Beginning this October, hospitals will face penalties from the Centers for Medicare & Medicaid Services (CMS) for excess chronic obstructive pulmonary disease (COPD) readmissions—and many organizations are scrambling to manage a patient population that has been off their radar. One exception is Charlotte, N.C.-based Carolinas HealthCare System, which has been actively managing its COPD population for years.
In 2010, a project team led by Jean Wright, MD, vice president of innovation, recognized there was a huge need for COPD management in three counties served by the system. A few miles from Wright’s hospital, a cigarette plant handed out free cigarettes to employees at the end of every week. “COPD is a big disease, but one we weren’t focusing on,” Wright says. “Most patients with COPD have at least one other chronic condition and are high utilizers of healthcare services. We thought if we could target a disease where there wasn’t a lot of management already, we could make a difference.”
The strategy worked: During the pilot, the COPD readmission rate dropped from 21.8 percent in 2010 to 13 percent in 2013.
To improve COPD outcomes during the pilot, Carolinas HealthCare System staff continually identified patients with COPD, and then ensured these patients received the care they needed so they were less likely to be hospitalized. The tactics they used during the pilot included the following:
Use technology to address an unmet need. The health system’s focus on better COPD management was buoyed by a $16 million Beacon Community grant, funded through the American Recovery and Reinvestment Act (ARRA). As part of Community Care of Southern Piedmont, Carolinas HealthCare System was one of only 17 communities nationwide to receive ARRA funding to build health information exchanges and expand IT capabilities in both inpatient and outpatient settings.
“The grant gave us the technology infrastructure to improve care coordination in the community,” says Wright, who served as principal investigator for the project. Specifically, the grant helped the health system link its hospitals and primary care medical homes. It also helped with meaningful use adoption.
Conduct a root-cause analysis on COPD readmissions. Initially, project leaders assumed patient adherence was most often to blame for COPD readmissions in the health system. However, a root-cause analysis revealed that problems with patients’ home equipment were actually more prevalent. Case in point: After one patient was readmitted six times in six months, a case manager discovered that a faulty valve in the patient’s nebulizer was to blame.
Focus on the emergency department (ED). The root-cause analysis also revealed that inadequate patient education and poor access to primary care were driving COPD readmissions from the ED. To address these problems, project leaders embedded a respiratory therapist in the ED to educate patients about disease management. ED nurses also booked follow-up appointments for COPD patients with a primary care medical home.
In addition, the health system created a flag in the EHR, which highlights COPD patients who return to the ED three times in six months. This helped staff prioritize which patients to focus on.
Improve inpatient COPD care management. COPD patients are identified at admission, and both a case manager and respiratory therapist follow each patient’s treatment and discharge plan daily. All patients were assigned a medical home and received education on their disease and inhaler usage. They also had a follow-up appointment scheduled within two to seven days of discharge. In addition, all patients received a call from a nurse within 48 hours of discharge, and received weekly and “as needed” calls from a case manager for 90 days.
Bring screening and respiratory therapists to key primary care offices. With their grant funding, the project team also embedded respiratory therapists one day a week in the five employed physician practices that had the highest number of COPD patients. While at the primary care offices, the respiratory therapists took specific steps to identify, enroll, and treat patients (see the exhibit below).
“Instead of trying to teach patients in the two or three days they are in the hospital, we thought, why not try it when they are in the outpatient setting?” Wright says. In just one year, respiratory therapists reached 5,000 COPD patients in the five primary care offices—10 times the number they typically reach in an inpatient environment.
Wright is cautiously optimistic about her health system’s decreased readmissions, recognizing that variances in flu season, unemployment rates, and other factors can affect readmissions from one year to the next.
To better understand which factors continue to drive readmissions, Carolinas HealthCare System is teaming up with a vendor to help analyze readmission data across the system. Together, they have developed a tool that case managers use on the inpatient units to show a patient’s risk of readmission in the next 30 days. The tool uses analytics to stratify all patients (not just those with COPD) by risk of readmission.
Wright offers this advice for developing a disease management strategy for the COPD population:
Develop a working structure. Carolinas HealthCare System established a steering committee and five focus groups, each led by a physician, to focus on COPD readmissions. The focus groups covered guideline development, disease management, staff education, patient education, and outpatient respiratory therapy (see the exhibit below). The steering committee assigned deliverables to each team to ensure accountability.
Access related tool: COPD Deliverables
Act like private investigators. To better understand patients with COPD, physicians, case managers, nurses, and respiratory therapists conduct regular follow-up interviews with COPD patients who are readmitted to the hospital. The interviews have helped the project team see the wide array of factors that affect a patient’s ability to keep COPD under control.
Recognize that pulmonologists do not “own” COPD. Unlike other chronic diseases, a specialist does not typically manage COPD. Instead, primary care practices usually treat these patients, Wright says. Understanding this helped the project team know where to focus: their existing primary care medical homes.
Educate physicians on evidence-based guidelines. Carolinas HealthCare System is currently embedding the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in their EHR, so primary care physicians have immediate access to the protocols and can treat patients according to these pathways.
Start a pulmonary rehabilitation program. Many communities lack pulmonary rehab, which is why Carolinas HealthCare System added the service five years ago. Wright says these programs are critical for providing COPD patients with supervised exercise, education, and group support.
Use dashboards to keep physicians engaged. Carolinas HealthCare System uses a dashboard to track all-cause readmissions. The health system shares this dashboard every month with primary care physicians so they can see how they compare with their peers.
Start small to work out the kinks. Project leaders piloted the COPD outpatient program with five primary care practices, and later this year, they will include other practices. “Many organizations design these programs to roll out to the system at once, but we took an innovator’s approach,” Wright says. “Like an EHR rollout, you want to make sure the program works well in one place before you move on to the next.”
As the stakes get higher thanks to CMS penalties, Wright recommends focusing on just three to five COPD strategies to start. Otherwise, a project to reduce COPD readmissions can become overwhelming.
“Of all the metrics around readmissions, organizations will feel COPD most acutely because they are not prepared,” Wright says. “It’s a challenging population, and many organizations don’t know how much of their readmissions are being driven by COPD. In the future, we are all going to use more predictive analytics to determine which patients will likely come back to us. Our therapies, interventions, and programs like pulmonary rehab will be more targeted.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article: Jean Wright, MD, MBA, vice president of innovation, Carolinas HealthCare System, Charlotte, N.C.
This article is based in part on a presentation at an Institute for Healthcare Improvement conference in December 2013.
ClearBalance: Boosting Patient Payment through Consumer-Friendly Loan Programs
In this Business Profile, Bruce Haupt, president and CEO of ClearBalance, discusses how a patient loan program can increase patient collections, reduce bad debt, and speed cash flow.
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.
Deloitte Consulting LLP: Employing Innovative Solutions to Optimize Revenue Cycle Performance
In this Business Profile, Jerry Bruno, principal with Deloitte Consulting LLP, discusses the importance of choosing revenue cycle solutions that help an organization meet the challenges of a quickly evolving healthcare environment.
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.
Grant Thornton LLP: Maintaining and Improving Collections During an EMR Implementation
In this business profile, Lane Jackson, a partner in the Grant Thornton LLP Health Care Advisory Services practice, with extensive experience in overseeing system implementations and revenue cycle reorganizations, discusses best practices for elevating revenue cycle performance during an EMR implementation. Grant Thornton LLP is a sponsor of the Large System Controllers Council Affinity Group.
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.
KeyBank: Offering Expertise in Tax-Exempt Financing to Give Health Systems Flexible Options for Growth
In this business profile, Amy Gross, senior vice president of Key Government Finance, discusses the benefits of private placement transactions to support large-scale financing projects.
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.
Xtend Healthcare: Enabling Efficient Business Office Workflow
In this business profile, Doug Polasky, executive vice president at Xtend Healthcare, explains the importance of having sound workflow processes in a consolidated business office to ensure optimal performance and reduce costs.
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.
SSI: Bringing Patient Access to the Next Level
In this business profile, sponsored by SSI, Jay Colfer, vice president of sales and marketing, shares how patient access solutions are reversing the trend toward increased bad debt resulting from the rise in high-deductible consumer health plans.
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.
Deloitte: Helping Organizations Elevate the Healthcare Consumer Experience
In this business profile of Deloitte Consulting, Matthew Hitch and David Betts explore the potential benefits of elevating the customer experience and outline strategies to change service delivery.
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.
TriMedx: Elevating and Streamlining Clinical Engineering
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
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.
McKesson: Leveraging Predictive Analytics to Rein in Operating Costs
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
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.
Improving Care Delivery: Coordination and Partnership Across Settings
From payment incentives to value-based purchasing penalties, the national focus in healthcare is on improving patient care and lowering costs. Coordinating care for patients as they move from one care setting to another can help meet these goals, but the greatest success will come when the patients healthcare providers work together. By enhancing a team approach to care and providing cost efficiencies, partnerships between acute and post-acute settings benefit patients and the healthcare providers taking care of those patients.