The term care coordination is becoming increasingly prevalent in every aspect of health IT, from HIPAA to patient satisfaction. The Agency for Healthcare Research and Quality defines care coordination as: “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.” Few would argue about the importance of the concepts noted above, and the potential positive impact those can have on both quality of care and patient outcomes.  What the success some early adopters of value-based programs shows us, though, is that improved care coordination can also result in better business outcomes for physicians and practices.  While fee-for-service payment methodologies remain a stronghold, to many providers it may seem counterintuitive to redesign care processes for the smaller percentage of payments driven by quality, or value. By choosing the right care coordination tactics, though, practice improvements can be made that positively impact outcomes regardless of specific payment methodology in question. So how, then, can your practice achieve some of these net-positive outcomes by improving your care coordination?

First, let’s discuss some of the specific aspects of care coordination that positively impact patient reported outcomes.

1. Deliberately organizing patient care activities – Using proven evidence-based clinical protocols, and layering in the necessary administrative steps through which a patient must be managed – registration, appointment scheduling and attendance, and billing and accounting – enables consistency in care delivery and reduction of waste and delay that is often accompanied by unnecessary variability.
2. Sharing information among all participants concerned with a patient’s care – a shared, meaningful and contextual view allows providers to make quick, informed decisions on patient care and communicate all pertinent details to colleagues on the care team, providing an accurate view of patients’ progress in real time.
3. Patients’ needs and preferences are known ahead of time and communicated at the right time to the right people – Patients are assessed early and often on a number of different facets, and their response data is used to uniquely tailor their care experience to their needs and manage their risk at the most appropriate level.
4. Patient information is used to provide safe, appropriate, and effective care to the patient – Actionable data points are collected, secured, and readily available for monitoring care delivery performance, quality and outcomes performance, and more.

Selecting cost-effective, achievable measures to track your progress towards your care coordination goals will save time and money, allowing you to increase efficiency and improve patient-reported outcomes at every step of the care process.

Care Coordination and Return on Investment

As reimbursement models incorporating outcomes measures continue to take hold across all points of care delivery, the demand for dedicated care coordination solutions continues to grow.  Whether you are a self-employed clinician or a hospital CFO, it is likely that one of your goals is to measurably improve patient outcomes, without incurring additional undue costs.  The published return on investment for care coordination varies wildly, from a net-no-return to, in some cases, over 600 percent. Those models that have shown the most efficacy have emphasized patient and caregiver education, standardization of care protocols, multidisciplinary provider collaboration, and a focus on patient management particularly around care transitions and follow-up. Larger investment has not necessarily been shown to result in better return, but rather a more targeted approach towards a narrower patient population.  In Part 2 of this blog series, we will explore this in more detail.

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Is your care coordination solution and patient outcomes management process saving your team time and money? Contact MDnetSolutions to learn how you can optimize the process through MDMessenger, Pathways, and our concierge services including our NurseLine and Medical Call Center. Or call us at 888.986.3638.

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Hayley Kenslea, Director, Product Management Hayley Kenslea ensures that our technology delivers for clinicians, patients, and systems by coordinating the work of our technical teams and client services. Our product knowledge expert and workflow engineer for Pathways and Call Center services, Hayley joined MDnetSolutions with almost 10 years of experience in physician practice management, workflow reengineering, and EMR and BI optimization. Hayley earned a Bachelor of Arts in Psychology & Global Health from Emory University and a Master’s in Healthcare Administration from the Johns Hopkins Bloomberg School of Public Health.

We’re thrilled with the excitement and recognition that MDPathways has received. Our new patient engagement and management platform recently debuted at conferences from California to Chicago to Puerto Rico — creating a buzz at ASMBS ObesityWeek 2015, SHSMD Connections by the American Hospital Association, and the Puerto Rico Hospital Association’s 2015 Convention. MDPathways is pioneering change in patient engagement and challenging the healthcare industry as a whole. To best explain these achievements, and bring you up to speed whether you’ve seen us at a recent show, have participated in a demo, or are even one of our inaugural users, here is a Q&A with those closest to the development of this patient engagement product — Gopi Yeleswarapu and Hayley Kenslea.   First tell us a bit about your role in this project. Gopi Yeleswarapu: As Chief Technology Officer, I’m responsible for planning the new product development; hiring software development teams and setting up the product development process; building the cloud infrastructure on Microsoft Azure; and managing budgets and leading software development towards the successful development and release of this product.   Hayley Kenslea: My role is Director of Product Management, so I work to ensure the end users are happy with the tool. “Happy” means many things – can users understand how to use the tool? Do they know where to find things while logged in? And is the overall look and feel (what we call the User Interface) fresh and inviting?   So exactly what is MDPathways? H: It’s a tool that helps users — from front-line staff, to clinicians and managers — to better manage patients throughout a care process, ultimately allowing them to understand, anticipate, and react to trends in their programs. G: From a technical perspective, it is cloud based software as a service (SaaS) platform that integrates with EMRs, PMSs, CRMs and other automation systems in addition to facilitating two-way communications via email, phone calls and text messages to deliver the best possible patient outcomes. What was the push for creating MDPathways? G: MDPathways is a brand new upgrade and complete refresh of our proprietary Patient Engagement and Management system, LeadTracker. In this new Avataar, LeadTracker has been transformed from a web based application to a cloud based SaaS platform designed to streamline workflow throughout a practice’s care continuum; help eliminate the risk of data inaccuracies; and engage patients one on one to help providers deliver the best possible outcomes. What are the top 3 successes of this product? H: The updated look and feel; the improved reports (no more downloading Charts & Reports on your local desktop); and the speed and more intuitive layout — I could talk about how great MDPathways is for days! Oh, and its integration abilities mean we can feed data directly into or out of MDPathways, which decreases the risk of duplicate data entry and error on behalf of our users. G: First I’d like to answer this with a quote from Eugene Pototsky, Lead Engineer and Architect who has been instrumental in the design and development of MDPathways SaaS platform development: “The biggest success is the chance to be pioneers of a complex solution within the healthcare industry. This multilateral product required us to develop for all aspects of the care continuum — we needed to create a simple and straight forward user interface (UI) for patients; a functional-rich UI for hospital users; and both of those required the support of a complex, customizable backend platform.” It is truly remarkable. From my perspective, the biggest successes have been: 

1. Building a ubiquitous software platform that is ready for the new healthcare challenges.
2. A clean user interface that will help our clients manage their patients efficiently and always know what a particular patient’s needs are. That in turn has a potential to help those patients achieve their goals for a healthy life.
3. Setting up a repeatable process to continue improving the product to provide powerful new features. 

What has been the biggest challenge with the MDPathways development? G: Aside from vetting the proper technology to build the product, and recruiting a team able to plan, design and develop, one of the biggest challenges was delivering the product on-time. This, by far, was the most arduous task because we had to maintain a fine balance between prioritizing product features that would enhance usability with making sure we could deliver the full product within the originally planned timeline. H: We have many different profiles of user — call center, nurses, doctors, non-clinical staff — so feeling like we accurately addressed each of those users’ priorities was tough to balance. How are the trial users responding to the new product? G: It’s still early but we are already receiving positive feedback from our newly on-boarded clients as well as prospective clients that have seen our product demos. Our sales and on-boarding teams are doing an awesome job with their product evangelism! H: Users — call center, nurses, doctors, staff, everyone — love the look and feel, and easy flow of information throughout the tool. Looking ahead, what new developments and improvements do you expect for MDPathways? H: Users always want to see graphical representations of data trends so we’ve already added a lot of updates for the Reports function into the development pipeline. We also have a lot of new features around automating updates in MDPathways from an integrated EMR or PMS to continually improve and streamline workflows. G: This next big upgrade to our patient engagement and management platform actually launches in a few days — we’re integrating a pre-configured patient intake form portal that will allow patients to report about their health. This will help maintain accurate patient data for our clients. We’re also meeting this week to prioritize several new features like integration with EMRs, appointment schedulers, advanced automation and other features that can help clients, as well our own teams, efficiently manage and engage with patients. Thanks to you both for taking the time to chat with us, and a huge congratulations to you and the rest of your teams on such a radical development in the healthcare industry!

When a patient is discharged from a hospital, the discharge planning nurse should probably end the conversation with the patient by saying, “Best wishes and we will see you in a couple of weeks.” One in five elderly patients makes a return trip to the hospital less than a month after initial discharge. Called the revolving door syndrome in a report conducted by the Robert Wood Johnson Foundation, titled Care About Your Care, the frequent return trips to the hospital come with a $26 billion price tag annually for Medicare patients. The report goes on to say 65 percent of the total cost could be prevented if hospitals tweaked their system of care. Too often patients do not comprehend the doctor’s instructions prior to leaving the hospital. The end result is poor medication adherence and failure to get the proper follow-up care. A key to cutting down the number of readmissions is to identify patients most at risk of returning to the hospital. It is impossible to have a readmission program targeting every patient. Too much energy is wasted and the program is rendered ineffective. Considering 80 percent of all readmissions come from 20 percent or less of the same patients, it is paramount hospitals identify those patients and implement programs to prevent readmissions. An effective way of identifying high-risk readmissions is a health risk assessment (HRA) and continued communication with the patient to bolster patient engagement. MDnetSolutions has developed a digital HRA form that is easy to use and can be accessed online. HRAs can determine the current status of a patient’s health, estimate the level of health risk involved with a procedure, and more importantly, inform and provide feedback to patients via online reports. The patient, or his or her caregiver, can access these online reports and continue the personalized care that hopefully will prevent the patient from returning to the hospital.

Identifying the Need for Intervention

In addition to MDnetSolutions’ HRA program, the Atlanta-based company also has increased its ability to help hospitals transform patient care and remain actively engaged with the patient following discharge by acquiring IVR Care transition Systems, which excels in providing support for patients making the transition from the hospital to home. Using an interactive voice response telephone system and carefully developing surveys, or HRAs, members of the IVR care team, which is available to hospitals, gather vital information from the patients’ responses to the assessment. These responses can identify early signs and symptoms of clinical problems or issues with medication adherence and the need for follow-up care after hospital discharge. The results of the HRAs are sent to the healthcare team at the hospital on a daily basis, and if warranted, the healthcare professional will follow up with the patient with a phone call. This provides an opportunity to identify a problem before it turns into a serious condition, requiring a return trip to the hospital and costing both the patient and the facility money. In the long run, using the patient engagement solutions created by MDnetSolutions is a win for patients, who receive quality, personalized healthcare and for the hospitals that save on patient readmissions.

Improved communication leads to higher patient satisfaction, and for healthcare providers who want to involve patients in their own care and form closer ties with consumers, now might be the best time in years to implement a patient portal solution. The Pew Research Center’s Internet & American Life Project reports 69 percent of U.S. adults track a health indicator for themselves or a loved one. The California HealthCare Foundation also reports, “Patients pay more attention and become more engaged in their health and medical care when they have easy access to their health information online.” Although there is clear data supporting the need for providers to offer effective and user-engaging patient portals, many systems launched to date have fallen short of meeting patients’ needs. At Guideway Care, we have worked with practices of every size to install an online patient portal enabling both the patient and the doctor to know, see and find vital patient information in one convenient location. Our solution, which is HIPAA-compliant, is housed on your practice’s existing website or we can build you an entirely new website, including the patient portal. The portal is a convenient two-way street of communication between patient and provider. Both sides can view, store and record information, get lab results, schedule doctor appointments, refill medication, view a billing statement and easily communicate with one another in a private secure web-based system. A patient portal is an engaging way to encourage patients to regularly access their information. It could be a routine like updating your Facebook status, “tweeting” on twitter or creating a “pin” on Pintrest. These sites have one thing in common—users interact with the sites many times a day, returning multiple times to access new content. This type of engagement should be the ultimate goal for patient portals. The portal is helping to alleviate follow-up phone calls to physician offices, allowing the practice’s staff to focus on taking care of patients who are in the office. Overall, the most significant benefit of the portal is the opportunity to offer an accessible, effective engagement tool to patients and your community. Our patient portal is much more than just an online tool; it supports a strategy focused on enhancing patient engagement within our community and with our providers. The patient portal also can be an efficient and effective method of communicating with patients outside of the office. However, the most pronounced portal benefit is the improvement in healthcare quality it encourages, stemming from patients’ active engagement in their own health and healthcare. Don’t delay, contact a sales rep at Guideway Care today and let’s begin the engagement. Donna Roach, CIO of Borgess Health/Ascension Health Information Services in Kalamazoo, Mich., helped contribute to this blog.

As a kid I remember spending hours planning imaginary road trips using the Rand McNally Atlas. I was an only child and had to entertain myself somehow. Living in North Carolina, I would plan trips to Laramie, Wyo., Pierre, S.D., excursions into Mexico and to exotic locales such as Moose Jaw, Saskatchewan. I meticulously carved out the route from my home to my selected destination, much like we do today by typing in our starting and ending point in a GPS or some other navigational system.  The old paper atlas of my youth has gone digital, much like our medical records. However, unlike simply pushing a couple of keys on the screen embedded in the dashboard of your car, the transition from paper to digital when it comes to electronic medical records (EMR) has been anything but smooth. The government-led transformation of healthcare information has become a taxing process for the healthcare industry. According to the U.S. Department of Health and Human Services, office-based physicians using an EMR increased from 48 percent in 2009 to 78 percent last year. However, some medical practices are still using the old paper format. One of the major solutions to increasing patient engagement is an EMR system. Doctors are aware of this and most are eager to go digital. The goal of an EMR system is to make the process of patient recordkeeping easier, more accurate, more comprehensive and more efficient. It helps enhance patient care and improve patient outcomes. However, many doctors are not happy with their current system. In an article appearing on www.politico.com, American Medical Association President Steven Stack called electronic health records systems as “infuriating and cumbersome.” Healthcare professionals agree with Stack’s opinion. “We’re basically key-punch operators, transcriptionists having to input the data ourselves,” said James Gilbaugh, a physician in Wichita. “It has essentially tripled the time to complete a medical record. How do you accomplish that when we are already working 12 to 14 hours a day?” Gilgaugh’s contemporaries echo the Kansas doctor’s sentiments about EMR systems. In this year’s national survey by the MPI Group and Medical Economics, 70 percent of physicians described their EMR investment as not worth the effort, resources and cost. The main complaint (67 percent) was the functionality of the system, followed by cost (48 percent) and poor customer service from the EMR vendor (33 percent). Instead of making the doctor’s office run more efficiently, the EMR system is becoming problematic. In terms of quality of care made possible by EMR use, 45 percent of physicians reported their EMR system made patient care worse. A staggering 69 percent said their current system posed an even greater threat to care coordination. At MDnetSolutions, we are the experts in developing solutions to increase patient engagement, streamline patient management processes and improve outcomes management. Our EMR solution can bolster your ability to better manage your patients. Many EMR programs require you to conform to their system, but our web-based system is easy to use and configures seamlessly with any existing records system. We are able to replicate the way your practice manages patient encounters. From initial contact with your practice to post-operative procedures and continuing education, MDnetSolutions’ EMR system accurately records patient information to help reduce errors and aid in your patients receiving optimum care. Our EMR system eases patient intake, insurance verification, scheduling consultations, surgeries and follow-up visits. Combine our EMR system with our other patient management solutions, like the LeadTracker ™, our boutique medical call center and our HIPAA-compliant NurseLine, staffed around the clock by registered nurses, and your practice will be running more efficiently and effectively in no time. Our EMR solution helps eliminate the need for paper and puts an end to costly transaction fees. Your practice also saves on having to hire additional office staff. By partnering with MDnetSolutions, you spend more time taking care of your patients and less time being an administrator to your practice. Don’t delay, visit www.MDnetSolutions.com today or call 888.986.3638 and schedule a demo. Together we can transform healthcare.

Is your practice answering the phones in a timely and compassionate manner? Does lack of proper phone management interfere with your patients getting the proper care they deserve? Every call missed hurts not only your revenue, but more importantly your reputation. Don’t gamble when it comes to patient engagement. Let MDnetSolutions full-service, boutique orthopedic call center solve these problems for you. As a seamless extension to your practice, our orthopedic call center provides the timely and compassionate assistance your patients need. We handle scheduling appointments right into your current scheduling book and we perform appointment reminders and rescheduling. Because our trained staff is here to serve, your patients speak to a live enthusiastic voice, eliminating the need to leave a message after hours or during high-volume call times. Not only do we provide your patients with top-notch scheduling services, MDnetSolutions also offers you a 24/7 NurseLine, providing access to a nurse triage servic, providing access to a nurse triage service staffed by professional RNs. Your patients are engaged around the clock, as our professionally-trained, HIPAA-compliant staff handles each call with dedication and compassion. 24/7, full-service, boutique orthopedic call center NurseLine When your practice teams with MDnetSolutions, your patients are always connected to you. Reach out and connect with us today. Be sure to visit our booth #27 at OrthoSummit 2014 and schedule a demo. Together we can transform patient care.

It has been a little more than two years since the United States Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). Since that historic decision, hospitals have felt the pinch thanks to performance-based penalties levied by the federal government. Regulations are stricter, penalties continue to increase and hospital administrators are facing shrinking bottom lines. Medical professionals are taxed and the general public is living an unhealthy lifestyle. Obesity is becoming an epidemic, creating more patients in an all ready crowded space. The solution is not admitting patients to the hospital, fixing them and sending them back into the world. The key is patient engagement and education. Guideway Care is transforming the patient experience. When hospitals team with us, they are in constant contact with the patient. Hospitals are engaged with the patient and manage the patient throughout the hospital stay and remain in contact after the patient goes home. Patients get the care they deserve, and hospitals avoid costly penalties created by the healthcare law. When PPACA came into existence, the Centers for Medicare & Medicaid Services (CMS) set guidelines regarding excessive readmissions of Medicare patients within 30 days of being discharged from the hospital. It was called the Hospital Readmissions Reduction program and reduced Medicare payments for excess readmissions beginning Oct. 1, 2012. According to a report from Kaiser Health News, in the first year of the mandate, 2,211 hospitals lost payments because of excess readmissions in 2013. Kaiser reported a total of $280 million was lost due to CMS penalties. Specifically the report found 278 hospitals lost 1 percent of their base Medicare payments, then the maximum allowed by the healthcare law. Nearly two thousand hospitals lost a percentage of 1 percent of their base Medicare payments in the first year of the law. Last year, nearly 18 percent of Medicare patients, who had been hospitalized, were readmitted within a month. Roughly 2 million patients return a year, costing Medicare $26 billion. Officials estimate $17 billion of the cost comes from potentially avoidable readmissions. Federal records released on Oct. 8 showed Medicare is fining a record number of hospitals – 2,610 – for having too many patients return within a month for additional treatments. Even though the nation’s readmission rate is dropping, Medicare’s average fines will be higher, with 39 hospitals receiving the largest penalty allowed, including the nation’s oldest hospital, Pennsylvania Hospital in Philadelphia. Under the new fines, three-quarters of hospitals subject to the Hospital Readmissions Reduction Program are being penalized. From Oct. 1 through next Sept. 30, they will receive lower payments for every Medicare patient stay — not just for those patients who are readmitted. Over the course of the year, the fines will total about $428 million, Medicare estimates. The healthcare law was designed to improve healthcare in America and increase access to get affordable healthcare for patients. The levied penalties were designed to curb rising medical costs and encourage hospitals to improve performance and manage expenses more efficiently by preventing patient readmissions. Clearly the fines aren’t working. However, what does work is patient education and maintaining a relationship with the patient from initial contact and patient intake to post-procedure care, hospital discharge, follow-up visits and other outreach efforts. When a patient was discharged, hospitals offered paper instructions and reminded the patient to follow up with his or her doctor in a couple of weeks. It is no wonder readmissions are costing hospitals millions. Teaming with Guideway Care, hospitals offer more than a piece of paper and well wishes. Patients gain access to ongoing patient education, health and wellness coaches, preventive reminders and care coordinators who remind the patient of follow-up doctor visits. Hospitals are learning the hard way – financial penalties – care doesn’t end when the patient leaves the hospital. More active efforts are required and Guideway Care can meet those requirements. With our help, patients avoid readmission and the hospitals avoid financial penalties. It’s a win-win situation. Don’t delay, call or schedule a demo today.

Although the calendar says there’s three more weeks of summer remaining, the unofficial end of the season is looming for most, as Monday is Labor Day. Like several people, you are probably hitting the road this holiday weekend, trying to cram in that last family vacation before the kids go back to school. Perhaps it is heading to the beach or lake or perhaps checking out a baseball game or a road trip to catch your alma mater kick off the college football season. While you are away from the office, your patients’ problems are not taking a vacation. Mrs. Smith is concerned about an upcoming procedure; Mr. Jones has questions about a new medication, and Mrs. Jones can’t make her scheduled appointment for the following Tuesday and needs to reschedule. Another patient will take her last prescribed pill at 6:30 p.m., on Friday and realize she doesn’t have anymore refills. What are they supposed to do? Try calling your practice and leaving a message, hoping one of your employees may happen to swing by the office on his or her free time? Try calling you directly while you are enjoying a little R&R with the family and away from the rigors of your practice? By implementing MDnetSolutions patient management solutions, your patients stay connected to your practice. Whether you are hiking in the Rockies or fishing in the Florida Keys, your patients can reach your practice. When you put MDnetSolutions full-service, boutique medical call center to work for your practice, we become an extension of your staff. Just like your receptionists, our staff exercises sympathy and compassion when speaking with your valued patients. When a panicked mother, concerned about her child, reaches out to your practice, the last thing she wants to hear is a recording telling her to leave a message. With our patient management solution, that same mother talks with a real, live person on the other end of the line. Our staff offers sound medical advice and acts as a calming influence. With MDnetSolutions medical call center and our 24/7 NurseLine, staffed by registered nurses, your patients are able to connect and be engaged with your practice around the clock. So while you are working on your tan, perfecting your short game or cheering your favorite team to victory this weekend, be rest assured your patients are getting optimum medical advice and are able to get prescription refills and reschedule Tuesday’s appointment. If your practice has partnered with MDnetSolutions, kick back and enjoy the long weekend, knowing your patients are in good hands. If you haven’t made the call to us yet, imagine how many phone calls and potential new patients your practice is missing while your doors are closed. When teaming with MDnetSolutions, your practice becomes more patient-friendly because we never take a day off and are fully engaged with your patients. Check us out at www.mdnetsolutions.com and schedule a demo today.

Is your practice answering the phones in a timely and compassionate manner? Does lack of proper phone management interfere with your patients getting the proper care they deserve? Let Guideway Care full-service medical call center solve these problems for you.

As a seamless extension to your practice, our healthcare call center provides the timely and compassionate assistance your patients need.

We handle scheduling appointments right in to your current scheduling book and we perform appointment reminders and rescheduling. Because of our trained staff, your patients speak to a live enthusiastic voice, eliminating the need to leave a message after hours or during high-volume call times.

Not only do we provide your patients with top-notch scheduling services, Guideway Care also offers NurseLine services which provides access to arguably the finest nurse triage service available with professional RNs. Your patients are engaged around the clock, as our professionally-trained, HIPAA-compliant medical experts handle each call with dedication and compassion, regarding their treatment.  

Missed calls and long wait times can cost your practice thousands of dollars in revenue and hurts your reputation, your referrals and your patient satisfaction. All of these pressures can be eliminated with one call to Guideway Care.

When your practice teams with Guideway Care, your patients are always connected to you. Reach out and connect with us today. Contact Us Today!