Volume 6, Number 3
March 1999
Laura Himes
Iversen, Editor
Laura Cashore, Assistant Editor
We welcome comments regarding CareLink's content and
format. Please send comments to mbany@nccconline.org. Please send
subscription or transmission inquiries to mbany@nccconline.org.
In CareLink you will see references to chronic care
networks (CCNs). Since 1990, the NCCC has focused on establishing
CCNs, which are networks of care specifically designed to address
the needs of people with chronic disease and disability. The focus
of CCNs is to change prevent, delay, or minimize the progression
of disability associated with chronic conditions. CCNs change
health systems operations to establish new methods of managing
chronic care across time, place, and profession and to provide
whatever combination of care is most efficient and effective in
achieving cumulative cost and quality objectives.
TABLE OF CONTENTS
INTEGRATED SYSTEMS MANAGEMENT
1. HEDIS Draft Measures
Emphasize Chronic Care
2. Building Consumer-Friendly CCNs
INTEGRATED CARE MANAGEMENT
3. Enhancing Practitioner
Customer Satisfaction Skills
4. New Rapid Health-Assessment
Tool
INTEGRATED INFORMATION
5. Case Studies of What
Works
6. Electronic Reminders Promote Guideline Use
INTEGRATED FINANCING
7. Medicare HMOs Get
Risk-Adjustment Phase-In
8. Disease Management Programs Cut
Costs
INTEGRATED POLICY
9. Medicare Reform: A View From the
Trenches
10. A Look at Lobbyist Wishlists
OTHER RESOURCES OF NOTE
11. NCCC Conference: Looking
Through New Lenses
12. Self-Help Course: Arthritis
13.
Online Database: Practice Guidelines
14. Report: State Policy
Update
15. Occasional Paper: Controlling the Supply of
Long-Term Care Providers
16. Guidebook: 1999 Disease Management
Directory and Guidebook
17. Special Articles: Primary Care,
HMOs, and Nursing Home Residents
18. Video: Dementia
19.
Funding Opportunity: AIDS as a Chronic Illness
20. Special
Announcement: Mathematica Searching for Best Practices
BEST PRACTICE LAB NOTES
21. CHF/COPD Care
22.
Diabetes Care
23. Dually Eligible Care
24. Integrated
Pharmaceutical Care
25. Frail Elderly Care
26. Chronic
Disease Management
27. Alzheimer's Care
INTEGRATED SYSTEMS MANAGEMENT
1. HEDIS Draft Measures Emphasize Chronic Care
The Health Plan Employer Data and Information Set (HEDIS), a
set of measures used to assess certain aspects of health plan
performance, has been updated to include a greater focus on
chronic care. The National Committee for Quality Assurance (NCQA)
released a draft version of HEDIS 2000 in early February that
included new items relating to asthma, chlamydia, heart disease,
and menopause. The new version also places a greater emphasis on
outcomes related to both acute and chronic care. A draft of HEDIS
2000 can be viewed at www.ncqa.org/hedis/H2000.htm. Comments on
the draft are due to NCQA by March 19.
Starting in July of this year, "plans that undergo NCQA
accreditation will have their HEDIS measures count toward 25% of
their accreditation scores." Unfortunately, the cost of collecting
such data can be daunting for health plans, especially for small
or newly formed organizations. However, says Sidney Smith, past
president of the American Heart Association, "the return on plans'
investment in information systems equipment and software will pay
high dividends in the long- term."
Source: Bryant M. HEDIS 2000 Draft Targets Chronic
Conditions, Women. Medical Utilization Management 1999 Feb 4;
27(3): 5-8.
2. Building Consumer-Friendly CCNs
What practical steps can chronic care network (CCN) governance
and management staff take to promote a more consumer-friendly
environment for chronically ill patients? First of all, advises a
recent report by California Health Decisions (CHD), an
organization seeking to incorporate member values and views into
its policies should include at least one member representative on
its governing body. CDH offers this and five other general
recommendations based on 14 years of "listening to health care
consumers." Other recommendations generally applicable to CCNs
include
Create "an active member advisory committee that contributes
to the development, implementation and evaluation of processes and
practices."
Establish "policies and lines of accountability for obtaining
and incorporating member feedback into the policies and operations
of all departments."
"Maintain an environment that views all components in your
health care delivery system (provider organizations, purchasers,
members, as well as the plan) as partners rather than antagonists
or competitors."
Source: Severoni E. Straight Talk From Managed Care
Members. Healthplan 1999 Jan/Feb; 40(1): 24-30.
INTEGRATED CARE MANAGEMENT
3. Enhancing Practitioner Customer Satisfaction
Skills
After Fairfax Hospital in Virginia required emergency
department staff to attend an eight-hour customer satisfaction
course, patient complaints dropped 70 percent, and patient
compliments rose more than 100 percent. Fairfax's successful
program- geared to staff serving an acute care population-also has
valuable lessons for providers of chronic care. A formal course
can bolster a clinician's ability to create "power and control
options for patients," negotiate situations where physician and
patient expectations are out of sync, and resolve problems quickly
before they "take on a life of their own." Staff and clinicians
have also learned that "not every complainer is wrong" and that
"happy customers reduce bad debt."
Assuring customer satisfaction also involves knowing who your
customer is. In a recent article Connie Zuckerman and Carole
Levine discuss the need to accommodate families as well as
patients in the care process. There is a "persistent tendency" in
health care, they say, to equate "families with trouble." However,
"a complete understanding of the patient's personhood must
consider the significant individuals who help define his or her
core identity." The authors suggest that professionals can better
meet the needs of families "through education and skills
acquisition; establishing partnerships with families; and ongoing
dialogue and communication."
Sources:
ED Staff and Clinicians Learn Essential Human Relations
Skills. Healthcare Cost Reengineering Report 1999 Jan; 4(1): 9-13.
Levine C, Zuckerman C. The Trouble with Families: Toward an
Ethics of Accommodation. Annals of Internal Medicine 1999 Jan 19;
148-52.
4. New Rapid Health-Assessment Tool
Health and functional assessments are a critical part of a
CCN's care management program, and a new tool may help CCNs
complete these assessments more quickly and accurately. The
Dynamic Health Assessment System (DynHA) is designed to combine
the simplicity of short-form health assessment tools with the
comprehensiveness of traditional instruments. Developed by Jon
Ware Jr., M.D. and Quality Metric Inc., DynHA has "the added
benefit of being accessible by phone, by Web, or on a physician's
office computer." The computerized assessment uses a patient's
answers to initial questions to query followup responses only when
necessary. Such a computer-based assessment may be especially
useful for patients with chronic conditions because the "physician
can easily compare assessments for one patient over time, allowing
analysis of how well the patient is responding to care." The
system is also said to reduce "patients' burden in describing
their symptoms and completing written questionnaires" and to be
"less time-consuming for the provider to score."
Source: Flinn S. Psychometric Model Offers Tailored, Rapid
Health Status Assessment. Report on Medical Guidelines and
Outcomes Research. 1999 Jan 21; 10(2): 8-12.
INTEGRATED INFORMATION SYSTEMS
5. Case Studies of What Works
Health Management Technology recently selected winners of its
"What Works" awards, highlighting healthcare information
technology innovations that may be of particular interest to CCNs.
The top three winners were
Scott and White Memorial Hospital, for its mobile training
facility that allows an information system (IS) conversion team to
conduct "off-site-on-site" training
The University of Pennsylvania Health System, for its
prototype disease management system that provides "electronic
distribution of best-practice clinical guidelines, patient and
provider education materials, on-line data entry, and an outcomes
database and reporting mechanism"
Children's Hospital in Cincinnati, for its customized Lotus
Notes application developed by Chart Links. This "comprehensive
workflow application has minimized documentation time and
increased efficiency and communication while automating the entire
patient care cycle."
Source: Tjapkes S. The What Works Awards. Health Management
Technology 1999 Feb; 20(1): 12-4.
6. Electronic Reminders Promote Guideline Use
When Kaiser-Permante of the Northwest (KPNW) in Portland,
Oregon "embedded a guideline on the appropriate use of upper GI
examines into a point-of-care electronic patient record,"
guideline compliance rose from 55 percent to 88 percent, and the
number of upper-GI series ordered dropped from 1,200 to 700
between 1995 and 1997. KPNW's experience underscores the
importance of integrating care management and information system
structures to improve care. KPNW's system "consist[s] of [a]
read-only results reporting system, which requires little effort
from physicians, and a comprehensive outpatient computerized
patient record, developed by the Madison WI-based EpicCare."
Source: Electronic Point-of-Care Systems Boost Guideline
Use. Medical Outcomes and Guidelines Alert 1999 Jan 28; 7(2):
4-5.
INTEGRATED FINANCING
7. Medicare HMOs Get Risk-Adjusted Phase-In
The absence of a risk adjustment for Medicare managed care
payments can result in overpayments to organizations that serve
relatively healthy populations and underpayments to organizations
that serve a high proportion of people with serious chronic
conditions. Consequently, the Health Care Financing Administration
(HCFA) was directed to implement a risk-adjusted payment system in
the year 2000. Now, however, HCFA has announced that it will phase
in its risk-adjusted payment system over four years. HCFA says it
will provide a "10-90 blend of risk-adjustment and non-risk
adjusted rates in 2000; 30-70 in 2001; 55-45 in 2002; and 80-20 in
2003." Rates will be fully adjusted in 2004. This change in policy
is designed to cushion Medicare HMOs from sudden shifts in payment
rates; the HMO industry has generally stated that full
implementation of the risk adjustment in 2000 could persuade even
more HMOs to drop their Medicare-risk plans.
Source: Medicare HMOs Win Relief on Risk Adjustor. Medicine
and Health 1999 Jan 18; 53(3): 1-2.
8. Disease Management Programs Cut Costs
Disease management (DM) programs are increasingly important in
helping integrated delivery systems monitor the quality and cost
of care. A growing number of organizations are also reporting
financial gains when DM programs are implemented within and across
network settings. For example:
At North Arundel Hospital in Glen Burnie, Maryland hospital
costs have dropped as lengths of stay for total hip replacement
have fallen from a range of between three and six days to an
average of 3.1 days. North Arundel's program includes an initial
screening where a treatment team looks for comorbidities and plans
post-acute care.
At the Palo Alto Clinic in California, a DM program for
congestive heart failure (CHF) uses a home monitor to keep
practitioners advised of changes in a patient's status. CHF costs
have consequently fallen due to lower hospital readmission rates
and fewer emergency room visits.
The Diabetes Treatment Centers of America reports that its DM
program saved participating health plans more than 12 percent in
its first year of use, and some CHF programs report savings of
more than 50 percent.
Sources:
Total Joint Replacement Program Prevents Costly Complications.
Healthcare Demand and Disease Management 1999 Jan; 5(1): 9-12.
Timely Access to Patient Information Cuts CHF Costs.
Healthcare Demand and Disease Management 1999 Jan; 5(1): 14-5.
DM Sages See Year of Progress, Growth, Consolidation. Disease
Management News 1999 Jan 10; 4(6): 1, 8.
INTEGRATED POLICY
9. Medicare Reform: A View From the Trenches
"No single organization," write Nancy Whitelaw and Gail Warden,
"is better positioned than HCFA to take the leadership in framing
a new approach to care of the elderly and disabled." In a recent
article Whitelaw and Warden address the potential of Medicare to
improve care for people with chronic conditions, using NCCC member
Henry Ford Health System (HFHS) as an example of "how Medicare
looks from the trenches of health care delivery." Suggestions for
improving care include
HCFA and others should recognize that Medicare is not merely a
payment system; it is a powerful force shaping healthcare.
There "must be a willingness to risk parting with what we know
does not work and to build organizational and payment systems
based on coordinated systems of care and chronic disease
management."
Transforming Medicare will also require an "infusion of
resources, no matter how politically unpopular that may be."
Other articles in the January/February issue of Health Affairs
also address medicare reform (see "Health Care for the Elderly:
How Much? Who Will Pay for It?" and "Will Care Be There?
Vulnerable Beneficiaries and Medicare Reform").
Sources: Whitelaw N, Warden G. Reexamining the Delivery
System As Part of Medicare Reform. Health Affairs 1999 Jan/Feb;
18(1): 132-44.
10. A Look at Lobbyist Wishlists
For a view of the healthcare policy landscape, you might want
to take a look at the "wishlists" of major healthcare lobbying
groups published in this month's issue of Hospitals and Health
Networks. Excerpts related to chronic care include
The American Association of Health Plans wants to stabilize
the Medicare+Choice plan and boost payments to Medicaid HMOs.
In notes on Medicare reform, the American Medical Association
says that the "Bipartisan Commission on the Future of Medicare
recommends mechanisms to ensure financial viability of the program
by increasing financial responsibility of beneficiaries, raising
eligibility age, giving beneficiaries a greater choice of plans,
and ensuring funding for graduate education."
The American Association of Retired Persons calls for
stabilization of home care benefits and the Medicare+Choice
program, as well as more funding for Medicare+Choice education.
Source: Meyer H. Wishlists. Hospitals and Health Networks
1999 Jan; 73(1): 64-72.
OTHER RESOURCES OF NOTE
11. Conference: Looking Through New Lenses, Reinventing
Healthcare.
May 23-26, 1999. San Francisco, California.
Sponsored by the National Chronic Care Consortium with its
national conference partners. Price: $875. Call (612) 858-8999.
12. Self-Help Course:
The Arthritis Foundation has
developed an Arthritis Self-Help Course. Call (404) 872-7100 for
information. (Reported in Arthritis Self-Help Course Cuts Senior
Costs, Doctor Visits. Public Sector Contracting Report 1999 Jan;
5(1): 15.)
13. Online Guideline Database:
The Agency for Health
Care Policy Evaluation, the American Medical Association, and the
American Association of Health Plans are developing an online
database of evidence-based guidelines. See www.guideline.gov.
(Reported in Medical Utilization Management 1999 Jan 21; 27(2):
8.)
14. Report: State Policy Update. American Senior Housing
Association:
Washington, DC. Price: Free. Call (202)
974-2300. (Reported in Newsfronts. Contemporary Long Term Care
1999 Feb; 22(2): 8.)
15. Occasional Paper: Controlling the Supply of Long-Term
Care Providers at the State Level.
Wiener J, Stevenson D,
Goldenson S. The Urban Institute: Washington, DC 1998.
16. Guidebook: 1999 Disease Management Directory and
Guidebook.
Published by National Health Information. Price:
$279. Call (800) 597-6300.
17. Special Articles:
Two articles in the February
issue of JAGS examine primary care provided by HMOs to nursing
home residents. A third article presents "Managed Care for Older
People: A Primer for the Geriatrician." See JAGS 1999 Feb; 47(2):
131-8, 139-44, 241-9.
18. Video: Dementia-Putting Together the Pieces of the
Puzzle.
Aquarius Health Care Videos. Price: $195. Call
(508) 651-2963
19. Funding Opportunity: National Institutes of Health/AIDS
as a Chronic Long-Term Illness.
Contact Willo Pequegnat at
the National Institute of Mental Health at (301) 443-6100 or
wpequegn@nih.gov. (Reported in Funding Opportunities. Aging
Research and Training News 1999 Jan; 22(1).
20. Special Announcement: Best
Practices.
Mathematical Policy Research, Inc. is searching
for best practices in coordinated care for people with chronic
illness. The best practices that Mathematica identifies, which may
include programs of case management, disease management, or
geriatric evaluation and management will serve as models for a
federally-funded demonstration of coordinated care in
fee-for-service Medicare. In conducting this study for HCFA,
Mathematica Policy Research welcomes comments on this search and
nominations of coordinated care programs from healthcare
organizations, providers, and other knowledgeable professionals.
Currently functioning coordinated care programs developed by
entities such as HMOs, home health agencies, community agencies,
private insurers, commercial firms and academic medical centers
are eligible for consideration. Programs must have documented
evidence of cost savings or improved patient outcomes. For more
information please contact Ms. Kristin LaBounty via telephone
(609-275-2263), fax (609-799-0005), or e-mail Klabounty@mathematica-mpr.com.
BEST PRACTICE LAB NOTES
21. CHF/COPD
Johnson Memorial Hospital in Franklin, Indiana has developed a
CHF patient education plan that spans service settings and
encourages patient compliance with CHF protocols. When a CHF
patient checks into the hospital, he or she watches a CHF
education video, receives an educational packet, and gets a
briefing from a case manager or floor nurse. The education program
also includes a teaching checklist that follows the patient to
home care, extended care, or assisted living settings. If the
patient is discharged to home, a copy of the checklist is sent to
his or her physician.
Sources: Continuum Improves CHF Patient Education. Hospital
Case Management 1999 Feb; 7(2): 29-32.
22. Diabetes Care
Diabetes patients can get a lot more than their fruits and
vegetables when they go to Wegeman's grocery store in Syracuse,
New York: the store includes a diabetes management program site
complete with an office, laboratory, and classroom space for 35
participants. The site was established when Wegeman's and Crouse
Hospital determined they had similar goals for community
residents. The hospital "wanted a disease management program in
the community that improved patient health and supported the
primary care physician, and Wegemen's wanted to improve the health
of people who live and shop here."
Source: Hospital Puts Diabetes Education, Screening on
Patients' Grocery Lists. Healthcare Demand and Disease Management
1999 Jan; 5(1): 12-4.
23. Dually Eligible Care
Medicare and Medicaid waivers allow states to develop managed
care options for people dually eligible for Medicare and Medicaid.
In reviewing the strengths and weaknesses of waiver programs,
Walter Leutz notes that strong waiver programs share some common
characteristics, such as consumer/caregiver participation in
decisionmaking. New directions in waivers, he says, can be summed
up in three words: capitate, integrate, and privatize. States may
experience substantial barriers when trying to move in this new
direction. For example, they often lack the data and expertise to
develop appropriate payment rates. Also, there may be a bias
against home and community-based services (HCBS) and toward acute
and institutional services that "are more highly valued or better
understood by medical system managers." Leutz advises states to
carefully (1) examine implementation challenges related to
capitated, integrated, privatized approaches, (2) resist ad hoc
fixes, (3) clarify entitlements to HCB benefits, and (4) attend to
long-term care infrastructure.
Source: Leutz W. Policy Choices for Medicaid and Medicare
Waivers. The Gerontologist 1999 Feb; 39(1): 86-93.
24. Integrated Pharmaceutical Care
Alameda Alliance for Health and Community Health Center Network
have teamed up to provide a pharmacy educational program for
Medi-Cal patients (California's version of Medicaid), to help
patients understand "the how, what and why of their
prescriptions." The health plan and physician group are also
"training area pharmacy chains on the basics of managed care and
the processes for working with the plan."
Source: Severoni E. Straight Talk from Managed Care
Members. Healthplan 1999 Jan/Feb; 40(1): 24-30.
25. Frail Elderly Care
NCCC member Crozer-Keystone Health System is launching its
population-based disease management (DM) program-called the frail
elderly program-with a pilot project involving 50 frail elder
patients. The goal of the program is to "facilitate the
appropriate management of the elderly population, increase
awareness of guidelines for care, and support health professionals
with resources and information." The program will track elderly
patients "across the continuum of care." To prepare for this and
other DM programs, Crozer-Keystone has worked to develop a broad,
corporate view of integration, using the NCCC's SASITM tool and
related strategies.
Source: Postacute Expected to be Disease Management Growth
Area with Payment Potential. Postacute Payment Report 1998 Dec;
2(12): 186-88.
26. Chronic Disease Management
Drawing upon the experience of several large healthcare
systems, a recent article in Physician Profiling and Behavior
Change Report offers practical suggestions for winning physician
buy-in for disease management (DM). Suggestions include (1)"use
profiling data to prove your point" (e.g., show how DM programs
effect patient satisfaction and care outcomes) and (2) use the
"ten-second rule" (e.g., "doctors are not saying 'throw money at
me;' they're saying 'take less of my time'").
Source: Data, MD Collaboration Yield Elusive Support for
DM. Physician Profiling and Behavior Change Report 1999 Jan; 2(1):
1-7.
27. Alzheimer's Care
When people have dementia, monitoring their quality of life
(QOL) can be problematic. Clinicians and researchers have often
relied on proxy measures. Now, however, Meryl Brod and colleagues
report on a new instrument that can be used to directly assess
QOL. The 29-item tool was found to be reliable and "shows evidence
of validity." The researchers conclude that "persons with mild to
moderate dementia can be considered good informants of their own
subjective states, paving the way to consider patient responses
rather than proxy measures as the gold standard for assessing QOL
for persons with dementia."
Source: Brod M et al. Conceptualization and Measurement of
Quality of Life in Dementia: The Dementia Quality of Life
Instrument. The Gerontologist 1999 Feb; 39 (1): 25-35. Editor's
note: Due to copyright laws, we cannot provide copies of the
articles mentioned in CareLink. However, all or nearly
all of the articles are from major health and long-term care
journals that can easily be found in large public libraries,
university libraries, or health system libraries. For hard-to-find
articles, a successful technique is to call your local library,
obtain the name of the journal's publisher, and call the publisher
to order back issues.
JOURNALS CITED IN THIS CareLink:
| Journal Name |
Publisher's Phone
No. |
| Annals of Internal Medicine |
(215) 351-2657 |
| Aging Research and Training
News |
(800) 247-6737 |
| Contemporary Long Term Care |
(212) 592-6273 |
| Disease Management News |
(301) 604-4001 |
| Gerontologist |
(313) 763-7232 |
| Health Affairs |
(800) 765-7514 |
| Health Care Cost Reengineering
Report |
(800) 597-6300 |
| Healthcare Demand and Disease
Management |
(800) 597-6300 |
| Healthplan |
(202) 331-7487 |
| Health Management Technology |
(941) 966-9521 |
| Hospitals and Health Networks |
(312) 440-6800 |
| Hospital Case Management |
(800) 688-2421 |
| JAGS (Journal of the American
Geriatrics Society) |
(800) 759-6423 |
| Medical Outcomes and Guideline
Alert |
(212) 967-7060 |
| Medical Utilization
Management |
(630) 305-7251 |
| Physician Profiling and Behavior
Change |
(800) 597-6300 |
| Post Acute Payment Report |
(800) 597-6300 |
| Report on Medical Guidelines and
Outcomes Research |
(800)
655-5597 |
