Transitional Care Management: Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost

Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative.

A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:

1. Start discharge at the time of admission.
2. Ensure medication education, access, reconciliation, and adherence.
3. Arrange follow-up appointments.
4. Arrange home healthcare.
5. Have patients teach back the transitional care plan.

A Behind-the-Scenes Look at Healthcare IT Analyst Rankings and Reports: What You Should Know

Healthcare leaders often turn to healthcare IT analyst rankings and reports for information that drives vendor-related decision making.

Knowing the key differences between several notable healthcare and cross-industry IT analysts—what methodologies they employ to gather data, their missions and goals (ranking vs. consulting), and how much of their own opinions they interject (unbiased vs. opinionated)—will help healthcare leaders be more educated consumers of the reports and rankings that saturate healthcare.

This article provides a high-level overview of the key differences between several healthcare IT analysts:

• KLAS Research (ranking focus)
• Black Book Rankings (ranking focus)
• Chilmark Research (ranking and consulting focus)
• Advisory Board (consulting focus)

It also looks at the most notable cross-industry IT analysts that apply a healthcare-specific lens to their findings:

• Gartner
• International Data Corporation
• Frost & Sullivan

Healthcare leaders with the ability to interpret these rankings and reports to extract the information they need, will make them more effective decision makers.

Delivering The Healthcare Pricing Transparency That Consumers Are Demanding

Have Data—Need Analysts. Lessons Learned From The Woodworking Industry

Using Data-Driven Insights to Improve Practice Management

Effective practice management includes tracking and reporting patient outcomes, and effectively managing revenue cycle, as well as keeping an eye out for market changes and growth opportunities. Well-managed practices effectively balance supply and demand on a daily, weekly, and long-term basis, actively managing encounter volume, panel size and scope, timeliness of available appointments, and payer mix.

John Muir Health faced challenges in obtaining data that would provide leaders with strategic decision support information that fostered effective practice management. John Muir Health had attempted to use its EHR to obtain this information, but discovered it was unable to meet the complex demand. As a result, the organization relied on burdensome manual work processes, resulting in delays and a backlog of data requests, and limited ability to make well-informed, data-driven decisions.

After leveraging the information within its data warehouse and analytics platform to create a network leadership encounter application, John Muir Health acquired the following capabilities:

• All leaders have on-demand access to performance data at multiple levels from the organization-wide performance down to the patient and provider level.
• Senior leaders are making data-driven decisions for strategic responses across John Muir Health to shifts in market, growth opportunities, and emerging markets.
• The regional management teams are using the application to inform:
  • Daily operations.
  • Encounter processing
  • Patient access
  • Budget variances.

By leveraging these new capabilities, John Muir Health has achieved:

• Transparency of the data and accountability of the regional management teams for key performance indicators
• 14 percent improvement in completed physician encounters, resulting in faster revenue capture, when compared with the previous year.
• Eliminating the encounter-associated report backlog.

Capturing the Voice of the Patient: Using PROMs Improves Shared Decision Making

Healthcare suffers from an overabundance of metrics, many of which are used to determine payment in several federal healthcare programs. While these metrics are intended to improve the quality of care that patients receive across the country, they provide no insight into how disease and treatment impact patients’ daily lives.

Partners HealthCare recognized that while it had data for patient outcomes such as mortality and morbidity, and an abundance of data for process measures, it did not have data about patient symptoms, function, or quality of life. To improve care, the healthcare system needed to engage patients to understand the impact of treatment on how patient’s felt and functioned following treatment.

Partners implemented a patient-reported outcome measures (PROMs) survey program to collect this data. Partners now has several years of experience collecting PROMs and is gaining insight into how to successfully collect and use the information to improve shared decision making with patients and their providers.

• Patients have completed nearly 300,000 questionnaires in more than 20 specialties and over 75 clinics at most of Partners’ hospitals.
• Clinicians actively use this data to facilitate shared decision-making with their patients.

Health Catalyst Named One of Utah’s 20 Fastest Growing Companies For Third Year in a Row