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Get advice on care management, chronic disease management, and care coordination.
Proactively managing your patients’ health will benefit them as well as your independent practice. When you implement panel management, you are taking steps to ensure that all of your patients are current on their basic preventive care. The emphasis there is on “all” of your patients, not just the patients who come into the office for an illness or a checkup. You can start panel management in your independent practice following these five tips:
The database, or registry, will include details about all of your patients and their immunizations, screenings, and preventive and chronic care tests.
Decide on practice guidelines for preventive and chronic care services, then use those guidelines to establish target levels for health indicators. If this is your initial attempt at implementing panel management in your independent practice, you might decide to use evidence-based national guidelines created and updated by authoritative organizations.
Panel management is a practice-wide responsibility. Your staff, including nurses, medical assistants, and reception should be trained in panel management strategies. A successful panel management approach is adopted throughout the practice.
When a patient is not meeting a goal or is overdue for a preventive test, they have a gap in their care. You can use your Clinical First EHR 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.
Contact us for more information about identifying care gaps as you implement panel management in your independent practice.
You and your independent practice staff can reach out to your patients to ensure they are getting all the care they need, including preventive care. Outreach panel management includes the proactive measures you and your staff take to contact patients through letters or calls between visits. Inreach panel management happens when you and your staff communicate care gaps to patients who come to your office for a visit.
Some additional points to consider as you start panel management in your independent practice are suggested by the Patient Centered Primary Care Institute (PCPCI):
Rod Farvard April 23, 2020Read
While there are many common factors and benefits in the two healthcare approaches, there are also significant differences between panel management and care management. Both are proactive and are focused on improved outcomes and reduced costs for patients and physicians. The details regarding which patients are managed and how they are managed differentiate panel management and care management.
As the name implies, panel management involves the physician’s entire panel of patients. Aligned with the concept of population health management, panel management (as defined by the University of Washington Department of Medicine Lexicon) means that “the care team is concerned with the health of the entire population of its patients, not just those who come into the clinical setting for visits.”
The AMA explains that panel management is a “proactive approach to ensuring that all patients whom a physician or practice is responsible for receive preventive care, not just those who come in for appointments” and recommends the following approach to establishing a panel management program:
The care management approach focuses on collaboration among multiple healthcare providers, managed by the primary care physician. As defined by the Center for Health Care Strategies, Inc. (CHCS), the goal of care management is to “achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.” The potential for unnecessary and even contradictory laboratory and diagnostic services as well as medications prescribed by multiple physicians without coordination and oversight is significantly reduced or even eliminated with care management.
Care management also takes into consideration non-medical factors, such as social determinants of health, and engages the patients and their families in their healthcare plan. When patients are engaged in their own treatment, including preventive care measures, the quality of their outcomes increase and costs decrease for both patient and physician.
Rod Farvard April 1, 2020Read
The triple aim of healthcare, as outlined by the Centers for Medicare & Medicaid Services (CMS) is better care for individuals, better health for populations, and lower cost. These are also the basic goals of a Care Management program for your patients and your independent practice. Lowering costs can also help increase your independent practice revenue.
Most independent physicians are searching for ways to increase their practice revenue. In a 2019 Physician Report, “22 percent of respondents said their practice is doing better than a year ago, 52 percent are doing about the same, and 26 percent are doing worse.” Options for increasing revenue include increasing the patient panel, which would require additional staff, and improving productivity and efficiency.
Care management enables the physician to more effectively and efficiently manage a patient’s treatment plan by coordinating with other healthcare providers to reduce unnecessary tests or office visits. While primarily a mechanism for improving the patient’s healthcare outcomes, the program also results in lower costs for the independent physician’s practice. When costs are lowered, net revenue increases.
How does a quality electronic health record (EHR) solution
improve your independent practice’s efficiency?
To further increase your independent practice revenue, you might consider adding services within your practice rather than referring patients to other specialty providers. For example, Coley Bennett, CMM, CHA, practice manager at A Plus Medical, P.C., an independent primary care practice in Tacoma Park, Maryland, suggests that embedding a behavioral health specialist in the practice makes sense since the physician has established a rapport with the patient. The independent physician’s office can serve as a resource for the patient and the additional offering can potentially increase revenue for the practice.
Reimbursement for additional services will certainly increase your practice’s revenues. A behavioral health specialist can also help diagnose and address underlying problems that could benefit the patient and the physician. Improved outcomes for the patient’s physical health conditions are typically realized when the mental health and social determinants of health are also addressed. Treating all aspects of the patient’s condition and coordinating that treatment in the most effective and most cost-efficient manner are integral to a quality care management program, which will help increase your independent practice revenues.
Rod Farvard March 16, 2020Read
Identifying the need, developing a tailored plan, and engaging with the patient and other providers are among the best practices cited by experts and researchers for effective care management. White papers published by Health Care Transformation Task Force and the Center for Health Care Strategies, Inc. (CHCS) point to the need for care coordination, particularly for high risk patients with chronic or complex conditions.
CHCS cites that fact that “Across the country, innovative states are implementing programs that provide ‘high touch’ care management for targeted groups of beneficiaries.” The organization’s research identified a number of best practices for care management, including:
The Health Care Transformation Task Force, in its paper titled Developing Care Management Programs to Serve High-Need, High-Cost Populations, states that “Effective care management programs will utilize both qualitative (physician- or patient-reported information) and quantitative (claims, electronic data) resources to identify high-need, high-cost patients.” The paper adds that care management best practices “will take a holistic, person-focused and family-centered approach to health including its behavioral, social, and physical aspects.”
Coordinating care for a patient includes consideration of the patient’s social determinants of health, involvement on the part of the patient as well as the patient’s family in the decision-making process, and physician engagement and communication with the patient as well as the patient’s other healthcare providers. As the Task Force explains it, “Best practice models of care management will emphasize care coordination across providers and have robust primary care capabilities at their center.”
Utilizing an effective electronic health record (EHR) to collaborate enables the providers to communicate with the patient and with each other, and, more importantly to automatically share updates directly from the Clinical EHR. Other providers get immediately notified so they can take action based on the most up-to-date clinical information.
The Task Force emphasizes that “Care management programs should be structured in a way that best suits the patient demographics and available resources of the provider organization, and care managers should work to engage patients and caregivers in creating the care plan and managing a patient’s health.”
Rod Farvard March 4, 2020Read
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.
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, 2020Read
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:
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, 2020Read
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:
(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, 2020Read
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.
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, 2020Read
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, 2019Read
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, 2019Read