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From the editor

Dear Healthcare Intelligence Network Client,

HIN Managing Editor Patricia Donovan

Improperly managed, the transition between leaving the hospital and returning home can turn into a dangerous care and communication void, particularly for patients with heart failure. A featured study this week from Duke University found that most hospitals have no formal follow-up procedures for these patients, with only about 40 percent seeing a healthcare provider within seven days of discharge.

Susan Shepard, director of patient safety education at The Doctors Company, shared a story during last month's webinar on coordinated discharge planning: The CMO of a large health system was hospitalized because of an emergency surgical procedure. While he was delighted with the care he received, he said that the biggest surprise was that when he went home, he felt alone, fearful, uninformed and disconnected. He had received no real education on how to take care of himself, had no way to reach out for that information and had no guidance or coordination of care.

Aetna's care transitions initiative, described in this issue, is attempting to close care gaps for its Medicare patients. Our chart of the week on Home Visit Tasks, developed from our 2009 Care Transitions survey, illustrates other ways to put recently discharged patients on the path to self-management. We've just launched the 2010 version; take the Managing Care Transitions Across Sites by May 31 and find out how your peers are closing care gaps, avoiding unnecessary hospitalizations, readmissions and ER visits, reducing medication errors and raising the bar on care quality with transition management programs.

Your colleague in the business of healthcare,
Patricia Donovan
Editor, Healthcare Business Weekly Update

Please send comments, questions and replies to pdonovan@hin.com.

HIN Associate Editor Jessica Papay
Associate Editor:
Jessica Papay, jpapay@hin.com

Publisher:
Melanie Matthews, mmatthews@hin.com

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This week's featured download: Care Transitions Across Sites — Closing Gaps in Healthcare Settings

Care Transitions Across Sites — Closing Gaps in Healthcare Settings

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May 10, 2010
Vol. XII, No. 18

Sponsored by:
Patient-Centered Medical Home Transformation: 9 Key Hurdles for Physician Practices To Overcome

This week's industry news:

  1. Can Transitional Care Programs Reduce Avoidable Readmissions?
  2. Reducing Readmissions
  3. Patients Lack Early Follow-Up Care After Heart Failure Hospitalization
  4. Reducing Readmissions for Heart Failure Patients
  5. Healthcare Business White Paper: Interactive Patient Care
  6. Outcomes-Based Approach Improves Children's Mental Health Service Delivery
  7. New Chart: Home Visit Tasks
  8. Model Medical Homes
  9. Spouses of Dementia Patients Have Six-Fold Increased Risk of Dementia Onset
  10. Assessing and Predicting Health Risk in the Elderly
  11. Michigan is 38th State to Enact Smoke-Free Law
  12. Health Coaching Benchmarks, 2010 Edition
  13. HealthSounds Podcast: Health Coaching Evaluation
Please pass this along to any of your colleagues or, better yet, have them sign up to receive their own copy and learn about our other news services.

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This week's industry news

1.) Can Transitional Care Programs Reduce Avoidable Readmissions?

Dr. Randall Krakauer, national medical director for Aetna’s Consumer Segment, describes the changes to the hospital discharge program that helped to reduce avoidable hospital readmissions.

Get the full story.

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2.) Reducing Readmissions: Interventions, Incentives and Infrastructure

Reducing Readmissions This resource presents case studies from three healthcare organizations whose efforts have significantly reduced avoidable hospital readmissions in high-risk populations and include the alignment of financial incentives to readmission rates.

Learn more about this resource.

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3.) Most Patients Lack Early Follow-Up Care After Heart Failure Hospitalization

Early follow-up care following hospital discharge reduces readmission rates for heart failure patients, but most hospitals have no formal follow-up procedures in place, according to a new study by researchers at the Duke Clinical Research Institute (DCRI).

Get the full story.

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4.) Reducing Readmissions for Heart Failure Patients: A Multidisciplinary Approach for the Medicare Population

Reducing Readmissions for Heart Failure Patients Learn how Hackensack Hospital is reducing readmissions of heart failure patients through a program of continuous care, patient education and self-management.

Learn more about this resource.

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5.) Healthcare Business White Paper: Interactive Patient Care — The Missing Link In Consumer Directed Healthcare

While consumer directed healthcare (CDH) is receiving wide-spread attention from the media, the scope is often on EMR adoption or health savings accounts. While these are important developments in improving care and lowering costs, they do little to address the critical aspects of patient education, satisfaction and empowerment. At a time when the CMS-enforced Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance measures may impact Medicare reimbursement rates for hospitals, what can hospitals do to ensure patient education and satisfaction? In other words, how can you ensure patient empowerment?

Download this complimentary white paper.

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6.) Outcomes-Based Approach Improves Children's Mental Health Service Delivery

According to the results of a five-year study by Magellan Health Services, Inc., an analytical model may be used to provide more effective and efficient mental health services to youth.

Get the full story.

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7.) New Chart: Home Visit Tasks

Home Visit Tasks

Sometimes it takes a home visit to a patient with complex chronic conditions to understand the barriers to care compliance that they face. We wanted to see which tasks are being performed during home visits.

Click here to view the chart.

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8.) Model Medical Homes: Benchmarks and Case Studies in Patient-Centered Care

Model Medical Homes This resource is a landmark publication that documents the healthcare industry's adoption of the patient-centered medical home (PCMH) model of care, and includes highlights from programs working to integrate mental health into the medical home model. This exclusive 65-page report contains case studies on medical home adoption by Geisinger Health Plan, MetCare, Reardon Consulting, the HealthQuilt Quality Health Record and Hagen Wall Consulting.

Learn more about this resource.

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9.) Spouses of Dementia Patients Have Six-Fold Increased Risk of Dementia Onset

Older married adults whose spouse has dementia are at significantly higher risk for developing dementia themselves, compared to similar older married adults whose spouse never develops dementia.

Get the full story.

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10.) Assessing and Predicting Health Risk in the Elderly

Assessing Predicting Health Risk in Elderly To increase and maximize revenue, many health plans are focusing on the health risk assessment scores of the elderly population they serve, including Medicare members. Managing these risks can have a bottom line impact by reducing healthcare resource utilization through early identification and management of potentially high expense conditions. During this February 2010 webinar, an expert from Aetna Medicare discussed what to assess in the elderly population, how to match interventions based on risk score and the impact of this type of initiative.

Learn more about this resource.

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11.) Michigan is 38th State to Enact Smoke-Free Law

The Dr. Ron Davis Law, which bans smoking in all Michigan worksites, including bars and restaurants, went into effect on May 1, making Michigan the 38th state to enact a smoke-free law.

Get the full story.

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12.) Health Coaching Benchmarks, 2010 Edition: Operations and Performance Data for Optimal Program ROI and Participant Health Status

Health Coaching Benchmarks, 2010 Edition This resource analyzes responses of 212 healthcare organizations to HIN's second annual 2009 Survey on Health and Wellness Coaching. An all-new follow-up to the best-selling 2009 Health Coaching Benchmarks, the 2010 edition is packed with actionable new data on health coaching activity, with the latest metrics on the prevalence of health coaching, favored delivery methods, targeted populations and lifestyle conditions, preferred behavior change models, coaching case loads and much more.

Learn more about this resource.

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13.) HealthSounds Podcast: Health Coaching Evaluation — Measuring the ROI on Healthcare Utilization and Costs

Dr. Jim Reynolds The dismal economy of 2009 has been a bright spot for health coaching and other health improvement programs, notes Dr. Jim Reynolds, chief medical officer for Health Fitness Corporation. Dr. Reynolds also compares early results from a Massachusetts' smoking cessation program for Medicaid beneficiaries with outcomes in commercial populations, and describes what Year 1 of a coaching program for improved medication adherence might yield in the way of behavior change and cost impacts.

Listen to this podcast.

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