Monthly Archives: November 2013

Chronic Care Management

Let’s presume the starting point for a particular individual’s engagement with a Chronic Care Management program begins after transition from an inpatient stay back to home. As a part of the care transition process, the individual, optimally, is in possession of their healthcare record and understands their health status upon discharge. Using this baseline, the Chronic Care Management team can begin the long term job of keeping that individual in the community and avoiding acute events.

The core job of the Chronic Care Management team is to provide the extensive and ongoing supports required to help the patient and their caregivers handle obstacles that arise and have the potential to result in an exacerbation of their chronic condition. Success is measured in improved health and quality of life, reduced hospitalizations and ER visit, reduced duplication of diagnostic tests and decreased overall medical expenses.

The caseload management approach utilized by Pyramid Home Health services’ regional care teams, MSW/ LCSW, RN and MTM certified pharmacist coupled with para- professional care givers is a model that lends itself perfectly to the cause of Chronic Care Management. These teams are skilled in disease specific patient education. They actively manage the inflow of information from medication screens, tele-monitoring devices in patient’s homes and family caregivers and react as necessary. Where acute incident seem to be developing they communicate effectively with the patient’s broader medical team, intervene as necessary and stop the advancement of symptoms that can lead to the ER or a hospitalization.

Notwithstanding the capability of our credentialed team members, Chronic Care Management is not solely the responsibility of credentialed clinicians. For example, many chronically ill individuals know what they should be doing to control their disease(s). Many just don’t do it or they need help doing things like checking their insulin, remembering to weigh daily, take medication and make physician appointments. Sending a trained clinician to the home of these individuals daily to help with these sorts of issues is simply not cost effective over the long term. Sending one of Pyramid Home Health Services’ Para-professional care givers, utilizing our automated medication reminder call program, multi-dose medication packaging, pre-scheduling services for physician visits and assistance arranging transportation is. Matching the appropriate support and assistance to the most cost effective deployment thereof is an important part of an effective Chronic Care Management program.

Pyramid Home Health Services provides HCBS, Home Health and Pharmacy services for a large population of Missourians residing in both rural and urban areas. Our Care Management teams effectively serve patients in 110 Missouri counties daily. Should you require assistance implementing a Chronic Care Management Program or require the same for a family member, patient or patient population contact Pyramid Home Health Services at 888-880-6565 or visit us at

Care Transitions and Chronic Care Management

Merging Transitional Care Programs with Chronic Care Management Models at the community level is the key to long term cost control and patient satisfaction where the dual eligible, frail elderly are concerned. These initiatives should be given great consideration where transformation and reform of the healthcare system that meets the needs of these beneficiaries is concerned.

First let’s define these two terms:

A Transitional Care Program is using LCSW, RN and Advanced Practice Nurse, and clinical pharmacist in a team to provide, pre and post hospital discharge, patient education and assistance in the following areas: medication self-management, use of a personal health record, follow-up with Primary Care and Specialty Physicians, warning signs of potential health problems, and advanced care planning.

A Chronic Care Management Model is the ongoing application of population/ condition unique healthcare protocols to improve aggregate health and avoid acute exacerbations of chronic conditions avoiding additional medical cost and generalized worsening of individual(s) health.

In this week’s blog we are going to focus on what an effective Transitional Care program looks like. Next week we will discuss how an effectively deployed Chronic Care Management model keeps the successfully transitioned patient out of the hospital over the long- term and then; in our November 29th post, we will explain how a fully integrated Home and Community Based healthcare provider like Pyramid Home Health Services can be a hospital, managed care plan or state government’s best partner where meeting the need for consistent and broad geographic deployment these services is concerned.

So why do we need Transitional Care programs? The difficulties of moving from one health care setting to another are challenging for anyone and particularly so for a frail elderly individual. It is at this point of transition that the likelihood of emergency department visits and hospital readmission really spikes. Just think about it; you’ve just been discharged from a hospital after having had a multi- day stay and following a procedure; you have new and discontinued medications to deal with, a modified ability to meet your routine and/or new self- care needs and now something just doesn’t feel right. It’s not hard to understand how this scenario so frequently leads to an ambulance ride to the nearest ER and then readmission to the hospital.

So what do the Transitional Care Team members do? How can an LCSW, RN and clinical pharmacist avoid the undesirable outcome described above?

1- They Identify the High-Risk Senior before they are discharged. Team members can make daily telephone rounds discussing with the hospital’s in-patient case managers the health status of patients pending discharge and determine who on the hospital’s census needs to be added to the list of persons the Care Transition Team needs to meet in person and begin to engage.

2- Before discharge the Care Transition Team can meet with the patient, develop a basic rapport and elicit consent for a home visit to occur no later than 72 hours post discharge and preferably within 48 hours. At this time the Care Transition Team coordinates with the physician that will follow the patient upon discharge and ensures all appropriate orders and conveyance of referrals to required ancillary care providers occurs.

3- Provide the patient a “Transition Packet” that contains their medical record, advanced directives or election documents therefore if the patient does not have an advanced directive, list of clinical warning signs and relating to their condition, symptoms to be aware of and actions to take to avoid condition worsening, and a list of the urgent care locations in the vicinity of the patient’s discharge address with contact information and hours of operation should they need seek medical care unexpectedly.

4- Conduct the 1st post-discharge home visit. At that visit the team must, (A) Make sure the patient has a current list of all their prescription and over the counter medications, screen that list for adverse reaction, ensure the patient understands why they are taking each medication, how to take the medications and if there are any barriers to the patient’s medication compliance. When identified, address those barriers. (B) Review and explain the contents of the patient’s medical record. Make sure they understand the importance of sharing the same with their primary care physician, specialists, and post- acute ancillary care providers. (C) Schedule the necessary follow-up visits then and there and confirm or transmit to the following physicians all discharge orders. (D) Review with the patient their condition specific warning signs. (E) Complete a full patient health evaluation and affect a baseline health status post discharge with a copy retained by the patient in their Transition Packet and to be shared with following physicians and other post- acute providers.

5- At least 1 follow-up call with 48- hours of initial home visit and continued contact as necessary.

As documented by the National Transitions in Care Coalition, effective Transitional Care Programs have a huge and positive impact where reducing ER and hospital re-admission risk for the frail elderly is concerned. In some initiatives observed rates of re-hospitalization have decreased by as much as 60% with ER visits decreasing by more than 30%.

Pyramid Home Health Services has 16- Regional Care Management Teams; each of whom is staffed by LCSW/ MSW, RN and Advanced Practice Nurses, and MTM certified Pharmacists. Additionally, our HIPPA compliant Tele-Health Portal can provide the patient’s physicians the ability to participate with, real time, the patient and their Pyramid Team while all are in the patient’s home.

Traditionally, HCBS and Home Health Services more specifically, have been thought of as “Post -Acute” and “Post Discharge” services. Notwithstanding, the same professionals that make up a Pyramid Home Health Care Team can also deliver a very effective Transitional Care Program for Hospitals and Managed Care companies working to improve the success and satisfaction rates of their patients and beneficiaries transitioning from the in-patient to home setting.  Where these organizations are concerned Pyramid Home Health Services represents a more cost effective solution than implementation of their own teams to accomplish the same or their contracting with call center based third parties who have to further contract with additional providers to actually and meaningfully “touch” a patient. Simply stated, Pyramid Home Health Services permits Hospitals and Managed Care entities to avoid the added cost and managerial responsibilities associated with doing it themselves and the unnecessary cost of adding a middle-man to the equation. When coupled with the financial capacity and willingness to contract on an “At Risk” basis, Pyramid Home Health Services represents a great partner for Hospitals, Managed Care Entities and State Government wishing to improve Care Transitions for Missouri’s dual eligible.

If you would like to discuss implementing a Transitional Care Program for your patients or beneficiaries please contact us at or via phone at 888-880-6565.

Case Management of Chronically Ill Elderly Dual Eligibles

With chronic illnesses like diabetes and heart disease being cured isn’t the goal; feeling better on average, not going to the hospital as much, living a longer and higher quality life is the goal. The existence of chronic illness is a somewhat ironic demonstration of modern medicine’s success. Three decades ago, many chronic conditions killed you at much younger ages. Today, many like heart failure can be fought off for years or indefinitely.

Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. According to Mr. Thorpe, “This is the Willie Sutton rule; If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”

This is the basic health profile of full Dual Eligible, a population in the United States of more than 7 million people and in Missouri more than 168,000 of our citizens.  As we’ve discussed in earlier blog posts, dual eligible individuals are using the full benefits available to them under both Medicare and Medicaid. 61% are over 65, 39% are younger than 65 and disabled. Half have dementia or another mental impairment and 55% have three or more chronic conditions. This is the highest cost group of consumers in the American medical system. They are 15% of the Medicaid population and account for 40% of total Medicaid spending. In Missouri we spend in excess of $2 billion annually on this group’s healthcare.

Individuals with chronic conditions, many dual eligible, represent perhaps the best group for home health and community based services (HCBS) generally to demonstrate their biggest benefit to the healthcare system overall.

Many traditional care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. These centers are often housed within insurance companies or subcontracted providers to insurance companies who have capitated contracts with state governments to manage chronically ill Medicaid beneficiaries and, increasingly, the dual eligible population at large.  That model has mostly proven to be a failure where maximizing long term savings to state governments is concerned and, more importantly, where improving the long term quality of life for beneficiaries is concerned. Most savings driven by this model are attained via provider reimbursement cuts and minimization of services which produce early savings that then tend to marginally abate with time.

While many are familiar with the use of home health nurse visits in the days and weeks after a serious hospitalization or nursing home discharge; a much greater benefit to the system can be achieved by sending a nurse to regularly visit chronically ill patients at home. Using home health in this fashion basically redefines the health-care system’s role where the elderly and chronically ill are concerned. It acknowledges that being older and chronically ill is a condition that requires ongoing, professional medical management. In this acknowledgement there is tremendous improvement in quality of life at much lower public expense, especially where the dual eligible beneficiary is concerned.

Many chronically ill patients think of the hospital as a place people go to get better. What providers of Home and Community Based services (HCBS) realize is that, in reality, a hospital is a place where chronically ill seniors get worse. Being in the hospital for multiple days is often the point at which a chronically ill but basically stable senior’s health condition really begins to deteriorate. It’s when the individual ends up in a nursing home and in some cases never makes it back to their own home. It’s also the point at which public health cost absolutely skyrocket. Keeping seniors out of the hospital and out of the nursing home is the core focus of HCBS; they cut cost and save and preserve quality of life; and it saves money, lots of it.

At home is where chronically ill elderly patients spend the time they don’t lose to hospitalizations. It’s where they take their medicine or fail to properly, eat healthy meals or eat poorly, are engaged or become depressed, get around or fall down. This is the key to the power of home health and HCBS; in the home a trained medical professional can see trouble before it becomes too late. As well intended as they may be, clinicians in call centers in O’Fallon and Omaha can’t get the same level of understanding of a situation as can a clinician on-site. It’s just very difficult to build an effective relationship over the phone that makes a lasting difference.

Pyramid Home Health Services has been building these relationships with Missourians suffering from chronic illness since 1972.  We fundamentally believe that where chronically ill dual eligible are concerned, you can’t treat them when they’re sick and ignore them when they’re well. You need to know them well enough and see them frequently enough to catch if they are depressed, if their color is good or bad, if they understand their medications and are managing them appropriately. When you consider that a relatively high acuity dual eligible with multiple chronic illness can be effectively kept out of the hospital and nursing home for approximately $4,000 annually and a very high acuity individual for less than $8000 annually and compare the same to one, three day hospital stay at $5,800, and $125 per day for rehab in a skilled nursing facility afterward, which can often run up to 100 days, the economic benefits of using HCBS to case manage the health of chronically ill elderly become abundantly clear. Further add to that fact that home is where everyone would rather be unconditionally.

If Pyramid Home Health Services can assist you or your organization with case management and/or additional HCBS for a chronically ill loved one or a population for whom you’ve contracted to manage, please contact us at 888-880-6565 or visit us at

The Medical Home Model and Dual Eligible

Last week we discussed the two main types of Financial Alignment Demonstrations sponsored by CMS and for full dual Eligible. These are:

  • The Capitated Model. This is a model that pays private health plans that contract with the state a PMPM rate to provide all Medicare and Medicaid benefits to full dual eligible on behalf of the state.
  • Patient Centered Medical Home Model. This model allows states to design systems to coordinate care for full dual eligible while Medicare and Medicaid continue to pay providers directly for delivered services.

This week let’s take a deeper look at the Patient Centered Medical Home Model in Missouri. Like we discussed last week, Missouri submitted in its proposal on May 31st, 2012 for a Patient Centered Medical Home Financial Alignment Demonstration.

Missouri proposed to build their Patient Centered Medical Home demonstration around their existing Medicaid Health Home initiatives. You may know, the state of Missouri applied for and received approval from CMS for two Health Home programs under Section 2703 of the Affordable Care Act (ACA) in January 2012. We were actually the 1st in the United States to be approved. These health homes currently provide care coordination services state-wide to 11,996 dual eligible Missourians. The first of the two programs, the Community Mental Health Center (CMHC) Health Home program, targets individuals who have serious mental illness in combination with another chronic condition. The second approved program, the Primary Care (PC) Health Home, targets individuals who have multiple and chronic conditions. There are currently 29 Community Mental Health Center based health homes and 24 Primary Care Health Homes mostly located in Missouri’s FQHC.

Missouri’s Financial Alignment Demonstration requests to extend Missouri’s existing Health Home initiative for select, full- dual eligible within the state. So what are the hallmarks of the Patient Centered Medical Home Model?

1. Strategies to target high-need, high cost beneficiaries. Missouri identifies eligible not already enrolled in a health home and who have 2 or more chronic conditions and/ or serious mental health issues through analysis of healthcare claims data and via referral from providers.

2. Care team led by a Care Coordinator who is the patient’s Physician or Advanced Practice Nurse.

3. Coordination of Multidisciplinary care teams that integrate behavioral and physical health. The care coordinator unites the disparate pieces of the health care delivery system and makes them work collaboratively for each beneficiary. Additional physicians (specialist), Nurse Practitioners, Psychiatrists, Behavioral Health Consultants, Nurse Care Managers, Dietitians, Diabetes Educators, Pharmacist, labs and other ancillary care providers work as governed by the beneficiaries personal plan of care as coordinated by their health home care coordinator. The Patient Centered Health Home locates, conducts outreach to and manages the ongoing treatments of all the extended team members. In Missouri these health homes receive a per member, per month payment of approximately $60 for the Primary Care Health Home Program and $80 PMPM for the Community Mental Health Center Health Home.

4. Enhanced access. This is early identification of need for and connection to community services that can avoid higher cost and usually facility based services after an acute event.

5. Provider and Payer Alignment. This is accomplished through PMPM case management fees and in some cases additional provider participation in shared savings.

6. The ability to drive Medicare and Medicaid Savings. In Fiscal year 2012 alone the Missouri State Budget was benefited by $44 million in avoided healthcare expenditures from existing Patient Centered Health Home initiatives.

Home Health and HCBS services can greatly extend the inherent benefits of the Patient Centered Health Home model. By effecting an ongoing relationship with the patient and the their health home based practitioners, a home health partner can ensure the dual eligible patient’s physician has a more granular understanding of the daily challenges a patient faces where adherence to recommended behavior and compliance with physician orders is concerned. HCBS services can assist as well to educate and train the patient’s friends and family in providing the supports necessary to better their adherence to the plan of care.

Additionally, where more complex co-morbidities exist, for example, a diabetic with open wounds, a home care provider with an expertise in advanced wound healing can add exponentially to the effectiveness of the health home team by bringing specific expertise in the form of knowing how to deploy, at home, support surfaces, wound vacuums, advanced debridement techniques and alternative dressings. This reduces the need for inconvenient and more expensive out of home trips for follow-up care and minimizes the potential for infection which often results in avoidable hospitalization and SNF rehabilitation.

Pyramid Home Health Services Wound Healing Program consists of the following:

  • WOCN, a credentialed specialist RN, who reviews each patient’s H&P, initial assessment/ wound etiology, electronic wound photos, and consults on a holistic POC recommendation with the treating physician. They are also available for patient, physician and family in-home and in-office consultations and case conferences.
  • Case Manager that tracks compliance with POC, monitors healing progress, coordinates the communications of treating clinicians, the patient’s physician(s) and Pyramid’s WOCN using electronic medical record updates and digital transmission of wound care photos and treatment notes.
  • Treating Clinicians that are trained in and receive continuing education on advanced wound treatments, dietary and behavioural management techniques and patient education.

If Pyramid Home Health Services can assist you Medical Home Model please contact us at 888-880-6565 or visit us at