicine as well. In fact, much has been written in recent years about some of the “poor” evidence that is used to support studies that are published in peer reviewed journals, including even the New England Journal of Medicine.

This has given rise to the “comparative effectiveness” movement. The U.S. Agency of Healthcare Research and Quality (AHRQ) has taken a leadership role in promoting research and medical interventions that are more transparent and accountable. AHRQ notes:
Comparative effectiveness research is designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.[1]

Even the Congressional Budget Office touts the benefits of comparative effectiveness research in a 2007 report[2]. CBO defined the concept as: “As applied in the health care sector, an analysis of comparative effectiveness is simply a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients.”[3] A primary motivation for CBO’s support is the ability to save costs in the Medicare and Medicaid programs.

Dr. Wilson, founder of the Population Health Impact Institute – PHI Institute (www.phiinstitute.org), has worked closely with CMSA to operationalize the principles of comparative effectiveness criteria in the case management environment, including presenting at several CMSA conferences, providing an online individual certification course, and an accreditation program for organizations.

And now Dr. Wilson and the PHI Institute has teamed with Anne Llewellyn and Dorland Health to provide the “Health Care Effectiveness Review”, a new kind of "peer" reviewed publication targeted to real-world workers and designed to enhance measurement and performance of care management programs.

As noted in Dr. Wilson’s description of the conference session, the “peer-reviewed learnings” will focus on the easy-to-understand “Method Evaluation Process” (MEP) developed by PHI Institute. Articles selected for publication can be either new submissions or articles that have been published previously, but may need some re-formulation. All articles submitted will be reviewed by true “peers”--individuals who have been granted MEP certification and wish to help the real world writers and readers advance the cause of care coordination learning.

As Dr. Wilson notes, “the goal is to provide a number of educational forums and opportunities to support research at the design, study, analysis and publication phases. Credible research can add important insights on how case managers and others can better manage individuals, especially those with a number of co-morbidities”.

If you want to consider a 1st step, take a look at PHI Institute’s transparency pledge at http://phiinstitute.org/transparency-pledge. Your 2nd step should be to listen to Dr. Wilson’s session as soon as it becomes available with all the course offerings from the conference on the CMSA website. And if you want to take a “really big” 3rd step, why not submit an article for publication? Come on. It may be easier than you think!

Documenting case management outcomes is an ongoing journey. By using resources made available by AHRQ, PHI Institute, CMSA and others, the journey can be made more educational, focused, effective, and FUN!

[1] See http://www.effectivehealthcare.ahrq.gov/index.cfm/what-is-comparative-effectiveness-research1/.

[2] See “Research of the Comparative Effectiveness of Medical Treatments” COB (December 2007, 48 pages) at http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf.

[3] Ibid at page 11.

Originally published in the CMSA's Member eNewsletter (July 2011)

A priority of every case management intervention is to support the patient to make sure that they are getting the best care and support over a continuum of time to achieve positive clinical outcomes. However, case managers also need to deal with the “medical appropriateness” or “medical necessity” of care. This function is referred to as “utilization review” or “utilization management” (referred to collectively as “UM”).

Clearly, UM oversight does have a role in case management interventions. We are reminded of this relationship by a 2002 CMSA/URAC regulatory study that showed over a dozen states reference UM programs when defining the practice of case management.[1] In addition, the CMSA’s Standards of Practice highlight the close relationship between UM and case management programs when defining “managed care.”[2]

UM interventions help ensure that patients receive the “right care at the right time” to improve clinical outcomes and lower costs. UM’s goal is not meant to merely “limit or restrict” care, but to assure that “appropriate” care is received. The Institute of Medicine (IOM), the Robert Wood Johnson (RWJ) foundation and other experts have highlighted the overuse and underuse of healthcare services, and that either of these can result in the potential risks that can greatly outweigh any potential benefits. For example, spending and doing more does not necessarily equate to better care.[3]  A recent Health Affairs article also highlights that private insurers do a better job controlling costs than Medicare by using UM programs.[4]

Evidence-based, decision support criteria from Milliman, InterQual and others are an essential part of any UM program by providing objective criteria to help determine the “right” care. Managed guidelines for conditions, particularly where there is wide practice variation, present a means of increasing cost effectiveness while improving outcomes across the board. 

Over or under-utilization can lead to lower quality care with higher costs and health risks.  But UM, in combination with evidence-based treatment guidelines and standardized clinical pathways, helps to determine what is medically necessary, and as a result, enhances the quality and effectiveness of a patient’s care. It represents an evidence-based approach to optimize care, while eliminating excessive treatment and expense.

To further that end, case management software applications must provide case managers with easy access to information, enhanced documentation, and improved accountability. The application needs to be integrated with other sources of patient information, (i.e., claims, lab results, medications, health risk assessments, UM and DM data, etc.), so all the data needed for decision-making is available in one integrated system. Based on this information and built-in business rules, the application should be able to automatically present appropriate care options to the case manager, so he/she can develop individualized care plans that meet the unique needs of each patient.

The good news is that technology now offers these types of functionality that were only dreamed about a few years ago. They provide case managers and other caregivers with the ability to develop automated high-level care plans that provide each patient with the “right care at the right time”.

One of the recent buzz words that we hear about these days is the concept of health IT “interoperability.” For years, the federal government has been pushing for the broader implementation of electronic medical records to promote efficiency and better clinical outcomes. 

With so many diverse and disparate IT systems deployed in healthcare today, the need to connect those systems is paramount. That is why the notion of “interoperability” is key to making sure that all healthcare stakeholders are getting the right information in a timely basis when treating a patient. 

Although usually thought of as a technical term, the definition of “interoperability” shares some of the same attributes with the underlying mission of case management. The technical term is defined by Wikipedia as “the ability of diverse systems and organizations to work together (inter-operate). The term is often used in a technical systems engineering sense, or alternatively in a broad sense, taking into account social, political, and organizational factors that impact system to system performance.”

The clinical definition for “interoperability” is also implied in CMSA’s definition of case management - “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.” 

The context of “interoperability” sounds familiar in both areas of practice, doesn’t it? They are both focused on making sure all stakeholders have quick, easy access to pertinent data from all systems and collaborators, so everyone can work together to seamlessly coordinate care.   I think of a case manager as a “human health data exchange,” specifically as a “connector” of healthcare information and intervention strategies that in turn empowers treating providers to bridge gaps in care. But case managers are not just “technical robots”. Their clinical knowledge and experience are key to providing individualized quality care coordination for a patient across the continuum of care. No computer system, regardless of how good it is or how integrated it is with other systems, will be able to replace a case manager, but they can certainly help the case manager maximize their efficiency.  

In terms of managing chronically ill or targeted populations, case managers are in the best position to identify, implement and revise healthcare strategies. However, we are now reaching a point where case managers sometimes can have access to too much information about a patient. In such cases, we need to make sure that information is stratified and prioritized in way that really helps, not hinders, the review of data.

Ultimately, the quest for the right “interoperable” system in healthcare is tied to effectively integrating the right technology applications with the skillsets of a case manager -- but in such a way that pertinent information is available, avoiding information overload.

¹McGuire Woods Legal Update 7/30/2010.  See http://www.mcguirewoods.com/news-resources/item.asp?item=4995
²To download a copy of the HIT Survey Report, log on to www.tcshealthcare.com and click the “Health IT Survey” button or log on to http://www.cmsa.org/HealthITSurvey.

A new research report by TCS Healthcare Technologies (TCS), in conjunction with the Case Management Society of America (CMSA) and the American Board of Quality Assurance Utilization Review Physicians (ABQAURP), finds that health information technology (HIT) systems are having an impact on a variety of medical management interventions, but less quickly than anticipated. The first HIT study was conducted in 2008 to examine HIT trends in the field of care management. ABQAURP and CMSA rejoined with TCS in 2010 to conduct the second survey, resulting in two years of comparison data.

A core objective of both HIT surveys was to assess general trends related to HIT systems, especially the trends for care management software applications, as well as the specific capabilities within those applications. The research further examines additional electronic applications used by providers, payors, care managers, and others to support patient care.

While progress is slow, it is occurring. More specifically, trends related to interoperability, functionality, and satisfaction levels indicate more work needs to done in leveraging best practices for medical care.

In the 2010 survey findings, respondent trends include:

• 69% use multiple health IT systems, while 16% use only one health IT system;
• 23% of information technology system(s) is/are fully integrated and interoperable with other external IT applications;
• 23% have moved to a completely paperless environment regarding patient or care management records;
• 54% scan medical records, documents, or communications into their medical management information system;
• 35% can share clinical data electronically with other providers; and
• 26% allow providers to access report cards that show physician- and patient-specific compliance with reporting initiatives.

Regarding patient communication strategies, respondents sound a strong positive note about embracing emerging communication options within the next two years. They anticipate a three-fold increase for using text messaging, smart-phones and wireless remote monitoring. A doubling in the use of online personal health records, patient portals, remote monitoring and social networking is also projected.

The survey results also offer interesting insights about the average number of caseloads handled per week:

• the most frequently selected caseload range is 25-49 cases per week; and
• the most time spent in face-to-face contacts with patients is 100 to 124 cases per week.

This last response conflicts with general wisdom about how case managers spend their time. For example, one would assume that the more face-to-face contacts a case manager has with patients, the smaller the caseload – but as it turns out, this does not appear to be the pattern. This result should be studied in more detail through additional analysis of the current survey and in future surveys. Are the nurses in each of these categories working in the same field, e.g., telephonic versus on-site with patients at clinics? If so, the latter group would probably report more “face-to-face contacts”.

Responses to several satisfaction questions indicate challenges remain for mobilizing HIT software platforms that satisfy the desires of case managers and other users. Dissatisfaction with current platforms offers an important window of opportunity for vendors to develop and sell software applications that are based upon designs that will increase user efficiency and satisfaction.

The study concludes that many opportunities exist to leverage technology to enhance the care management process through the following principles:

• Implementing sound platform designs – that support the natural workflow processes of the care management professional.
• Moving toward integrated and interoperable HIT systems – that minimize the need to identify and collate data manually across systems and platforms.
• Promoting automation – that reduces the number of actions care management professionals need to perform while conducting the basic actions affiliated with their work.
• Leveraging emerging communication portals – that include text messaging and social media as long as protected health information is properly safeguarded.
• Using the right information at the right time – that enables patients, their providers, and other stakeholders to access the patient’s health information, care plans, evidence-based protocols, and other information to make meaningful decisions.
• Increasing workflow efficiencies – that should allow care managers and other professionals to spend more quality-based time interacting with and supporting their patients.
• Increasing transparency and accountability – that in turn enhance feedback loops in ways that can further improve care management interventions.

For copies of this survey, log on to http://www.tcshealthcare.com and click the “Health IT Survey” button.