What are some useful care management tools?

Implementing an effective care management program requires planning and the right tools. The independent physician who sees a need to implement a comprehensive care management plan must first consider the factors involved for the practice as well as for the patients. Useful tools will enable the provider to then develop and maintain a care management plan that reduces costs, reduces or eliminates unnecessary visits and procedures, and provides a higher quality of care.

Useful care management tools include:

A pre-visit planning checklist

AAFP recommends this tool to “identify potential care gaps and otherwise better prepare for an upcoming patient appointment.” The checklist can be completed by a medical assistant or another member of the independent physician’s clinical staff who initially meets with the patient to gather a history and a list of additional healthcare providers treating the patient.

A patient-centered care plan

As described in an NEJM Catalyst article, a patient-centered care plan “encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.”


Learn more about how Elation Health can help you develop your patient-centered care plan.


Patient diaries

Records kept by the patient regarding exercise, food intake and voiding, and the timing and description of symptoms can aid the provider in determining the appropriate strategy and coordination of care. Patient diaries can become a valuable tool for an effective care management plan.

Electronic health records (EHRs)

Care management plans involve gathering, maintaining, and monitoring patient data. The EHR is a useful tool for the independent physician as well as for the patient. The NEJM Catalyst article details the need for technology, particularly when encouraging patients to fully participate in their own healthcare management. EHRs provide patients with “24/7 online portals that let patients schedule appointments, get information about their condition and care instructions, review lab results and doctor’s notes, and pay bills at their convenience.”

EHRs, such as Elation’s Clinical First solution, enable the provider to maintain a more comprehensive and longitudinal patient record. Independent physicians can take advantage of this useful care management tool to quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.

Rod Farvard
February 14, 2020


What are the benefits of care management?

While care management is typically thought of as an effective healthcare approach for patients, independent physicians and their practices can also realize benefits from implementing such plans. Ranging from improved finances to higher quality outcomes, the positive results of care management can be seen in a number of areas.

Care management brings together the patient, the primary care provider, specialty providers, and the patient’s family and caregivers to coordinate care for the best possible outcomes for that patient. Care management particularly benefits those patients with chronic or complex conditions who see multiple providers and require diagnostic or laboratory services in addition to medications.

The Department of Health and Human Services (HHS) states that “by 2030, 25 percent of the U.S. population will be 60 and older, and 19 percent of the population will be 65 years of age and older. At least 90 percent of those 65 and older now have one or more chronic conditions.” Further, HHS explains that if the health-related needs of this population are not met appropriately, through enhanced clinical and community coordination, that “may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.”

Care management delivers benefits to the aging population and those patients with chronic conditions by:

  • Reducing treatment costs
  • Reducing the rate of hospitalizations
  • Eliminating unnecessary and redundant testing
  • Managing medications to prevent adverse interactions
  • Involving the patient’s family and community to boost emotional well-being
  • Ensuring the primary care physician maintains a complete picture of the patient’s overall health
  • Enabling the provider to properly manage all care, improving outcomes for the patient

In its publication, Health Plan Innovations in Patient-Centered Care: Care Management, the Alliance of Community Health Plans examines a number of case studies that demonstrate reduced emergency room visits and hospitalizations, reduced costs for the provider in treating the patient, and improved “health status and health-related quality of life” for patients included in care management programs. Costs are significantly reduced by proactively coordinating care among the healthcare providers and engaging patients to be more involved in their own healthcare program.

The bottom line for patients and providers is that care management, by enabling the primary care physician to provide more efficient and coordinated healthcare, improves outcomes and reduces costs for all involved.

Rod Farvard
February 5, 2020


What is Care Management?

Focused on the patient and involving an entire team of providers, care management is, in the simplest of terms, collaborating to improve outcomes. More than care coordination, however, care management is an episodic approach that also more effectively manages population health. The goals of care management programs include reduced costs, reduced hospitalizations and emergency room visits, and increased patient satisfaction.

AHRQ defines care management as a “fundamental vehicle for managing the health of populations,” adding that care management “is organized around the precept that appropriate interventions for individuals within a given population will reduce health risks and decrease the cost of care.”

AAFP outlines some of the activities involved in a care management program:

  • Patient education
  • Medication management and adherence support
  • Risk stratification
  • Population management
  • Coordination of care transitions
  • Care planning

(Learn how to coordinate care more effectively with Elation’s Collaborative Health Record.)

Why is care management necessary? Many patients see more than one provider, particularly those with chronic or complex condition. Ensuring that all patients understand the full spectrum of their diagnoses and treatment plans, are on appropriate medications, and have support throughout their healthcare programs will make a significant difference in their outcomes. A report published by the Robert Graham Center states:

On average, Medicare patients see seven physicians at four practices. A staggering 75% of hospitalized patients are unable to identify the clinician in charge of their care. Nearly 20% of Traditional Fee-For-Service (FFS) Medicare beneficiaries are re-hospitalized within 30 days of discharge, and half of those patients failed to see their primary care provider (PCP) in the interim.

Care management is one of the five key functions of patient-centered medical homes (PCMH). The PCMH is focused on the continuing care of the patient, rather than simply treating one condition for a limited period of time.

In a PCMH, the primary care physician is able to engage the patient, to ask pointed questions, and to observe changes or signs that may need further exploration by a specialty provider or diagnostic lab. Care management enables that physician to also manage patients’ visits and treatments outside the primary care office, ensuring that the overall care plan is appropriate and effective.

Rod Farvard
January 28, 2020


5 tips to start care management at your independent practice

An effective care management program will help your independent practice reduce costs and improve outcomes for your patients. How do you get started on such a program? There are some important elements involved in implementing and maintaining a quality care management program. Here are five tips to get yours started:

Develop working relationships with specialty providers

Patients who benefit the most from care management tend to have chronic or complex conditions. They see multiple physicians, which is one of the biggest reasons they need you to manage their care. Implementing a quality care management program in your independent practice requires establishing a positive and productive working relationship with those specialty providers.

Train staff

Your clinical staff will become instrumental in your patients’ care management. In fact, the Agency for Healthcare Research and Quality (AHRQ) suggests that “in value-based payment models, alignment of clinic staffing with the needs of patient populations may be the most cost-effective approach.” Rather than creating a new position for the care management role, train current staff in workflow and communication strategies that will optimize the positive outcomes for your patients.

Implement guidelines for population health management

The AMA emphasizes that “population health success is closely tied to a shift from reliance on the physician to making the best use of everyone’s skills at a practice.” Guidelines for your team would include identifying patients who would benefit from care management. Take into consideration not only their medical conditions and diagnoses but other factors, such as social determinants of health to establish care management for your specific patient population.

Establish your practice as a patient-centered medical home

For the patient who sees multiple providers, coordinating that care from a home base can be critical to the quality of the patient’s healthcare outcomes. Establishing your practice as a patient-centered medical home (PCMH) is an integral part of developing and maintaining a care management program. The PCMH is focused on the continuing care of the patient, rather than simply treating one condition for a limited period of time. In a PCMH, the primary care physician is able to engage the patient, to ask pointed questions, and to observe changes or signs that may need further exploration by a specialty provider or diagnostic lab.

Take advantage of available technology

Effective care management in your practice is facilitated through options available in your electronic health record (EHR) technology. The EHR enables you to quickly identify patients who aren’t meeting goals based on custom care management protocols. Collaborating with other providers is also made more efficient through a progressive patient record that allows physicians to effortlessly collaborate and coordinate care.

Rod Farvard
January 21, 2020


What you need to know about the Medicare Shared Savings Program (MSSP) performance results

A data activation platform company, Innovaccer, recently compiled data regarding the performance of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP). The organization’s report, State of the Union Report for Medicare ACOs, details the results of a proprietary algorithm Innovaccer used “to look at the quality, performance, utilization and expenditure data for every region in the U.S., based on the performance of Medicare ACOs participating in the MSSP in program year 2017.”

The study found that ACOs participating in the MSSP have generated $1 billion in savings since their inception. Going forward, the report adds that “adoption of value-based care models is expected to account for 59 percent of healthcare payments by 2020, as the healthcare industry uses value-based care to address these high-cost utilizers.”

As rising healthcare costs are of concern to patients as well as providers, researchers identified the top measures that contribute the most to healthcare expenditure per capita. Nine of the fifty-three parameters affecting the performance of ACOs were found to “the most significant.” Those included: long-term care hospital discharges; COPD or asthma discharges; skilled nursing facility discharges; emergency department visits; MRI events; unplanned admissions for patients with chronic conditions; use of imaging for low back pain; use of statin therapy; and controlling high blood pressure.”

Social determinants of health were also factored into the ACO performance data, “showing the vulnerability of all the states across the U.S. against the social factors affecting their populations.” The study found North Dakota to be the least vulnerable to social determinant factors and Hawaii to be the most vulnerable. Social determinants of health include socioeconomic factors, education level, economic environment, job opportunities, and social supports.

As of July 1, 2019, ACOs may participate in the Shared Savings Program for agreement periods of at least five years, under one of two tracks: the BASIC track (which includes a glide path for eligible ACOs), or the ENHANCED track, which offers the highest level of risk and potential reward. ACOs participating in the BASIC track’s glide path may begin under a one-sided model and progress through incremental levels of increasing risk and potential reward.

Nick Dealtry
October 17, 2019


Who really owns your patient data?

Implementing a new electronic health record (EHR) system involves many steps, including choosing a new EHR vendor, training staff on the new system, and migrating data from the old system to the new. The process of data migration may bring with it some surprises for the independent physician as well. The costs and challenges of working with your current vendor to transition to your new EHR can be significant for an independent practice.

The costs of migrating data can total tens of thousands of dollars. Many EHR vendors will charge independent practices for migrating their own data or will refuse to provide the data in an acceptable format for migrating to the new system. A recent article in Medical Economics explains that “Another frequently underestimated cost of switching EHRs is the price tag that comes with moving data out of the old application…. This process may involve fees to both the previous EHR vendor as well as the new one.”

The independent physician may also incur costs for managing the data, to ensure that it meets the requirements of standard structure and format. The Office of the National Coordinator for Health Information Technology (ONC Health IT) explains that:

In the absence of a contractual obligation that specifies the EHR vendor’s data transfer requirements, your outgoing EHR vendor may take the position that it can satisfy its obligations by providing you with all historical records in a format that is inconvenient or impractical rather than working with you in good faith to deliver the records in a standardized structure and format that is then generally accepted in the health IT industry.

Additional fees incurred during data migration could include outside consultants necessary for converting data to the acceptable format and archiving certain data that must be kept for regulatory requirements. Independent physicians are advised to negotiate and understand data transfer fees and processes with the initial implementation of the EHR system.

Unlike other vendors, Elation Health can import all the data from your old EHR, no matter the brand, with exceptional results. We can integrate full patient charts, including old notes, into your new Elation experience. We have transitioned data from many other vendors and can work with whatever system you may have.

Nick Dealtry
September 20, 2019


EHR implementation tips

The electronic health record (EHR) implementation process starts before you make the decision on which EHR solution to purchase for your independent practice. You will first need to determine your goals, assess your readiness, and prepare your team for the technology change. Patients will also need to know that you are implementing an EHR system, so communication and education will be necessary to ensure they are prepared as well.

Some EHR implementation tips that will help your independent practice be more successful with your new system include:

Prepare your team. Assess your team’s comfort level and understanding of computers, workflows, and clinical needs. It will be necessary, once your new system is in place, for your team to be trained on the EHR solution and the process used to optimize its effectiveness. They should be prepared to participate fully in learning how to properly use the EHR.

Prepare your patients. When your practice implements a new EHR system, there will be changes in the way you interact with your patients and in the way patients access their own medical data. Preparation and communication before implementation will ensure these changes are positive, benefitting both patient and independent practice.

Develop a plan. Include a timeline for announcing your new EHR, for training, for testing the system, and for fully implementing and using the EHR solution. Share the plan with all team members in the practice and encourage leaders within the organization to assist in implementing the plan.

Install the EHR. Work with your vendor on implementing the new system, migrating your data, and securing training for your team. Elation’s Clinical EHR takes less than one hour to learn and you will receive one-on-one implementation support from our dedicated team.

Seek assistance and guidance when you need it. With Elation, you will enjoy ongoing support. Your practice’s success is our primary focus, and we make it easy to get help when you need it. Contact us with the click of a button, on the phone, or via e-mail for unlimited, free support 24/7.


Nick Dealtry
August 30, 2019


Population health and social determinants of health

A patient’s health can be determined by genetics, lifestyle, and other factors specific to that patient. Other determinants, however, may become more significant factors for that patient and for the population of patients that share similar determinants. These social determinants of health contribute to the patients’ adverse and complex health conditions, such as obesity, heart disease, and diabetes.

Social determinants of health (SDOH), as defined in a recent NEJM article, are “intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.”

The Centers for Disease Control and Prevention (CDC) indicates that “differences in health are striking in communities with poor SDOH such as unstable housing, low income, unsafe neighborhoods, or substandard education.” A 2018 consumer survey “that 68% of consumers had at least some level of SDOH challenges. The most commonly reported issues are financial insecurity and social isolation. Individuals with high social determinants of health stress are 50% more likely to suffer from chronic conditions and 2.3 times more likely to rate their health as ‘fair’ or ‘poor.’”

For the primary care physician, social determinants of health can impact decisions made for population health management, in particular regarding treatment plans, prescriptions, and even nutritional recommendations. The physician must take into consideration whether patients can afford to eat healthy foods, fill their prescriptions, and follow other plans of care that may be out of their range either financially or logistically.

As suggested by Healthcare IT News, “As a better picture can be painted about patient populations, clinicians can better target populations who may be in need of additional services. These small upfront costs can help reduce the need for more major and costly treatment later on.” When the primary care physician develops a more in-depth understanding of the circumstances that patients experience, including such factors as whether they have access to transportation or whether they experience food insecurity, the provider will be better equipped to “find easy-to-solve problems outside of the care environment that can have a huge and costly impact on a patient’s well-being.”

Nick Dealtry
August 2, 2019


IPAs and value-based care

Independent physicians who want to remain independent but who feel the need to be part of a larger organization in order to provide value-based care more efficiently might consider joining an independent physician association (IPA). The IPA offers independent practices more bargaining power but enables all of its members to remain autonomous in their daily practice management.

The AAFP defines the IPA as “a business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs).”

Independent practices might be better equipped to participate in value-based care as part of an IPA. As a recent article in Medical Economics explains, the IPA can “help practices transition to value-based care by providing the administrative support, tools and negotiating leverage that comes with size.” The original intent behind the concept of the IPA was to focus on fee-for-service rates, but with the movement toward value-based care, IPAs are now transitioning to negotiating value-based contracts.

Though independent physicians may be understandably concerned about maintaining their independence while joining a larger group, AAFP emphasizes that “Such strategies also enhance physicians’ access to the capital and management resources necessary to pursue cooperative business ventures such as managed care contracts and direct health care services contracts with employers.”

AAFP outlines the many potential benefits for an independent physician joining an IPA, including many that will contribute to more effective and more efficient delivery of value-based care:

  • Appropriate alignment of physicians’ financial incentives
  • Efficiencies in practice administration and management
  • Political influence within the medical and wider provider community
  • Peer support
  • Optimized facilities
  • Enhanced ability to negotiate favorable contracts with other entities such as MCOs, ACOs, radiology, laboratory, and hospital systems
  • Autonomy and local financial and care management control in managed care
  • Improved services, including expanded hours, urgent care, outreach services for prevention, telephone triage, and follow-up expertise.

Nick Dealtry
July 25, 2019


How ACOs could better utilize EHRs

Accountable care organizations (ACOs) are “composed of doctors, hospitals, or other healthcare providers that come together voluntarily to coordinate high-quality care for their patients and agree to be accountable for the total cost and quality of the care provided.” The idea behind the ACO concept is to enable independent physicians to realize the benefits of being a part of a larger organization while retaining autonomy in their own practices. ACOs also work to improve population health.

In May 2019, the U.S. Department of Health and Human Services Office of Inspector General published the results of its research into six Medicare ACOs that use health information technology for care coordination. The study offers “insights into how select ACOs have used health IT tools to better coordinate care for their patients.”

The Office of Inspector General conducted interviews during site visits to four Next Generation ACOs and two ACOs that participated in the Medicare Shared Savings Program. The ACOs were selected for the study based on “their performance on a quality measure focused on care coordination and patient safety, a minimum of 3 years of experience as a Medicare ACO, geographic variation, and recommendations from CMS and ONC (Office of the National Coordinator for Health Information Technology).”

After reviewing how each of the ACOs used information technology, including electronic health records (EHRs), the study concluded that “the full potential of health IT has not been realized.” The ACOs that used a single EHR system across all of their provider networks had the ability to share patient data in real time, optimizing their ability to coordinate care for their patients. However, ACOs that used multiple EHR systems faced challenges.

Interoperability, the electronic sharing of patient information between different EHR systems and healthcare providers, is a major concern for ACOs relying on health IT tools. Coordinating care effectively depends on EHR interoperability. “Achieving the interoperability needed for seamless care coordination places burdens on ACOs to either invest in a single EHR system, or use additional methods, such as non-health IT means like faxes and phone calls, to communicate health information.”

The study concludes by suggesting that “Some of HHS’s proposed initiatives might address concerns and challenges that we heard from ACOs. For example, ONC’s Trusted Exchange Framework and Common Agreement has the promise of facilitating interoperability across health IT networks, which might mitigate the problem that ACOs had in accessing data from HIEs (Health Information Exchanges) with little or incomplete data. With interoperability, an ACO would be able to access patient data even when patients visit providers outside the ACO.”

Nick Dealtry
July 8, 2019