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Success Stories

Improving Ohio's Health: Electronically Connecting the Community

16-Sep-2016

Electronically Connecting the Community: Making Care Plans Easier

by Dottie Howe, MA, MEd, Director of Communications

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It explores the exchange of patient health information through electronic referrals in a “medical neighborhood” made up of healthcare providers and social service entities in the Central Ohio region.

Four days a month, the indigent, immigrants, refugees, the uninsured and underinsured can access diabetes and hypertension screenings as well as other health and social services at a free clinic on Morse Road in Columbus, Ohio. Physicians traditionally have had a difficult time managing chronic conditions such as diabetes and hypertension in this patient population.

About 1,200 patients visit the Helping Hands Health and Wellness Center annually, which uses its electronic health record (EHR) system and additional functionality provided by the CliniSync Health Information Exchange (HIE) to overcome some of the related challenges to managing indigent and uninsured patients, especially those with chronic conditions. This electronic network connects hospitals, physicians and other providers across Ohio and is managed by the nonprofit Ohio Health Information Partnership.

The clinic now has the technological capability to electronically refer patients to other partners in the Central Ohio community, referred to as a “medical neighborhood.” This concept stems from the patient-centered medical home (PCMH) movement where the primary care practice is the hub of a coordinated care team involving other healthcare providers. While the medical neighborhood first sought to connect primary care with specialists, the community has expanded beyond ambulatory care.

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Improving Ohio's Health: Electronically Connecting the Community
Improving Ohio's Health: New Chronic Care Management Coding

16-Sep-2016

New Chronic Care Management Coding: Proposed CMS Coding Changes for 2017

by Cathy Costello, JD, CPHIMS, Director of CliniSyncPLUS Services

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It addresses changes in coding for Chronic Care Management and Transitional Care Management that CMS is proposing for the 2017 reporting year.

Let me guess: your practice looked at starting a Chronic Care Management (CCM) program. You thought it sounded like it might help with your diabetic patients and those with heart disease and COPD. You even went so far as to review all the technical requirements for starting one. But after you dug in, everyone in the office just rolled their eyes and said “Good idea; hard to execute.” Does that sum up your practice’s approach to CCM?
 
Well, look again. CMS heard about you and everyone else who hesitated to jump in to set up this brand new program and went back to the drawing board to develop a more user-friendly program.

We all know CMS is a big proponent of patient-centered care models. The cost of health care in the United States has climbed to $1 trillion. In 2014, almost 30 percent of that cost was attributed to hospital care.1 Approximately 15 percent of all hospital patients ended up being readmitted during 2014 according to CMS; so any program that can find new and creative ways to keep these hospital admission and readmission rates down receives a lot of attention by CMS.
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Improving Ohio's Health: New Chronic Care Management Coding
Improving Ohio's Health: Technology to Support Your Patients With Chronic Conditions

16-Sep-2016

Technology to Support Your Patients With Chronic Conditions - It Doesn't Have To Be Painful!

by Scott Mash, MSLIT, CPHIMS, FHIMSS
Director of Consulting Operations & HIE Outreach

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It explores the functionality of EHRs and other technology to meet the requirements of the Chronic Care and Transitional Care Management Programs and how best to manage patients enrolled in these programs, especially those patients with hypertension and diabetes.

In the recent past we have produced several webinars and articles outlining the Chronic Care Management (CCM) and Transitional Care Management (TCM) programs. This article will focus on the practical application of functionality in your electronic health record (EHR) to meet the requirements of CCM/TCM and to manage your patients enrolled in these programs. Many EHR vendors have not had sufficient time to provide needed functions or accommodate the most recent regulation modifying CCM that provided increased flexibility. This article addresses the program requirements of EHRs in general, although a few vendors are mentioned by name that provide specific functions.

Adoption of a CCM/TCM program in your organization is critical for improving the health of patients with two or more chronic conditions, such as hypertension and diabetes, while also providing the necessary funding to meet these goals. Studies show that approximately 68 percent of Medicare beneficiaries have two or more chronic conditions while 36 percent have four or more conditions. Ensuring that these patients receive the needed care and coaching to improve wellness necessitates services outside of regular face-to-face visits which, in turn, necessitates additional funding to provide these services. Thankfully, the CCM/TCM regulation makes additional funds available, and recent modifications to the CCM program makes documentation and technical requirements easier to meet. Also, developing strong CCM/TCM programs will build key core competencies for MACRA, CPC+ and other value-based payment programs.
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Improving Ohio's Health: Technology to Support Your Patients With Chronic Conditions
Improving Ohio's Health: Update on Ohio's Data

16-Sep-2016

Update on Ohio's Data for Managing Patients With Hypertension and Diabetes

by Cathy Costello, JD, CPHIMS, Director of CliniSyncPLUS Services

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It explores the most recent data collected on inpatient hospital discharges by county and by condition. It also reviews data collected to date on ambulatory quality reports on diabetes and hypertension.

 

It seems like everyone in health care is swimming in data. Anyone who works in the health care area knows that since the introduction of EHR systems, getting data is not the issue. The issue is being able to analyze and interpret the data to determine what may be meaningful for your day-to-day work with patients to improve care.

As a recipient of two grants from the Centers for Disease Control and Prevention (CDC), the Ohio Department of Health is working to improve the prevention and management of chronic diseases. Part of this is using hypertension and diabetes data to inform program initiatives and help guide hospitals and practices in setting priorities for workflow change. This grant provides the opportunity to look at this data over a period of several years. It supports population-wide approaches to the prevention of obesity, diabetes, heart disease and stroke in Ohio, starting with the collection of baseline data. Each year of the grant, the Ohio Department of Health (ODH) is collecting hypertension and diabetes data from health systems around the state.

Ohio started collecting both hospital discharge and ambulatory data in 2014. Over time, the data will be used to identify trends and support efforts to improve patient care.

 

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Improving Ohio's Health: Update on Ohio's Data

 

Improving Ohio's Health: Technology Tactics to Make Patient Engagement Easier

18-Aug-2016

Technology Tactics to Make Patient Engagement Easier

by Scott Mash, MSLIT, CPHIMS, FHIMSS
Director of Consulting Operations & HIE Outreach

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It explores the importance and use of technology for patient engagement as an essential key towards improving outcomes of patients with these conditions.

It used to be that patients would show up at the doctor’s office, do what the doctor said, never look at their own medical records, and rarely question decisions made about their health. But numerous studies today show that patients who are actively involved in their health care have better outcomes and experience lower costs. Lecturing patients about potential future health issues or worsening conditions does not provoke or inspire patients to become engaged. Instead, care teams should make information relatable and personal to engage patients to become partners in their own care. You probably already have taken steps in this direction in your own practice, so let’s look at what you can do to focus on engaging your patients and improving their care.

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Improving Ohio's Health: Technology Tactics to Make Patient Engagement Easier

 

Smooth Transitions of Care Through CliniSync

15-Aug-2016

by Dottie Howe, M.Ed., M.A.

Doctors and nurses caring for patients who leave the hospital and transfer to a nursing home, assisted living facility, or some other care setting can now have immediate, electronic access to that patient’s discharge information. That translates into better and more efficient care for patients.

About 400 long-term care, rehabilitation and home health facilities in Ohio have signed up to join the CliniSync statewide health information exchange (HIE). That’s on top of the 148 hospitals and thousands of physicians already contracted or live.

Read how these facilities are now part of the electronic exchange of patient health information.

 

 

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Smooth Transitions of Care Through CliniSync

 

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