Care Cycle Management

Patient-Centered Medical Homes (PCMH) are growing in popularity as the right thing to do improve patient care. PCMH are growing in popularity, as there is early evidence of their effectiveness (Egge, M. 2012). The PCMH concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions. This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the limitations of the current healthcare system (Wang, J. et al 2014). Currently, primary care in the United States is focused on acute and episodic illness, it inadvertently limits comprehensive, coordinated, preventive and chronic care (Bleser, W. et al 2014). The PCMH address these limitations through organizing patient care, emphasizing team work, and coordinating data tracking (Bleser, W. et al 2014). A PCMH and HMO have some similarities but are markedly different.

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

Overview of the Patient Centered Medical Home project piloted by Geisinger Health System in Danville, Pennsylvania

Health rule challenges continue, even as October 1, 2015 looms. Individual insurance benefits fluctuate as employers scramble to control costs, making it increasingly difficult for hospitals and physicians to stay on top of diverse policy provisions and exclusions. Myriad new regulations and mandates for providers and employers also means more responsibility for paying for health care services falls into the hands of patients. Large medical groups and care facilities rely on next generation revenue cycle management (RCM) solutions and medical billing software to automate their workflow and improve reimbursement rates. However, smaller practices and ancillary service providers may still be in the dark about emerging technology and tools to help them control costs without compromising care.

In some areas of population health, technology in enhanced patient information is utilized to perform risk stratification to identify the high risk patients. These patient’s often have uncontrolled BP, diabetes with an HgbA1c over 9, COPD, etc. Once identified as high risk or potential high risk, these patients receive additional care or patient outreach to help manage their condition. Some organizations employee RN Health Coaches and Care Coordination teams to help these patients and identify gaps in care. The primary care physician assumes care of the patient along with striving for the patient to become active in their overall health thereby keeping them out of the hospital (Sanford, 2013). One enhanced area of population management is the PCMH model. PCMH practices increase patient’s engagement in shared decision making while providing compensation for care coordination, care management and medical consultation outside of traditional face-to-face visits (Berryman, Palmer, Kohl &Parham, 2013). A patient centered approach pushes for changes not only in the delivery of medicine but in traditional encounters. In addition, PCMH encourages increased access to the patient’s primary care physicians and improved patient satisfaction scores. PCMH and population health encourages providers to increase after hours care to decrease emergency department visits and/or hospitalizations. Thereby reducing cost and improving the patient’s

Care coordination is key in the new value-based healthcare market. Poor follow-up care plans often lead to readmission penalties and decreased patient satisfaction evaluations. Before, if a patient sought care in an urgent care center, that information may have never made it back to the patient’s

Transition of care appeals to me the most in my practice as a case manager. When a patient gets admitted, the interdisciplinary team starts working on the discharge planning. I always wonder how can the team know for sure, that the patient is ready to be transitioned and how can we know for sure that the transition of care is safe and it would not be overlook?

One of the aims of the Patient Protection and Affordable Care Act (ACA) of 2010 is improved integration and coordination of services for primary patient care. The patient-centered medical home (PCMH) is one of the approaches by which improvements can be established. The patient-centered medical home model is particularly well-suited for people who have chronic illness. The design of the patient-centered medical home model departs substantively from traditional reimbursement policies, in that, the ACA provides for incentives and resources to enable care coordinators to be directly recognized and compensated for their care coordination work. Care coordinators are most often registered nurses who through their work that aligns with ACA engage in quality improvement work, cost-effectiveness measures, and patient advocacy. To bring the ACA model to a human scale, the authors present a case study of a care coordinator at a patient-centered medical home in rural Maine. The table provided below provides a basic textual analysis of the study as it is published in the professional nursing journal.

The patient- centered medical home is designed to improve quality of care through a team-bases coordination of care, which would treat the majority of a patients needs at once by increasing access to care and empowering patients to be a part of their own care (U.S Department of Health and Human Services, 2014). In order for these homes to work, the authors suggest that specialists might be the best candidates to certain conditions, however for these specialist to function in the capacity that is needed in these medical homes, they would have to have interest and proficiency to manage other conditions that fall outside of their

Competition in the home health field is intense, particularly in rural areas, where the need for services is in more demand. Because services are expensive to provide, it is critical for agencies to generate a volume of visits sufficient to cover fixed expenses plus make a small profit. Competition is primarily between another company Care One, Inc., a multicounty operation that has been established in the area for well over 10 years. AHHS surpassed them in total number of visits after its second year of operation and has been progressively growing. Many of the physicians in the area, however, continue to use Care One, and Care One receives more referrals from the local hospitals than AHHS. Currently AHHS has 32 employees, including 15 registered nurses, 8 nursing aides, 1 physical therapist, I speech language therapist, and 7 administrative staff.

healthcare services.2,3 Taken together, these challenges place significant stress on the healthcare system, prompting system stakeholders

As the shift for HCOs is made to a PCMH model, the financial aspect also has to make a transition to accommodate to the changes. In recent years, there have been implementations of different payment and reimbursement options, health insurance programs, and the establishment of the Affordable Care Act (ACA). Between May 2009 and April 2012, one of the initial PCMH pilot programs was conducted in Colorado, appropriately named The Colorado Multipayer Patient-Centered Medical Home Pilot. More than 100,000 patients within sixteen internal medicine practices participated in the experimental PCMH model, using six different health plans (Harbrecht & Latts, 2012).

The health care industry is one of the most dynamic and delicate industries in the U.S. having experienced healthy and substantial changes for the last thirty years most of which have aimed to improve health care management and services delivery to the patients. The changes have enabled the integration of technology into the industry such as in the area of informatics, science and research and payment services and clinical treatments. The health care sector has introduced various changes to address disease and health care management such as the Modernization Act of 2003, the Patient Protection Act and Affordable Act, which aim at improving health provision and most

Managing the growth of allied health care sector in the United State. Healthcare delivery system changings are most effectual when they are cohesive and ensure real answerability from providers to patient to improve outcomes. With the expected increase in allied health staff in the healthcare organizations, the first need will be to ensure that the care provided to patients is not impacted in anyway. Hiring new allied health staff allows organization to provide to provide adequate care for patients, but it also increases the cost to provide care. This means that recovering the financial costs of care and minimizing the cost of care takes a higher priority. Evidence proposes that multiple methods to delivery system changes may be necessary bend the cost curve and improve care quality. For example, the efficiency of a single disease administration program may be limited for patients who have multiple chronic conditions and who require coordinated care from many

Having a single view of the patient and their treatment and recovery plan is invaluable in ascertaining which are the most and least effective tactics in treatment. The 360-degree view of the patient and the many processes supporting them is crucial for increasing the accuracy, effectiveness and performance of treatment programs over time (Blakeman, 1985). Computerized management systems are critical for organizing, analyzing and translating the massive amount of data captured on patients, treatment and recovery processes, and the use of supporting IT systems to optimize patient health and organizational provider performance (Peshek, Cubera, Gleespen, 2010). The ability to aggregate and intelligently use all available data, information, patient-based and process-generated data to deliver higher levels of quality care is possible when computerized management systems are used throughout healthcare organizations.