Population Health Presentation

Athena Forum Institute®

ACO Workforce Performance21st Century Training for Healthcare Professionals

ACO Workforce Performance 2015 2

The Journey of ACO Performance Begins on Athena Forum.

Dear Director in Population Healthcare,

Our philosophy is that a Care Management Director can achieve goals

at a faster rate with a better educated staff.

Thanks to all the ACO Directors who contributed to this presentation.

Welcome!

TOM RASMUSSEN

Thomas A. Rasmussen

CEO & PublisherSenior Fellow, Jefferson School of Population Health

[email protected]

mailto:[email protected]


Human Capital

“Knowledge workers need knowledge. Knowledge workers are different from factory workers.

Knowledge workers can advance the strategic direction of your business.”

Peter Drucker

The Essential Drucker®

“ACO’s need to power-up their accredited training for front line care coordinators –

that’s a no brainer!” Federal Medicare Executive ACO Division

CMS.gov Baltimore MD October 2013

Baldrige National Quality Program in Healthcare

Baldrige criteria for healthcare companies:

1. Visionary leadership

2. A focus on the future

3. A focus on results to create value

4. Patient-focused excellence

5. Valuing workforce members

6. Managing innovation

7. Societal responsibility

8. Agility

Baldrige recipient Bronson Methodist Hospital – “for workplace excellence.”

Baldrige recipient Baptist Hospital – “for staff empowerment training in building patient relationships.”

Source: National Institute of Standards & Technology, U.S. Dept of Commerce. www.baldrige.nist.gov


http://www.baldrige.nist.gov/

Define Management!

“Management is getting work done through others.”


ACO Care Director

RN Care Coordinators

SW Care Coordinators

Pharmacist Care Coordinators


The Education Multiplier Effect

When ONE care coordinator completes ONE CE course = “advancing one’s practice.”

When the ENTIRE team completes the same course = “improving organizational performance.”

ACO Workforce Performance



Design

Athena Forum Institute® was designed in 2008 by executives from population health

companies including: Aetna, CIGNA, Humana & WellPoint. Before the “ACO” was invented.

Athena Forum has 3 features to improve organizational performance:

1. Management Tool: Directors assign courses to steer the team to ACO priorities.

2. CE Machine for Staff: Staff love Athena Forum for 700 CE accessible from any computer.

3. Clinical Reference Tool: 7,000 page curriculum is searchable (“21st Century PDR”)

Medicare Strategic Measures for the ACO

1. Demonstrate your preventive care program for Medicare seniors in your population,

2. Demonstrate your chronic care management care delivery network,

3. Demonstrate measures toward enhancing the patient experience & community involvement.


Medicare Patient Quality Measures for the ACO

1. Patient / caregiver experiences 7 measures

2. Care coordination / patient safety measures across the spectrum 6 measures

3. Preventive health / patient education measures 8 measures

4. The at-risk Medicare population clinical measures: 11 measures

Diabetes

Hypertension

Ischemic vascular disease

Heart failure

Coronary artery disease


Pricing

Athena Forum Tuitions:

Enroll 1 to 19 care coordinators $125.00 per person, per year

Enroll 20 to 49 $ 95.00

Enroll 50 to 99 $ 75.00

Enroll 100 to 499 $ 65.00

Enroll 500 + $ 35.00

Features:

1. All tuitions are paid by the company,

2. The company can add or delete personnel at any time; we pro-rate tuitions on a monthly schedule,

3. Each tuition is a flat rate with no other charges; all CE certificates are included,

4. Each enrollee has 24/7 access to all 7,000 pages, all 700 CE certs, from any computer,

5. All CCM CE are pre-approved and pre-paid; 160 CCM CE volume equals 200% of the 5 year CCM credential renewal,

6. RN and Social Work CE represents a 100% volume of license renewals in all 50 states,

7. ACO management personnel (up to 5 managers) can be enrolled on a complimentary account.


ROI Discussion

“We forecast a 100 X ROI for one tuition. This ROI is expressed as forecasting ~ $12,500 in reduced hospitalizations in

a year. Assume one care coordinator gains better health coaching skills from the education. Assume that same care

coordinator has a panel of 4,000 seniors. Assume that same care coordinator helps only ONE senior to asthma-proof

her home and avoid one asthma hospitalization in that year. The ROI of avoiding one hospital admit at $12,500 is then

100 X the Athena tuition of $125.00. Scale it to 100 people and you’re saving $1.2M. And this could be conservative.”

Chief Medical Officer

ACO Maine

“We see reduced readmission rates. The only variable is assigning Athena courses to the team and discussing at

monthly staff meetings. We mandate the courses and we hold staff accountable, and the ‘training for impact’ is real.”

Care Director

ACO Mid West

“Our ROI is to train people so we can protect our $200Million contract with Medicare. Our front line people are

assigned courses on Athena to support our compliance with Medicare’s Patient Quality Measures. Plus that we’ve

seen a boost in morale.” Vice President Finance

ACO Western States


Athena Forum Care Management Series® Slide 1 of 2

CM Express [for new hires] Establishing Your Professional Identity

Mod A: Essentials of Case Management Mod A: Essentials

Mod B: Importance of Claims Mod B: Critical Thinking

Mod C: Resource Management Mod C: Emotional Intelligence

Mod D: Transitions of Care / Patient Experience Mod D: Conflict Resolution

Mod E: Leadership

Discharge Planning Mod F: Difficult People

Mod A: Philosophy & Standards

Mod B: Patient Centered Approach to DP Hospital Revenue Cycle

Mod C: External Forces in DP Mod A: Industry Cash Flow

Mod B: Hospital Cash Flow: Claims, RAC, Avoidable Days

Ethics in Case Management

Mod A: Ethical Standards of Practice Patient Advocacy

Mod B: CM Ethics in the Hospital Setting Mod A: Advocacy & Care Management

Mod C: Ethics in the Telecare Era Mod B: Right Care Guidelines for our Patients

Mod D: Ethics in Large Corporate Cultures Mod C: Key Components to Care Success

Mod E: Ethics in the Community Health Setting


Athena Forum Care Management Series® Part 2 of 2

Population Healthcare CM Power [for advanced care coordinators]

Mod A: Prior Authorizations Mod A: Achieving the 6 Attributes of a High Performance Case Manager

Mod B: Concurrent Review Mod B: Improving the Financial Performance of our Hospital thro CM

Mod C: Transitions of Care Mod C: Optimizing Stakeholder Collaboration in the CM Sphere

Mod D: Mastering Our Hospital’s Strategy in Patient Engagement

Principles of Case Management

Mod A: Principles

Mod B: Access Management & UM

Mod C: ED Care Management

UM

Mod A: Standards & Regulations in UM

Mod B: Payers, Contracting & UM

Mod C: Quality of Care & UM


Athena Forum Clinical Care Series® Slide 1 of 3

Asthma CV Risk: Stroke & MI

Mod A: Prevalence & Pathophysiology Mod A: Prevalence & Pathophysiology

Mod B: Assessment Mod B: Stroke & The Care Manager’s Role

Mod C: Treatment Mod C: MI & The Care Manager’s Role

Mod D: Care Manager’s Role in Asthma

Colorectal Cancer Diabetes

Mod A: Prevalence & Pathophysiology Mod A: Therapies

Mod B: Symptoms & Management Mod B: Assessments & Complications

Mod C: Treatments & Interventions Mod C: Pharmacologic in Diabetes Care

Mod D: Standards of Medical Care

COPD EOL & Palliative Care

Mod A: Prevalence & Pathophysiology Modules A-E Symptom Management & CM Role EOL Care

Mod B: Assessments & Complications

Mod C: Pharmacologics in COPD Ebola Care Management

Mod D: Care Manger’s Role Modules A B & C: Assess, Manage & CM Role Ebola Care

Mod E: Pneumonia

COPD rates are rising in women.


GI Disorders Obesity Management

Mod A: Ulcerative Colitis Mod A: Prevalence & Pathophysiology

Mod B: Crohn’s Disease Mod B: Assessments & Complications

Mod C: Diverticulitis Mod C: Treatments & Interventions

Mod D: Care Manager’s Role in Obesity Management

Heart Failure Pain Management

Mod A: Prevalence & Pathophysiology Mod A: Pathophysiology of Pain

Mod B: Assessment & Complications Mod B: Acute Pain

Mod C: Treatments & Interventions HF Care Mod C: Chronic Pain

Mod D: CM Role in HF Care Mod D: Types of Chronic Pain

Mod E: Cancer Pain

Multiple Sclerosis

Mod A: Prevalence & Pathophysiology

Mod B: Symptom Management & Rehab

Mod C: Disease & Relapse Management

Mod D: Care Manager’s Role in MS




Rheumatoid Arthritis Women’s Health

Mod A: Prevalence & Pathophysiology Mod A: The Perimenopausal Years

Mod B: Assessments & Complications Mod B: Complications in Menopause Care

Mod C: Treatments & Interventions Mod C: Sexuality in Maturity

Mod D: Care Manger’s Role Mod D: Care Manager’s Role

Sepsis Care Wound Care

Mod A: Prevalence & Economics Mod A: Prevalence & Pathophysiology

Mod B: Pathophysiology & Assessment Mod B: Assessments & Complications

Mod C: Sources & Predispositions Mod C: Treatments & Interventions

Mod D: Prevention & Treatment Mod D: Prevention Strategies

Mod E: Care Manager’s Role in Sepsis Mod E: Care Manager’s Role in Wound Care


Athena Forum Behavioral Health Series®

Improving Outcomes in Abuse Management

Modules A & B: Domestic Violence

Modules C & D Child Abuse

Mod E: Elder Abuse

Mod F: CM Role in Abuse Management

Improving Outcomes in Depression Care

Mod A: Prevalence & Impact

Mod B: Pathophysiology of Depression

Mod C: Non-pharmacological Treatments

Mod D: Pharmacology in Depression Care

Mod E: CM Role in Depression Care

Harm Risk Behaviors & Suicide Prevention

Mod A: Prevalence & Societal Impact

Mod B: Pathophysiology & Associated Mental Disorders

Mod C: Assessment & Prevention

Mod D: Treatment Management

Mod E: CM Role in Suicide Prevention


Medicare patient quality measure: Diabetes

Athena Forum page (excerpt) supporting ACO care coordinators on Diabetes:

“Diabetes care is provided to achieve desired goals of treatment.

Glycemic goals are presented in Table 4.2. The American Diabetes

Association recommends that the goal of therapy should be an

A1C result of <7% and that physicians should reevaluate and,

in most cases, significantly change the treatment regimen in

persons with A1C test results consistently >8%.

“Again, these specific A1C values apply only to assay methods that

are certified as traceable to the DCCT reference method. Table 4.3

(below) identifies the correlation between A1C levels and mean

plasma glucose levels based on data from DCCT.

[Source: Athena Forum Course Diabetes, Mod A: Therapies, p 33 of 39]


Table 4.2. Goals for Glycemic Control

Normal Goal Action Suggested

A1C 4%-6% < 7% > 8%

Plasma Values

Average preprandial glucose

< 110 mg/dL

90-130 mg/dL

< 90 / > 150 mg/dL

Average bedtime glucose

< 120 mg/dL

110-150 mg/dL

<110 / > 180 mg/dL

Whole Blood Values

Average preprandial glucose

< 100 mg/dL

80-120 mg/dL

< 80 / > 140 mg/dL

Average bedtime glucose

< 110 mg/dL

100-140 mg/dL

<100 / > 160 mg/dL

Medicare patient quality measure: Hypertension

Athena Forum page (excerpt) supporting ACO care coordinators on Hypertension:

Hypertension: Symptoms

Usually, no symptoms are present. Occasionally, the person may experience a mild headache. If the headache is severe, or if any

of the symptoms below are experienced, the person must be seen by a doctor right away. These may be a sign of

dangerously high blood pressure (called malignant hypertension) or a complication from high blood pressure.

tiredness

confusion

vision changes

angina-like chest pain (crushing chest pain)

heart failure

blood in urine

nosebleed

irregular heartbeat

ear noise or buzzing

[Source: Athena Forum Institute® Course: CV Risk, Module B: Stroke & CM Role, page 9 of 34pp]


Medicare patient measure: Ischemic vascular disease

Athena Forum page (excerpt) supporting ACO care coordinators on Ischemic vascular disease.

Ischemic Stroke Diagnostic Procedures

Testing is the same for ischemic strokes as it is for hemorrhagic with the addition of the following:

Cholesterol Level

ECG - electrocardiogram (EKG)

Echocardiogram (looks for cardiac embolus)

Carotid Duplex (ultrasound of the carotids)

Transcranial Doppler (looks at the blood vessels in the brains and the velocity of the blood flow)

[Source: Athena Forum Institute® Course: CV Risk, Module B: Stroke & CM Role, page 21 of 34pp]


Medicare patient measures for: Heart Failure

Athena Forum page (excerpt) supporting ACO care coordinators on Heart Failure.

“Early diagnosis and treatment can help people who have heart failure (HF) live longer, more active lives.

Treatment for HF will depend on the type and the severity of the condition. The goals of treatment for all stages include

treating the underlying cause of the HF such as:

Coronary heart disease (CHD)

Hypertension

Diabetes

Treatment is also utilized to:

Reduce symptoms

Stop the HF from worsening

Increase lifespan

Improve quality of life

Treatments usually include:

Lifestyle changes

Medications

Ongoing care

More advanced HF may also require medical procedures, devices, or surgery. 1

[Source: Athena Forum: Course: Heart Failure, Module C: Treatments & Interventions in HF, Page intro/1 of 41 pp]


http://hcm.athenaforum.com/courses/hf/modc/appendix_2.asp#sdendnote1sym

Medicare patient quality measure: CAD

Athena Forum page (excerpt) supporting ACO care coordinators on Coronary artery disease:

“There are two main ways to express risk - "relative risk" and "absolute risk." Relative risk estimates percent increase or decrease

in a health event occurring in one group compared to another group. Absolute risk estimates the number of health events

among individuals in a group and gives a better sense of personal or individual risk. The risk to an individual can be low, but

in a large population the number of health events can be great. Increased risk, however, does not mean a person will

actually develop the specific disease.

Certain factors make it more likely that a person will develop CAD and have a myocardial infarction (MI) (heart attack).

Risk factors that cannot be modified include: Risk factors than can be modified include:

•Age - Smoking

◦Men: over age 45 - High blood pressure (HTN)

◦Women: over age 55 - High blood cholesterol

•Family history of early heart disease - Overweight and obesity

◦Heart disease diagnosed in father or brother before age 55 - Physically inactive

◦Heart disease diagnosed in mother or sister before age 65 - Diabetes (high blood sugar)

•Personal history of CAD

◦Angina or chest pain

◦A previous MI

◦A surgical procedure (angioplasty, heart bypass) to increase cardiac blood flow [Source: CV Risk, Mod C, page 2 of 51]


Benefits of workforce development

ACO directors report these benefits:

1. Higher core competencies of front line care coordinators

2. Improved morale

3. Improved focus on priorities

4. Better sense of teamwork

5. Leveraged time of leadership and clinical educators


Maximizing workforce development

ACO Directors on Athena Forum recommend:

1. Managers should assign courses to steer the team (popular pacing is 1 module per month),

2. Managers should lead monthly discussions (for staff compliance & align to your protocols),

3. Managers should delegate details of staff completions to: admin, senior staffer or educator).



Sample ACO Implementation Memo

Athena Forum ACO Course Assignments:

JAN: Diabetes: Module E: Medical Standards

FEB: Patient Advocacy: C Right Care Guidelines

MAR: CV Risk: Stroke & CM Role

APR: Heart Failure: Mod B Assessment

MAY: Professional ID: Critical Thinking

JUN: COPD: Mod A: Pathophysiology

JUL: COPD: Mod B: Assess & Manage

AUG: No assignment. At the beach.

SEP: Professional ID: Conflict Resolution

OCT: Heart Failure: Mod C Interventions

NOV: Hospital Revenue Cycle Module C

DEC: No assignment. Happy Holidays.

MEMO TO: All Care Coordinators

FROM: Sue Rittenhouse, RN, CCM, VP Care Management ACO Division

SUBJECT: Staff Development Program for Our Medicare Seniors

As mentioned, I’m pleased to announce that everyone has been enrolled on Athena Forum Institute.com – the

accredited educational service for improving care of our Medicare seniors in our ACO program.

Athena Forum is a new employee benefit at no cost to you, and you can earn CE for your license no problem. We’ll

be assigning course modules (see below) to move us all forward as a team, and this is a mandatory employee

program. You also have full access to hundreds of pages of other courses to support your interests and practice

advancement. Athena is accessible by mobiles such as Nook® Kindle® or iPad® and many people take courses at

wi-fi locations like Starbucks. Welcome to the 21st Century!

Please note: (a) Submit your CE certs to Michelle each month to document your course completions, and (b) Be

prepared to discuss the course topics at selected staff meetings so we all advance together.

Our senior leadership supports this program for achieving high ratings on Medicare Quality Measures.

Accreditations: 100% Volume for RN, SW, ACM, CCM

Athena Forum offers 700 CE contact hours for RN, Social Work, ACM and CCM professionals.

RN: Co-Provider with SutterHealth University by American Nurses Credentialing Center [ANCC]

RN California: Approved Provider with California Board of Nursing

RN Florida: Approved Provider with the Florida Board of Health in Nursing.

Social Work: Approved CE Provider by the NASW, Michigan and California (soon New York).

ACM: Approved Provider by the ACMA (American Case Management Association)

CCM: Approved Provider of CCM CE by the CCMC (Certified Case Managers Commission)



ACO Case Study #1: The Hospital-Based Care Team

ACO Chief Medical Officer explains:

“With Board approval, we closed our Labor & Delivery unit and renovated

it into our outbound call center for 20 care coordinators in 20 cubicles.

We also created management offices, a kitchen and conference rooms.

The last thing our board would approve was new plant construction.

“Each RN Care Coordinator has an EMR computer with a phone/headset.

“Among our 40,000 ACO seniors, each care coordinator gets a panel of

about 2,000 seniors each – with many of them well. Our goal is for each

care coordinator to cycle through their 2,000 panel each month.

“Our care director convenes morning meetings to share ideas on telephonic coaching, scheduling well-care

appointments through our PCP delivery network, and to refer complex cases to hospital case management. We also

hired a part-time consultant (retired from Humana) to do some stand up training on tele-health coaching.

“To keep the team focused on priorities, our care director assigns a monthly course on Athena Forum aligned to

Medicare measures on diabetes, HF, etc. The Humana coach was also on Athena there. Team morale is high.


ACO Case Study #2 The Care Coordination Trio in Network

Vice President, Care Management explains:

“We’re embedding 3 care coordinators at each of our 80 surrounding

medical groups in our delivery network.

“Each trio is an RN Care Coordinator, Social Worker Care Coordinator &

a Pharmacist Care Coordinator.

“Each trio gets a computerized panel of about 3,800 seniors each (our total ACO population is 300,000).

“We find it easier to schedule well-care appointments of seniors -- when our coordinators are on-location. We train

our employees in customer service and they greet our seniors at appointments.

“Our trios are assigned 10 modules a year on Athena Forum, no problem. Our people enjoy learning online and

the Athena courses are comprehensive and accessible 24/7 – very important. The CMO is on board with this; he’s

seen the Athena courses and said “The stand-up trainer model is not scalable; Athena is 24/7 from a Nook LOL.”

“This may not be our final configuration, but we’re all experimenting and this is working well so far.”

ACO Case Study #3: At-home Care Coordinators

Medical Director explains:

“We took a page out of the MCO companies’ playbook and hired 25 at-home RN case managers to reach out to our

40,000 covered lives. Each RN has about 1,600 members. We have a team of complex care managers for

hospitalizations. Here’s a day in the life of a care coordinator:

9am-Noon

50 outbound calls in the morning, leaving smiling voice messages on clinical conditions (asthma, diabetes, HF).

The nurse usually has about 5 live phone conversations in the morning. The RN personality is part of our brand.

Noon-1pm: The nurse has lunch and walks around the block for fresh air LOL.

1pm-5pm

50 outbound calls in the afternoon; with about 5 live conversations.

“It’s important to hire the right personality who enjoys working from home and chatting with seniors. It’s important to

convene the Wednesday team meeting 4pm-5pm without fail. This builds morale and team work. The CM’s share

ideas on tele-health coaching. The monthly course assignment from Athena Forum boosts clinical skills and morale

because it shows leadership cares about front line quality. That course on Critical Thinking Skills is cool.“


ACO Workforce Performance 201531

Sample Workforce Development Plan

Staff Performance Plan for 2015: Advancing Team Performance:

JAN 2015: Ischemic Vascular Disease This course supports the Medicare Patient Quality Measure

Mod B: CV Risk: Stroke & CM Role on improving care on ischemic vascular disease.

FEB 2015: Professional Identity Learn how to control your emotions to make better decisions.

Mod C: Emotional Intelligence

MAR 2015: Diabetes Supporting the Medicare Patient Quality Measure on diabetes.

Mod A: Diabetes Therapies

APR 2015: COPD Enhancing the patient-centered approach in COPD care.

Mod E: CM Role in COPD Care Instructs on motivational interviewing for behavior mod.

MAY 2015: Professional Identity News Flash! Sometimes there are difficult people in our work.

Mod F: Interacting with Difficult People This course instructs on getting the job done with less stress.


What does excellence sound like?

“Thank you for the training this morning, it was exactly what we needed.” CM Director VA

“Our team is ecstatic to have such an amazing tool at their fingertips.” CM Director WY

“Athena has exceeded our expectations. Keep up the good work!” CM Director TX

“The Athena Forum format is very user friendly.” CM Director CA

“Conversations are getting more professional. Social Workers love this.” CM Director IL

“We know it. We trust it. We love it.” CM Director KY

“Starbucks is the new Learning Café for our younger gen case managers.” CM Director WA

“Athena is the tide that lifts all boats.” CM Director LA


Contact us: Sarah Hill National Director, Healthcare

Sales [email protected]

Beverly Gulvin Sales Manager, Healthcare WEST

[email protected]

Kathy Coutouzis Assistant Sales Manager

[email protected]

Kim Billings Sales Manager,

[email protected]

Cindy May Assistant Sales Manager

[email protected]

Healthcare Sales






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