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For High-Risk Patients: ‘A Medical Home Within A Medical Home’

January 7, 2017
by David Raths
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Partners HealthCare fine-tunes an integrated care management program for patients with multiple conditions

What is a “patient-centered medical home within a patient-centered medical home”? According to Partners HealthCare’s Eric Weil, M.D., it describes his health system’s approach to dealing with patients with the most significant health risks.

Health systems are increasingly recognizing that better coordination of care for chronically ill patients with multiple medical conditions is key to improving care and reining in costs. But Dr. Weil, the medical director for primary care and high-risk care management within population health management for Partners, said that identifying which patients to target and how to set up the care management program can be challenging and depends on quality risk stratification, analytics tools and team-building.

Boston-based Partners has spent the last 10 years creating and then fine-tuning an integrated care management program (iCMP) for such patients. During a Jan. 5 webinar hosted by Health Catalyst, Weil detailed some progress and lessons learned.  

Early on, he said, Partners recognized that many patients with multiple chronic conditions were showing up in the emergency department or being admitted frequently because they didn’t have well-coordinated care, and that more preventive, proactive and coordinated work should be occurring. He also mentioned that all the changes it has made have been happening in an evolving payment environment as providers shift from a fully fee-for-service world to focusing more on managing risks and costs.

One of the key challenges is that among the core drivers for patients with complex illnesses, especially in Medicaid, are underlying social or behavioral health issues.


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Weil gave an example using “Wordles,” which are visual representations of how often terms are mentioned in documents or on social media — the more common the term, the larger the word appears in the visual. Weil said wordles about iCMP patients pulled from EHR data highlight diagnoses such as diabetes or congestive heart failure. But wordles of how these patients are described by providers feature terms such as absent family, isolation, no family support, and noncompliance. “This highlights the value of the data and the perspective of providers,” he said. “You need both. You can’t do this well without either one. “

Weil explained that iCMP was developed over the last decade, starting with Medicare contracts, and provides:

• A care manager per approximately every 200 patients in the program;

• Access to specialized resources including mental health, community resources expertise, pharmacy, and palliative care;

• Involvement through continuum of care with home visits, telemonitoring, integration with post-acute and specialty services;

• Patient self-management with health coaching and shared decision making;

• IT-enabled systems to improve care coordination leveraging real-time, automatic notification of admissions/discharges and EMR flags identifying iCMP patients;

• Data-driven analytics to support strategic decision making and operations;

• Intensive, ongoing support and training for teams and staff; and

• A payer-blind approach, with initial attention to Medicare, followed by commercial and Medicaid contracts.

But the first question was, could Partners identify which patients are most likely to end up in the hospital with heart failure, sepsis or pneumonia and follow those patients longitudinally in order to catch these conditions upstream. These patients have more than one condition. They might have heart failure and schizophrenia. They might have renal failure, be chain smoking and living alone.

Partners runs claims data through risk predictive modeling software to develop a list of candidates for the program. But it also asks care managers and physicians to review the list and eliminate any false positives. Some people  might seem acutely ill, but the physician will say, “No, that guy is back to playing golf,” Weil explained.

Partners also has found that allowing providers to opt in patients who don’t get captured by algorithms or who claims data may not have caught up with generates good will with providers and increases engagement.

The remaining candidates are added to a final list of patients in the high-risk program. Providers rank them as high, medium and low priority. “Some are very high risk,” Weil said.  “Others are stable. They are in the dugout.  The group in the middle is warming up. They are going to be at bat soon. They make up one of our largest areas of opportunity. That group is often the most missed.”

Partners expanded the program with a Medicare ACO in 2012 after a CMS demonstration project ended and last year it expanded the program into the Medicaid space. The decision to scale up the program was based on several key outcomes: For one, the hospitalization rate per 1,000 patients was 20 percent lower than in a comparison group, with 12.1 percent in gross savings to Medicare.

Weil demonstrated how within Partners’ EHR system, the patients in this program are flagged with a little iCMP button that specialists or providers in the emergency department can click on to get more information or contact the care managers.

In patient surveys, when asked if they were aware of anyone besides their doctor focusing on their care,  75 percent answered yes and many can name the individual. “Of course, that means that 25 percent don’t know that,” Weil said, “so we still have work to do.”

Weil said among the lessons learned is that you have to make sure you engage all the players where they are and in ways that support them to be effective. “The more transparent and inclusive you are, the more likely you are to be successful,” he said. “It takes longer, but it works better in the long run. Top down is not going to work.”

Partners allows local teams the freedom to innovate. “Then we ask them to tell us how they did it. With innovations that work, we will try to adopt them system-wide. Allowing for the spread of innovation is valuable.”

In closing, Weil reminded other health system executives that the results from these efforts are not immediate. “You are not going to see a significant change for 18 months to two years,” he said.





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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.


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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”


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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.



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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

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