This week's insight...
Kathy Brieger, RD, CDE
Chief Operations Officer of Hudson River HealthCare

July 25, 2012
Vol. I, No. 10

Kathy Brieger
Kathy Brieger,
Kathy Brieger, RD, CDE
Chief Operations Officer of Hudson River HealthCare

For Further Reading:

Case Management Metrics: Charting Care Coordination Across the Continuum

Which Decision-Making Tools Assess Levels
of Care Coordination for Diabetics?

"We wanted to start with patients who had a hemoglobin A1C of over 9. As we progressed, we realized there are people who have a controlled hemoglobin A1C, but have other areas that are out of control. We realized that we had to ask the providers, ‘Who are your frequent flyers? Who are the patients going in and out of the hospital?’ Then, we also looked at the patients who may be self-referring to the care manager and were having problems maintaining or controlling things. Therefore, using our COGNOS® report, we ran the data, which is one way to assess care coordination. You may also want to include the provider as well, who helps those people in the top 5 or 10 percent that require extra help.

There's also been work done on HARMS 8, a series of eight questions to identify patients who may end up in the hospital frequently. This has been tested out in our system. However, for patients who have some comorbidities, it depends on the condition you are looking at. Whether it is congestive heart failure (CHF) or mental health issues, each one would have to have its own set of criteria to be included in the high-risk group."

Kathy Brieger is a contributor to Patient-Centered Diabetes Management: Driving Outcomes with Education and Behavior Change, a 55-page special report that takes an in-depth look at three patient-centered programs for diabetes management that are improving clinical outcomes and bending the cost curve for program participants.

Read related blog post: New Diabetes Management Video Offers 4 Ideas for Weight Control.

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