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Now 78 years old, Martha had struggled with diabetes and chronic obstructive pulmonary disease (COPD) for years. But increasingly, her advancing illness made it difficult for her to live on her own. When her symptoms flared to an alarming degree, she had nowhere to turn but the emergency department (ED), and those visits often turned into hospital stays.
Then Martha’s physician referred her to Sutter Health’s Advanced Illness Management (AIM)® program for patients with late-stage chronic illnesses. Working with an AIM nurse, Martha (not her real name) learned how to correctly use her inhalers and nebulizer to prevent COPD flare ups. Easy-to-read charts helped her understand when her symptoms warranted a call to her physician. In addition, physical and occupational therapists helped Martha retain the strength and energy she needed to accomplish things that were important to her, such as cooking her own meals.
“AIM provides a continuity of care for these patients that didn’t exist before,” says Betsy Gornet, chief AIM executive at Sutter Health, a large Northern California health system. “We are engaging patients differently than we have before, and we’re helping them connect to their physicians in more fruitful ways.”
About 30 percent of Medicare dollars are spent on caring for chronically ill patients during the last two years of life, as detailed in a related Leadership
infographic. By ensuring that these patients receive coordinated care and avoid unnecessary ED visits and hospital admissions, Sutter Health is not only lowering costs, but improving the patient experience.
Current savings to payers now exceed $9,000 per AIM patient within 90 days of enrolling in the program. At the same time, satisfaction among patients and families is very high (4.7 out of 5). Gornet is confident that, by June, AIM will exceed its goal of $29 million in Medicare savings.
The concept of advanced illness management has been gathering steam for several years, and is described in detail in two
American Hospital Association reports. Advanced illness management often starts months, years, or even decades before a patient’s illness becomes terminal. The point is to provide coordinated care?both curative and palliative?to patients as their health declines (see Exhibit 1 below). Patients are also encouraged to develop advance directives to ensure their end-of-life choices are honored, and they are transitioned to hospice and palliative care as needed.
With its AIM model, Sutter is considered a pioneer in advanced illness management. After Sutter successfully demonstrated its model at two Northern California pilot sites from 2009 to 2012, the health system was awarded a three-year, $13 million Health Care Innovation Award from the Center for Medicare & Medicaid Innovation (CMMI) to expand the program throughout the Sutter Health service area.
A cross-continuum approach. The AIM model works around a virtual care team that follows patients from home to outpatient to hospital. At the center of the team is the patient’s primary care physician. Patients with advanced illnesses often see numerous specialists for various conditions, and the primary care physician can serve as the lead for that group of physicians, ensuring the patient’s curative and palliative goals are met.
Other core AIM team members are registered nurses and social workers who visit patients in their homes. Higher-acuity patients are seen by one of Sutter Health’s existing home healthcare teams, while lower-acuity patients are seen by AIM Transitions home-based teams.
Following the in-home care phase of AIM, patients are connected to one of the AIM tele-support nurses who work for the primary care practices. “If the physician thinks the patient needs additional help during the tele-support phase, one of the team members can go back to the patient’s home or we can get the patient to the doctor’s office,” says Gornet.
In addition, nurse liaisons are available at every hospital in the Sutter system. When AIM patients visit the ED or hospital, these nurse liaisons help coordinate and reinforce patients’ goal-oriented care and help them transition back into their homes.
A growth target. Sutter is on target to expand AIM to 14 virtual teams in 19 counties by this coming June, up from two teams in 2012. Thus far, more than 500 physicians, nurses, and social workers have been trained to serve AIM patients.
The number of patients enrolled in AIM will approach 10,000 by June, compared to just under 600 in 2012. AIM patients meet one or more of the following criteria:
“We identify the patients by talking to clinicians in doctors’ offices and in hospitals,” says Gornet. “We educate hospitalists, case managers, and nurses about the type of populations we are serving.” The hospital-based AIM liaisons are also critical in helping to identify patients, she adds.
Sutter Health is not allowed to release detailed AIM results until the CMMI study is completed. However, a preliminary analysis shows that the AIM program is demonstrating outcomes equal to or better than the pilot experience, including a 59 percent reduction in hospitalizations and a 67 percent reduction in ICU days among patients within 90 days of enrolling in AIM (see Exhibit 2 below).
Gornet believes four factors have been key to AIM’s success:
A consistent approach across settings. At the core of AIM is a respect for the patient’s personal versus clinical goals. “We really focus on the patients’ goals, and center the care activity and support around those personal goals,” says Gornet. “What are the patients trying to achieve, and where do they see themselves in the next three, six, or nine months?”
The AIM model consists of five pillars, which help to ensure that care plans are patient-centered:
“We use these five pillars consistently no matter where the patient is,” says Gornet. “It creates a structure and rhythm that makes it easier for everybody to know what’s going on, which is part of the beauty of what we’re doing.”
A skilled team. To help ensure a consistent approach, all new AIM team members participate in a four-day, 32-hour training program. “We use a lot of real-life case studies and scenario-based learning during training to help prepare AIM teams.”
In addition to teaching the five pillars, training focuses on team building. “We focus on the role of each team member and how the roles relate to each other. This is important because we have virtual teams. The team members would not typically see themselves as a team because they work in different settings.”
The training, for example, illustrates how to hand off information virtually and what the weekly team meetings should focus on. When discussing patients, team members are taught to use
SBAR (situation, background, assessment, recommendation) to streamline communications.
Within 90-180 days of initial training, each clinician and team is reassessed to ensure they are using the AIM pillars correctly and consistently. Follow-up training is provided to anyone who needs a refresher.
Patient engagement. AIM embraces the principles and tools of
integrated care management, which is a person-centered, evidenced-based approach to engaging patients and improving their self-management skills.
“The first part is making clinicians aware of health literacy,” says Gornet. “So many errors occur because we think we are communicating with patients, and we think patients understand us when they don’t. So the first step is understanding that the materials we give to patients and the way we communicate with patients must reach them where they are at that moment.”
A variety of tools help AIM team members achieve this goal:
Access related tool:
Sutter Health’s Heart Failure Stoplight Form
Data exchange and analytics. The lack of electronic interoperability among Sutter hospitals and affiliated physician practices has been both a challenge and an opportunity. On the pro side, it has forced AIM teams to devise a standardized, simple documentation approach.
“We try to keep documentation short and succinct to move away from physicians having to read a 19-page individualized care plan,” says Gornet. “We designed a note focused around our five pillars that begins with documenting the patient’s personal goals. By using this simple approach, physicians can readily identify new information and get a snapshot of where the patient currently stands. The plans are updated on an ongoing basis so that caregivers can just glance at the updated notes to see what has changed.”
However, ensuring that the AIM team notes are electronically available to hospitals and physicians is easier said than done. “We are dual documenting in multiple EHR systems and, when we can’t do that, we’re faxing,” says Gornet.
Sutter Health is now committed to improving data analytic capabilities to uncover targeted information that would help in better managing the AIM population. “We are looking at the total cost of care, and we are capturing both qualitative pieces of information (such as clinical outcomes, patient-reported outcomes, and patient/family experience), as well as quantitative data regarding utilization and cost of services across the entire care continuum,” says Gornet.
This has been a huge challenge, she adds. “We aggregate information from about 16 IT systems. And we recently layered Medicare claims data on top of that, which will give us a view of any cost or charge information outside of Sutter’s experience of these patients.”
When its three-year Medicare innovation award ends in June, Sutter Health hopes that CMMI will decide to expand the AIM program to other areas of the country. The health system is also exploring other ways to ensure the financial stability of the AIM program, including contracts with commercial payers.
Whatever the future may bring, it is clear that AIM is improving the day-to-day lives of people with advanced illnesses. Take Martha. Instead of having to see multiple physicians frequently, she now only has to visit her primary care physician, pulmonologist, and cardiologist—and in the past year, she has landed just twice in the ED.
“Even though she’s sicker than before, AIM has helped keep this patient out of the hospital,” says Gornet. “She’s able to manage her own symptoms and be in control of her care in a way she never had before.”
Betty A. Marton writes frequently about medical and healthcare issues for a variety of publications and organizations.
Maggie Van Dyke is managing editor, HFMA’s Leadership.
Interviewed for this article: Betsy Gornet is chief AIM executive, Sutter Health, Sacramento, Calif.
Communitywide Approaches to Aging
Creating Care Plans for Patients with Complex Needs
Funding Innovations for Aging at Home
Change Healthcare: Accelerating Revenue Cycle Transformation
Jason Williams, vice president for strategy and business analytics, Change Healthcare, discusses the importance of technology and technology-enabled services in reinventing the revenue cycle.
Ensemble Health Partners: Driving Revenue Cycle Innovation
Judson Ivy, president of Ensemble Health Partners, discusses the value of revenue cycle outsourcing and the importance of selecting the right partner.
Grant Thornton: Facilitating EAM
Priority Advantage: Helping Organizations Optimize Their Medicare Advantage Plans
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
Does Your Budgeting Process Lack Accountability?
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.