Population Health Management presentation JUNE2015
Published on: Mar 4, 2016
Transcripts - Population Health Management presentation JUNE2015
Athena Forum Institute®
ACO Workforce Performance
21st Century Training for Healthcare Professionals
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The Journey of ACO Performance Begins on Athena Forum.
Dear Director in Population Healthcare,
Our philosophy is that a Care Management Director can achieve goals
at a faster rate with a better educated staff.
Thanks to all the ACO Directors who contributed to this presentation.
Thomas A. Rasmussen
CEO & Publisher
Senior Fellow, Jefferson School of Population Health
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“Knowledge workers need knowledge. Knowledge workers are different from factory workers.
Knowledge workers can advance the strategic direction of your business.”
The Essential Drucker®
“ACO’s need to power-up their accredited training for front line care coordinators –
that’s a no brainer!” Federal Medicare Executive ACO Division
CMS.gov Baltimore MD October 2013
Baldrige National Quality Program in Healthcare
Baldrige criteria for healthcare companies:
1. Visionary leadership
2. A focus on the future
3. A focus on results to create value
4. Patient-focused excellence
5. Valuing workforce members
6. Managing innovation
7. Societal responsibility
Baldrige recipient Bronson Methodist Hospital – “for workplace excellence.”
Baldrige recipient Baptist Hospital – “for staff empowerment training in building patient relationships.”
Source: National Institute of Standards & Technology, U.S. Dept of Commerce. www.baldrige.nist.gov
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“Management is getting work done through others.”
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ACO Care Director
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The Education Multiplier Effect
When ONE care coordinator completes ONE CE course = “advancing one’s practice.”
When the ENTIRE team completes the same course = “improving organizational performance.”
ACO Workforce Performance
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Athena Forum Institute® was designed in 2008 by executives from population health
companies including: Aetna, CIGNA, Humana & WellPoint. Before the “ACO” was invented.
Athena Forum has 3 features to improve organizational performance:
1. Management Tool: Directors assign courses to steer the team to ACO priorities.
2. CE Machine for Staff: Staff love Athena Forum for 700 CE accessible from any computer.
3. Clinical Reference Tool: 7,000 page curriculum is searchable (“21st Century PDR”)
Medicare Strategic Measures for the ACO
1. Demonstrate your preventive care program for Medicare seniors in your population,
2. Demonstrate your chronic care management care delivery network,
3. Demonstrate measures toward enhancing the patient experience & community involvement.
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Medicare Patient Quality Measures for the ACO
1. Patient / caregiver experiences 7 measures
2. Care coordination / patient safety measures across the spectrum 6 measures
3. Preventive health / patient education measures 8 measures
4. The at-risk Medicare population clinical measures: 11 measures
Ischemic vascular disease
Coronary artery disease
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Athena Forum Tuitions:
Enroll 1 to 19 care coordinators $125.00 per person, per year
Enroll 20 to 49 $ 95.00
Enroll 50 to 99 $ 75.00
Enroll 100 to 499 $ 65.00
Enroll 500 + $ 35.00
1. All tuitions are paid by the company,
2. The company can add or delete personnel at any time; we pro-rate tuitions on a monthly schedule,
3. Each tuition is a flat rate with no other charges; all CE certificates are included,
4. Each enrollee has 24/7 access to all 7,000 pages, all 700 CE certs, from any computer,
5. All CCM CE are pre-approved and pre-paid; 160 CCM CE volume equals 200% of the 5 year CCM credential renewal,
6. RN and Social Work CE represents a 100% volume of license renewals in all 50 states,
7. ACO management personnel (up to 5 managers) can be enrolled on a complimentary account.
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“We forecast a 100 X ROI for one tuition. This ROI is expressed as forecasting ~ $12,500 in reduced hospitalizations in
a year. Assume one care coordinator gains better health coaching skills from the education. Assume that same care
coordinator has a panel of 4,000 seniors. Assume that same care coordinator helps only ONE senior to asthma-proof
her home and avoid one asthma hospitalization in that year. The ROI of avoiding one hospital admit at $12,500 is then
100 X the Athena tuition of $125.00. Scale it to 100 people and you’re saving $1.2M. And this could be conservative.”
Chief Medical Officer
“We see reduced readmission rates. The only variable is assigning Athena courses to the team and discussing at
monthly staff meetings. We mandate the courses and we hold staff accountable, and the ‘training for impact’ is real.”
ACO Mid West
“Our ROI is to train people so we can protect our $200Million contract with Medicare. Our front line people are
assigned courses on Athena to support our compliance with Medicare’s Patient Quality Measures. Plus that we’ve
seen a boost in morale.” Vice President Finance
ACO Western States
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Athena Forum Care Management Series® Slide 1 of 2
CM Express [for new hires] Establishing Your Professional Identity
Mod A: Essentials of Case Management Mod A: Essentials
Mod B: Importance of Claims Mod B: Critical Thinking
Mod C: Resource Management Mod C: Emotional Intelligence
Mod D: Transitions of Care / Patient Experience Mod D: Conflict Resolution
Mod E: Leadership
Discharge Planning Mod F: Difficult People
Mod A: Philosophy & Standards
Mod B: Patient Centered Approach to DP Hospital Revenue Cycle
Mod C: External Forces in DP Mod A: Industry Cash Flow
Mod B: Hospital Cash Flow: Claims, RAC, Avoidable Days
Ethics in Case Management
Mod A: Ethical Standards of Practice Patient Advocacy
Mod B: CM Ethics in the Hospital Setting Mod A: Advocacy & Care Management
Mod C: Ethics in the Telecare Era Mod B: Right Care Guidelines for our Patients
Mod D: Ethics in Large Corporate Cultures Mod C: Key Components to Care Success
Mod E: Ethics in the Community Health Setting
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Athena Forum Care Management Series® Part 2 of 2
Population Healthcare CM Power [for advanced care coordinators]
Mod A: Prior Authorizations Mod A: Achieving the 6 Attributes of a High Performance Case Manager
Mod B: Concurrent Review Mod B: Improving the Financial Performance of our Hospital thro CM
Mod C: Transitions of Care Mod C: Optimizing Stakeholder Collaboration in the CM Sphere
Mod D: Mastering Our Hospital’s Strategy in Patient Engagement
Principles of Case Management
Mod A: Principles
Mod B: Access Management & UM
Mod C: ED Care Management
Mod A: Standards & Regulations in UM
Mod B: Payers, Contracting & UM
Mod C: Quality of Care & UM
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Athena Forum Clinical Care Series® Slide 1 of 3
Asthma CV Risk: Stroke & MI
Mod A: Prevalence & Pathophysiology Mod A: Prevalence & Pathophysiology
Mod B: Assessment Mod B: Stroke & The Care Manager’s Role
Mod C: Treatment Mod C: MI & The Care Manager’s Role
Mod D: Care Manager’s Role in Asthma
Colorectal Cancer Diabetes
Mod A: Prevalence & Pathophysiology Mod A: Therapies
Mod B: Symptoms & Management Mod B: Assessments & Complications
Mod C: Treatments & Interventions Mod C: Pharmacologic in Diabetes Care
Mod D: Standards of Medical Care
COPD EOL & Palliative Care
Mod A: Prevalence & Pathophysiology Modules A-E Symptom Management & CM Role EOL Care
Mod B: Assessments & Complications
Mod C: Pharmacologics in COPD Ebola Care Management
Mod D: Care Manger’s Role Modules A B & C: Assess, Manage & CM Role Ebola Care
Mod E: Pneumonia
COPD rates are rising in women.
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GI Disorders Obesity Management
Mod A: Ulcerative Colitis Mod A: Prevalence & Pathophysiology
Mod B: Crohn’s Disease Mod B: Assessments & Complications
Mod C: Diverticulitis Mod C: Treatments & Interventions
Mod D: Care Manager’s Role in Obesity Management
Heart Failure Pain Management
Mod A: Prevalence & Pathophysiology Mod A: Pathophysiology of Pain
Mod B: Assessment & Complications Mod B: Acute Pain
Mod C: Treatments & Interventions HF Care Mod C: Chronic Pain
Mod D: CM Role in HF Care Mod D: Types of Chronic Pain
Mod E: Cancer Pain
Mod A: Prevalence & Pathophysiology
Mod B: Symptom Management & Rehab
Mod C: Disease & Relapse Management
Mod D: Care Manager’s Role in MS
Athena Forum Clinical Care Series® Slide 2 of 3
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Athena Forum Clinical Care Series® Slide 3 of 3
Rheumatoid Arthritis Women’s Health
Mod A: Prevalence & Pathophysiology Mod A: The Perimenopausal Years
Mod B: Assessments & Complications Mod B: Complications in Menopause Care
Mod C: Treatments & Interventions Mod C: Sexuality in Maturity
Mod D: Care Manger’s Role Mod D: Care Manager’s Role
Sepsis Care Wound Care
Mod A: Prevalence & Economics Mod A: Prevalence & Pathophysiology
Mod B: Pathophysiology & Assessment Mod B: Assessments & Complications
Mod C: Sources & Predispositions Mod C: Treatments & Interventions
Mod D: Prevention & Treatment Mod D: Prevention Strategies
Mod E: Care Manager’s Role in Sepsis Mod E: Care Manager’s Role in Wound Care
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Athena Forum Behavioral Health Series®
Improving Outcomes in Abuse Management
Modules A & B: Domestic Violence
Modules C & D Child Abuse
Mod E: Elder Abuse
Mod F: CM Role in Abuse Management
Improving Outcomes in Depression Care
Mod A: Prevalence & Impact
Mod B: Pathophysiology of Depression
Mod C: Non-pharmacological Treatments
Mod D: Pharmacology in Depression Care
Mod E: CM Role in Depression Care
Harm Risk Behaviors & Suicide Prevention
Mod A: Prevalence & Societal Impact
Mod B: Pathophysiology & Associated Mental Disorders
Mod C: Assessment & Prevention
Mod D: Treatment Management
Mod E: CM Role in Suicide Prevention
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Medicare patient quality measure: Diabetes
Athena Forum page (excerpt) supporting ACO care coordinators on Diabetes:
“Diabetes care is provided to achieve desired goals of treatment.
Glycemic goals are presented in Table 4.2. The American Diabetes
Association recommends that the goal of therapy should be an
A1C result of <7% and that physicians should reevaluate and,
in most cases, significantly change the treatment regimen in
persons with A1C test results consistently >8%.
“Again, these specific A1C values apply only to assay methods that
are certified as traceable to the DCCT reference method. Table 4.3
(below) identifies the correlation between A1C levels and mean
plasma glucose levels based on data from DCCT.
[Source: Athena Forum Course Diabetes, Mod A: Therapies, p 33 of 39]
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Table 4.2. Goals for Glycemic Control
Normal Goal Action
A1C 4%-6% < 7% > 8%
< 90 / > 150
<110 / > 180
Whole Blood Values
< 80 / > 140
<100 / > 160
Medicare patient quality measure: Hypertension
Athena Forum page (excerpt) supporting ACO care coordinators on Hypertension:
Usually, no symptoms are present. Occasionally, the person may experience a mild headache. If the headache is severe, or if any
of the symptoms below are experienced, the person must be seen by a doctor right away. These may be a sign of
dangerously high blood pressure (called malignant hypertension) or a complication from high blood pressure.
angina-like chest pain (crushing chest pain)
blood in urine
ear noise or buzzing
[Source: Athena Forum Institute® Course: CV Risk, Module B: Stroke & CM Role, page 9 of 34pp]
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Medicare patient measure: Ischemic vascular disease
Athena Forum page (excerpt) supporting ACO care coordinators on Ischemic vascular disease.
Ischemic Stroke Diagnostic Procedures
Testing is the same for ischemic strokes as it is for hemorrhagic with the addition of the following:
ECG - electrocardiogram (EKG)
Echocardiogram (looks for cardiac embolus)
Carotid Duplex (ultrasound of the carotids)
Transcranial Doppler (looks at the blood vessels in the brains and the velocity of the blood flow)
[Source: Athena Forum Institute® Course: CV Risk, Module B: Stroke & CM Role, page 21 of 34pp]
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Medicare patient measures for: Heart Failure
Athena Forum page (excerpt) supporting ACO care coordinators on Heart Failure.
“Early diagnosis and treatment can help people who have heart failure (HF) live longer, more active lives.
Treatment for HF will depend on the type and the severity of the condition. The goals of treatment for all stages include
treating the underlying cause of the HF such as:
Coronary heart disease (CHD)
Treatment is also utilized to:
Stop the HF from worsening
Improve quality of life
Treatments usually include:
More advanced HF may also require medical procedures, devices, or surgery. 1
[Source: Athena Forum: Course: Heart Failure, Module C: Treatments & Interventions in HF, Page intro/1 of 41 pp]
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Medicare patient quality measure: CAD
Athena Forum page (excerpt) supporting ACO care coordinators on Coronary artery disease:
“There are two main ways to express risk - "relative risk" and "absolute risk." Relative risk estimates percent increase or decrease
in a health event occurring in one group compared to another group. Absolute risk estimates the number of health events
among individuals in a group and gives a better sense of personal or individual risk. The risk to an individual can be low, but
in a large population the number of health events can be great. Increased risk, however, does not mean a person will
actually develop the specific disease.
Certain factors make it more likely that a person will develop CAD and have a myocardial infarction (MI) (heart attack).
Risk factors that cannot be modified include: Risk factors than can be modified include:
•Age - Smoking
◦Men: over age 45 - High blood pressure (HTN)
◦Women: over age 55 - High blood cholesterol
•Family history of early heart disease - Overweight and obesity
◦Heart disease diagnosed in father or brother before age 55 - Physically inactive
◦Heart disease diagnosed in mother or sister before age 65 - Diabetes (high blood sugar)
•Personal history of CAD
◦Angina or chest pain
◦A previous MI
◦A surgical procedure (angioplasty, heart bypass) to increase cardiac blood flow [Source: CV Risk, Mod C, page 2 of 51]
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Benefits of workforce development
ACO directors report these benefits:
1. Higher core competencies of front line care coordinators
2. Improved morale
3. Improved focus on priorities
4. Better sense of teamwork
5. Leveraged time of leadership and clinical educators
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Maximizing workforce development
ACO Directors on Athena Forum recommend:
1. Managers should assign courses to steer the team (popular pacing is 1 module per month),
2. Managers should lead monthly discussions (for staff compliance & align to your protocols),
3. Managers should delegate details of staff completions to: admin, senior staffer or educator).
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Sample ACO Implementation Memo
Athena Forum ACO Course Assignments:
JAN: Diabetes: Module E: Medical Standards
FEB: Patient Advocacy: C Right Care Guidelines
MAR: CV Risk: Stroke & CM Role
APR: Heart Failure: Mod B Assessment
MAY: Professional ID: Critical Thinking
JUN: COPD: Mod A: Pathophysiology
JUL: COPD: Mod B: Assess & Manage
AUG: No assignment. At the beach.
SEP: Professional ID: Conflict Resolution
OCT: Heart Failure: Mod C Interventions
NOV: Hospital Revenue Cycle Module C
DEC: No assignment. Happy Holidays.
MEMO TO: All Care Coordinators
FROM: Sue Rittenhouse, RN, CCM, VP Care Management ACO Division
SUBJECT: Staff Development Program for Our Medicare Seniors
As mentioned, I’m pleased to announce that everyone has been enrolled on Athena Forum Institute.com – the
accredited educational service for improving care of our Medicare seniors in our ACO program.
Athena Forum is a new employee benefit at no cost to you, and you can earn CE for your license no problem. We’ll
be assigning course modules (see below) to move us all forward as a team, and this is a mandatory employee
program. You also have full access to hundreds of pages of other courses to support your interests and practice
advancement. Athena is accessible by mobiles such as Nook® Kindle® or iPad® and many people take courses at
wi-fi locations like Starbucks. Welcome to the 21st Century!
Please note: (a) Submit your CE certs to Michelle each month to document your course completions, and (b) Be
prepared to discuss the course topics at selected staff meetings so we all advance together.
Our senior leadership supports this program for achieving high ratings on Medicare Quality Measures.
Accreditations: 100% Volume for RN, SW, ACM, CCM
Athena Forum offers 700 CE contact hours for RN, Social Work, ACM and CCM professionals.
RN: Co-Provider with SutterHealth University by American Nurses Credentialing Center [ANCC]
RN California: Approved Provider with California Board of Nursing
RN Florida: Approved Provider with the Florida Board of Health in Nursing.
Social Work: Approved CE Provider by the NASW, Michigan and California (soon New York).
ACM: Approved Provider by the ACMA (American Case Management Association)
CCM: Approved Provider of CCM CE by the CCMC (Certified Case Managers Commission)
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ACO Case Study #1: The Hospital-Based Care Team
ACO Chief Medical Officer explains:
“With Board approval, we closed our Labor & Delivery unit and renovated
it into our outbound call center for 20 care coordinators in 20 cubicles.
We also created management offices, a kitchen and conference rooms.
The last thing our board would approve was new plant construction.
“Each RN Care Coordinator has an EMR computer with a phone/headset.
“Among our 40,000 ACO seniors, each care coordinator gets a panel of
about 2,000 seniors each – with many of them well. Our goal is for each
care coordinator to cycle through their 2,000 panel each month.
“Our care director convenes morning meetings to share ideas on telephonic coaching, scheduling well-care
appointments through our PCP delivery network, and to refer complex cases to hospital case management. We also
hired a part-time consultant (retired from Humana) to do some stand up training on tele-health coaching.
“To keep the team focused on priorities, our care director assigns a monthly course on Athena Forum aligned to
Medicare measures on diabetes, HF, etc. The Humana coach was also on Athena there. Team morale is high.
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ACO Case Study #2 The Care Coordination Trio in Network
Vice President, Care Management explains:
“We’re embedding 3 care coordinators at each of our 80 surrounding
medical groups in our delivery network.
“Each trio is an RN Care Coordinator, Social Worker Care Coordinator &
a Pharmacist Care Coordinator.
“Each trio gets a computerized panel of about 3,800 seniors each (our total ACO population is 300,000).
“We find it easier to schedule well-care appointments of seniors -- when our coordinators are on-location. We train
our employees in customer service and they greet our seniors at appointments.
“Our trios are assigned 10 modules a year on Athena Forum, no problem. Our people enjoy learning online and
the Athena courses are comprehensive and accessible 24/7 – very important. The CMO is on board with this; he’s
seen the Athena courses and said “The stand-up trainer model is not scalable; Athena is 24/7 from a Nook LOL.”
“This may not be our final configuration, but we’re all experimenting and this is working well so far.”
ACO Case Study #3: At-home Care Coordinators
Medical Director explains:
“We took a page out of the MCO companies’ playbook and hired 25 at-home RN case managers to reach out to our
40,000 covered lives. Each RN has about 1,600 members. We have a team of complex care managers for
hospitalizations. Here’s a day in the life of a care coordinator:
50 outbound calls in the morning, leaving smiling voice messages on clinical conditions (asthma, diabetes, HF).
The nurse usually has about 5 live phone conversations in the morning. The RN personality is part of our brand.
Noon-1pm: The nurse has lunch and walks around the block for fresh air LOL.
50 outbound calls in the afternoon; with about 5 live conversations.
“It’s important to hire the right personality who enjoys working from home and chatting with seniors. It’s important to
convene the Wednesday team meeting 4pm-5pm without fail. This builds morale and team work. The CM’s share
ideas on tele-health coaching. The monthly course assignment from Athena Forum boosts clinical skills and morale
because it shows leadership cares about front line quality. That course on Critical Thinking Skills is cool.“
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Sample Workforce Development Plan
Staff Performance Plan for 2015: Advancing Team Performance:
JAN 2015: Ischemic Vascular Disease This course supports the Medicare Patient Quality Measure
Mod B: CV Risk: Stroke & CM Role on improving care on ischemic vascular disease.
FEB 2015: Professional Identity Learn how to control your emotions to make better decisions.
Mod C: Emotional Intelligence
MAR 2015: Diabetes Supporting the Medicare Patient Quality Measure on diabetes.
Mod A: Diabetes Therapies
APR 2015: COPD Enhancing the patient-centered approach in COPD care.
Mod E: CM Role in COPD Care Instructs on motivational interviewing for behavior mod.
MAY 2015: Professional Identity News Flash! Sometimes there are difficult people in our work.
Mod F: Interacting with Difficult People This course instructs on getting the job done with less stress.
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What does excellence sound like?
“Thank you for the training this morning, it was exactly what we needed.” CM Director VA
“Our team is ecstatic to have such an amazing tool at their fingertips.” CM Director WY
“Athena has exceeded our expectations. Keep up the good work!” CM Director TX
“The Athena Forum format is very user friendly.” CM Director CA
“Conversations are getting more professional. Social Workers love this.” CM Director IL
“We know it. We trust it. We love it.” CM Director KY
“Starbucks is the new Learning Café for our younger gen case managers.” CM Director WA
“Athena is the tide that lifts all boats.” CM Director LA
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Sarah Hill National Director, Healthcare
Beverly Gulvin Sales Manager, Healthcare WEST
Kathy Coutouzis Assistant Sales Manager
Kim Billings Sales Manager,
Cindy May Assistant Sales Manager