Medical Home Monitor
Medical Home Monitor
January 3, 2011
Vol. III, No. 17

Medical Home Monitor Archives

In This Issue:

  1. Q&A: Advanced Illness, Nursing Skills
  2. Collaborative Data, Best Practices
  3. New Chart: Reducing Readmissions
  4. Podcast: Prepping for an ACO
  5. Reducing Risk of Falls
  6. E-Survey: Reducing Readmissions
  7. Benchmarks: 2010 Health Coaching
  8. Editor's Pick

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Medical Home Q&A's:
Advanced Illness,
Nursing Skills

Medical Home Monitor

Advanced Illness Program

Q: What is Sutter Health's advanced illness program?
A: Think of palliative care in the outpatient arena. We are focused on identifying a crisis plan for our patients. If a patient has COPD or heart failure, we identify a crisis plan. It starts out in the home with both a visit from a nurse and a social worker. The social worker focuses on the Physician Orders for Life-Sustaining Treatment (POLST) and an advance directive to start those discussions. The nurse focuses on developing a crisis plan for the patientís chronic illness. We have quite a few oncology patients that are still being actively treated, so we will talk about that crisis plan. Sometimes the crisis plan goes to the doctorís office or the hospital or ED, but we try to avoid that if possible. Our goal is to keep the patients in the home.

Once we have a plan in place, it goes to the office case managers, who do the ongoing telephone monitoring. It goes to the case manager for the patientís doctor, so we are able to keep the provider informed as well. As the patient progresses in their illness, our hospice department has the ability to do a home visit. If they are starting to experience some signs and symptoms, then the nurse can go out to the home, see what is going on, and do the interventions with the physician if needed to keep them in the home. If their care goal is to stay in the home, we work closely with the patientís goals. We try to match treatment with goals; that is what the program is about.

Jan Van Der Mei, RN, MS, ACM, continuum case management director at Sutter Health Sacramento Sierra Region.

For more guidelines on patient-centered case management, please visit:

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Nursing Skills

Q: What type of experience or skill set do you look for when hiring nurses for the physician-nurse team-based approach?

A: Ideally, I am looking for somebody who is going to be innovative and independent and get things done. Especially in the model that weíve created, I'm looking for somebody whoís not afraid to make changes, suggest changes, do things differently, and who will come in with the expectation that their work is going to be different a year from now than is right now. Also, I need them to be willing to do some patient education and to actually take over an area of care. In other words, they have to be comfortable enough to be the one who makes sure that people have been counseled on these preventive services and document that. The type of nursing that Iím looking for is a little bigger and broader than what a lot of clinic nurses are doing.

Dr. David Eitrheim, a family physician with Red Cedar Medical Center, part of the Mayo Health System.

For more information on the physician-nurse team approach, please visit:

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6 Healthcare Systems To Share Cost Data,
Best Practices for 8 Key Conditions

Six of the nationís leading healthcare systems have agreed to share data on outcomes, quality, and costs across eight common and costly conditions and treatments.

Dartmouth-Hitchcock, Cleveland Clinic, Denver Health, Geisinger Health System, Intermountain Healthcare, Mayo Clinic and The Dartmouth Institute for Health Policy and Clinical Practice will share data and determine best practices for delivering care for knee replacement, diabetes, heart failure, asthma, weight loss surgery, labor and delivery, spine surgery and depression, which together result in hundreds of billions of dollars in direct medical costs each year.

The collaborative will disseminate actionable recommendations to providers and health systems across the United States for these conditions, for which costs have been increasing rapidly in recent years and for which there are wide variations in quality and outcomes across the country.

In addition to achieving better quality and outcomes, the collaborative intends to improve the efficiency of standard clinical care delivery to reduce the per capita cost in these conditions and to keep costs in pace with the consumer price index.

For more information, please visit:

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New Chart: Barriers to Reducing Readmissions
Healthcare organizations face many challenges related to the reduction of hospital readmissions. We wanted to see the most significant barriers to reducing readmission rates in their populations.

View the chart at:

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HealthSounds Podcast: The Medical Home's Role in the ACO
The accountable care organization (ACO) is a staple of healthcare reform. CMS will launch its Shared Savings Program ó an ACO for Medicare patients ó in January 2012. John Harris, principal with the consulting firm of DGA Partners, advises potential participants in an ACO to lay the groundwork now. In this interview, he recommends eight elements of an ACO infrastructure and weighs in on the medical home's role in an ACO.

To listen to this HIN podcast, please visit:

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Primary Care Interventions Reduce Falling Risk in Elderly
Primary-care based interventions can reduce falls in the elderly, according to a study published in the Annals of Internal Medicine. Researchers abstracted data from 61 randomized controlled trials (RCTs) on primary care interventions in community-dwelling older adults that reported falls or fallers as an outcome.

Iinterventions involving exercise or physical therapy, vitamin D supplementation and multifactorial assessment and management reduced falling risk in the elderly in varying degrees, according to the study.

Specifically, they found 16 RCTs in which interventions involving exercise or physical therapy reduced falling risk (risk ratio, 0.87) and nine RCTs in which interventions involving vitamin D supplementation reduced falling risk (risk ratio, 0.83). In 19 trials that involved multifactorial assessment and management, comprehensive management interventions seemed to reduce falling, but overall pooled estimates did not reach statistical significance.

"Although we conclude that exercise or physical therapy interventions and vitamin D supplementation reduce the risk for falling among community-dwelling older adults, it is unclear whether comprehensive multifactorial assessment and management interventions reduce the number of fallers. Overall, we found no major clinical harms for these effective interventions to prevent falls in older adults," the authors write.

For more information, please visit:

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HIN Survey of the Month: Reducing Hospital Readmissions in 2010
Today is the last day to describe your organization's efforts to reduce hospital readmissions and receive an e-summary of the results. Take our second annual e-survey on this topic and learn how your peers are curbing avoidable utilization.

Complete the survey by visiting:

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Health Coaching in 2010
This white paper captures the ways in which 161 organizations are implementing health coaching in 2010 ó including the top three areas targeted by health coaching ó as well as the financial and clinical outcomes that result from this health improvement strategy. These benchmarks are based on organizations' responses to the Healthcare Intelligence Network August 2010 e-survey on health coaching.

To download this complimentary white paper, please visit:

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EDITOR'S PICK: Save 10% on This Week's Medical Home Resource

Guide to Health Risk Assessment & Stratification

In the Guide to Health Risk Assessment and Stratification, 13 industry thought leaders describe the processes of health risk assessment (HRA) and stratification as well as applications and benefits of health assessment in the workplace and various healthcare settings. This 140-page guide also examines the HRA's impact on cost, utilization and patient health status. Its Q&A chapter answers more than 60 questions on health risk assessment.
  • Chapter 1: Overview
  • Chapter 2: From HRA Participation to Payoff
  • Chapter 3: Targeting the High-Risk
  • Chapter 4: Stratifying for Case Management
  • Chapter 5: Matching Risks to Interventions
  • Chapter 6: ROI from Risk Reduction
  • Chapter 7: Care Management Connection
  • Chapter 8: Q&A

Use ordering code MHMP to save 10 percent on this special report by visiting:

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Contact HIN:
Editor: Patricia Donovan,;
Publisher: Melanie Matthews,;

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ReadmissionsRx monthly e-newsletter delivers strategies to reduce hospital readmissions that encompass care planning, case management, care transitions, pre- and post discharge planning, medication reconciliation and much more ó with a special focus on reducing rehospitalizations of Medicare beneficiaries.

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