OIG Series 5: Coordinating Skilled Nursing and Home Healthcare

The innovation of receiving care in the home allows otherwise unable patients to receive the medical attention they need. In the recent Office of Inspector General (OIG) study, the fifth strategy that 20 high-performing ACOs used to achieve their outstanding clinical and financial results is to work closely with skilled nursing facilities (SNFs) and home health agencies (HHAs). Their practices have raised the quality of care in SNFs and HHAs, too, with simple organizational practices. The Challenges of SNFs and HHAs Joanne M. Chiedi, the Acting Inspector General of the Department of Health and Human Services, defined three primary challenges when …

Gaining Patient Buy-in for Chronic Care Management

Medicare patients who have two or more chronic conditions account for 93% of total Medicare spending. These patients are found to have higher rates of hospitalizations, pharmacy utilization, and specialist utilization, which increases costs for all stakeholders. Basics of CCMChronic care management (CCM) is a separately billed, non-face-to-face CMS covered service that is designed to be delivered through the primary care setting. To participate in the Medicare program, the patient must have two or more chronic conditions (conditions lasting more than 12 months or until the death of the patient). Physicians are given financial incentives from CMS to talk with …

Why ADT feeds matter and how providers can use them to deliver better care

Lightbeam’s population health management (PHM) platform includes HL7 ADT messages and feeds that transmit critical patient demographic information. The specific information helps providers stay on top of daily hospital utilizations and see which patients were admitted or discharged from a facility within 24 hours of an event. ADT Feeds Help Care Managers  Why is this information important? First, it enables providers to know who, out of their patient rosters, has been in hospital care over the past day, week, and even month to ensure that they receive the proper post-discharge care. By using these ADT feeds, care management teams can …