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Patient Engagement Green Management Consulting Group Susan A. Chen, RN MSN Susan Green.

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1 Patient Engagement Green Management Consulting Group Susan A. Chen, RN MSN Susan Green

2 What is Patient Engagement?  PCMH: plans demonstrate implementation of patient and family-centered care based on the needs and preferences of their patients, family and caregivers; ensure cultural and linguistic competency; and collect and act upon patient complaint and satisfaction data to continually improve care  Healthcare IT/ Stage 2 Meaningful Use: Patient engagement is driven by technology ranging from patient portals, to electronic data capturing platforms that result in more accurate and streamlined diagnostic information.  Generic: Patient engagement is the cooperation among health care practitioners, health care administrators and patients to improve and maintain patients’ health. This includes helping patients understand and manage chronic conditions and prepare for expected health events, such as childbirth. (NCQA) Green Management Consulting Group, Inc. 2

3 What’s needed to have Patient Engagement ?  Clinicians can’t assume they know what’s best for the patient  Need data to direct change– patient surveys, patient focus groups  Use Proven Strategies: motivational interviewing and shared decision making, practice structural changes including team-based care and intensive chronic disease management, Electronic Health Record and Tools. Green Management Consulting Group, Inc. 3

4 Patients, Providers & Technology Medscape survey Sept  96% of Patients & Providers think patients should be able to read their electronic medical records  89% of patients and 64% of providers think that patients should have the right to see all of the MDs notes  Most patients (54%) think the medical records belong to them, only 38% of physicians agree  Most providers (77%) think they should review lab results before they are given to the patient, but 34% of patients think they should have immediate access to lab results  About 40% of patients and providers have security concerns about EHR Unique survey because it asked the same questions of providers and patients 1400 providers, 1100 patients Green Management Consulting Group, Inc. 4

5 Strategies to improve patient experience & outcomes, and reduce costs Dominick Frosch, Ph.D.  Tailor communication approaches to support the patients needs.  e.g. translate medical information into lay language for the patient or implement a patient navigator program.  Train providers and staff to partner effectively with patients and families.  e.g. engaging patients and alerting them to community resources.  Review and design care and system processes, policies and structures to provide opportunities for partnerships between patients, families and the healthcare team.  e.g. Develop individual care plans reflecting the patient's goals, and provide coaching to help patients meet those goals.  Create new partnerships within the organization so patients and families become part of the governance structure.  Create clear lines of reporting for direct contact between patient advisers and leadership, and dedicate staff to oversee work with patient and family advisers Green Management Consulting Group, Inc. 5

6 Strategies to improve patient experience & outcomes, and reduce costs Dominick Frosch, Ph.D.  Develop measures and conduct research to improve care, facilitate changes in processes and assess the relationships between outcomes, patient experiences and engagement.  e.g., use video to capture interactions and observations.  Make data and information transparent to promote organizational accountability for quality, safety and enabling patients and families to be active in their care.  e.g. Use portals so patients can access their electronic health records anywhere, along with interactive tools that allow them to make corrections. Make sure they can include information that's important to them, such as goals of care.  making-with-dominick-frosch/ Green Management Consulting Group, Inc. 6

7 PCMH & Meaningful Use Elements of Patient Engagement Green Management Consulting Group, Inc. 7

8 Meaningful Use Requirement Stage 2: Eligible Professional Meaningful Use Core Measures Measure 17 of 17 Date issued: October, 2012 Use Secure Electronic Messaging Objective  Use secure electronic messaging to communicate with patients on relevant health information. Measure  A secure message was sent using the electronic messaging function of CEHRT by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. Exclusion  Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. Green Management Consulting Group, Inc. 8

9 Meaningful Use Requirement Definition of Terms  Secure Message – Any electronic communication between a provider and patient that ensures only those parties can access the communication. This electronic message could be or the electronic messaging function of a PHR, an online patient portal, or any other electronic means. Attestation Requirements  DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period.  NUMERATOR: The number of patients or patient-authorized representatives in the denominator who send a secure electronic message to the EP that is received using the electronic messaging function of CEHRT during the EHR reporting period.  THRESHOLD: The resulting percentage must be more than 5 percent in order for an EP to meet this measure.  EXCLUSION: Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. Green Management Consulting Group, Inc. 9

10 Stage 2 (MU2) Encouraging Data brief from the Office of the National Coordinator for Health IT  46% of patients who were offered access to their health records online viewed their records at least once--a level nine times higher than the required MU2 threshold.  54 % did not view their online information because the majority saw no need to. Others cited concerns such as privacy or security of the online medical record website and not having Internet access.  The survey of 2,100 people, conducted in 2013, however, found that only about 3 in 10 were offered access to an online medical record.  Almost 7 in 10 respondents considered having secure access to an online medical record as very or somewhat important, including 62% of those who did not access their records.  A majority of those who did view their records at least once said they found the access very helpful.  Three-quarters of those surveyed said they used the information to monitor their health, and 4 in 10 shared the information with someone else, such as a healthcare provider or a family member. Green Management Consulting Group, Inc. 10

11 What can EHR portals include?  Allow patients to sign themselves up from home upon provision of identifying information.  Choose a Provider and review their qualifications.  Send messages to their provider  Book/Review future/past appointments.  Review allergies/immunizations (not a substitute for the “yellow card”).  After Visit Summary  Video Provider Visits  Laboratory results  If auto released, they are available to the patient at the same time they are available to the provider.  Manually released tests are those which are of a more sensitive nature, such as those concerning hepatitis, STI’s, etc.  It is no longer illegal to post these results after provider has discussed with the patient. AB 2253 is the legislation passed in September  What is on your portal? Green Management Consulting Group, Inc. 11

12 Increasing the use of the EHR portal  Market to patients at “pain points”- for example when they are on hold for the call center/refill line, in pharmacy/medical office/lab waiting rooms, etc.  Posters and flyers are good tools  Consider having volunteers available in the waiting rooms  Have Call center staff sign up patients  Approach this as win/win for patients and providers  Providers and staff encourage patients to use during visits  Be sure to sign up your pregnant women to give them proxy access to their children’s records.  Parents can have proxy access to records for minors less than age 12 at same address  Proxy after age 12 requires a separate P&P and has limitations. Green Management Consulting Group, Inc. 12

13 Teens Kaiser Permanente guidelines for using the Act for a Family Member features:  Authorization to act for your child expires when your child becomes 12 years old.  Authorization to act for your teen expires when your teen becomes 18 years old.  When acting for your child Online features change when children reach age 12. This is due to state privacy laws. When your child turns 12 years old, you will still be able to act for your teen, but certain features, such as viewing lab results, will no longer be available. See the Additional References section below for more information.  When acting for your teenager Young adults take legal ownership of their medical records beginning at age 18. Therefore, your permission to act for your teen expires when your teen reaches age 18. At that time, your teen may grant you authorization for continued access if he or she wishes.  Secure messaging is a transparent way for families to communicate with their teen's doctors. Secure online features, including , are password protected. While messages to your teen's doctors and other health care professionals are secure, they are not confidential. If your teen has his or her own online account with us, he or she will be able to read what you write and you will be able to see messages to and from your teen and his or her doctors. For sensitive and confidential information, it is best to talk with your teen's doctor by telephone or in person.  Consistent with state laws, selected parts of a teen's medical record are protected. Therefore, parents and guardians have modified access to the following features:  Appointments. You can make appointments for your teen. You also have the ability to view, change or cancel appointments which are displayed. (Any appointments that your teen has scheduled privately, however, will not be shown.)  Prescriptions. You can get refills for your teen; however, a list of current prescriptions is not available for teens or parents of teens. This is due to state privacy laws.  Test results and past visit information. To protect confidentiality, these features are not available for teens or parents of teens. s/ncal/article_ xml Green Management Consulting Group, Inc. 13

14 Increasing the use of the EHR portal  Consider opportunities to sign patients up:  Sign patients up at registration  Sign patients up at intake  As a part of the visit discharge, have the MA hand the patient the AVS and then discuss the ways in which he/she might communicate with the provider’s office  Motivate your staff to encourage them to sign up patients  Consider team-based competitions  Modest prizes can be very effective Green Management Consulting Group, Inc. 14

15 Patient s via the portal  Workflow must be addressed in detail prior to “go live”  Have a Policy & Procedure outlining responsibilities  Utilize “smart phrases” for MA and Appointment Staff  Staff Training: Is the Message OK for LA Times!?!  Patients DO send s about urgent/emergent issues- you need a Policy and Procedure for handling them.  Strongly recommend messages go to “pools” rather than directly to physicians.  Pools can be at the level of the module, office or organization.  Pools are generally made up of a combination of RN’s, MA’s, LVN’s.  Scope of Practice Green Management Consulting Group, Inc. 15

16 Patient s via the portal  We highly recommend periodic quality checks - for workflow, quality of the messages, & timeliness.  Ensure providers are removed from patients’ dropdown menu when no longer employed there or are expected to be away for prolonged periods of time.  MA’s should not be on drop down menu  Coverage for the provider in-basket is essential.  If provider “out of contact” goes to pool or another provider  If provider works less than “X” may not be available for messaging Green Management Consulting Group, Inc. 16

17 Patient s via the portal  The volume of incoming messages varies greatly, based on how strongly providers encourage patients to use messaging. Range from messages/week.  Its possible for patients to attach JPG’s and PDF’s to messages. Patients use this to send tables of blood sugars, blood pressures, etc. in response to their care manager.  Some EHR’s allow for the use of “Out of Contact” notification for patients. Green Management Consulting Group, Inc. 17

18 What can an MA do within scope with regards to the portal?  Send preventive care reminder s. Use “notify me if not read by part of to identify who will require a follow up letter or phone call. Some systems call for the sending of batch s (great for preventive reminders).  Be part of a pool to receive and address messages that are within their scope and don’t need to be seen by the doctor (appointment requests or cancellations, need off-work documentation, etc.)  They can also identify s that need urgent attention and contact the appropriate provider.  Recommend against having MA’s in the drop downs (they should NOT receive messages directly).  Strongly suggest they be limited to “Smart Phrases” and not write messages from scratch.  They cannot translate Spanish messages on behalf of providers, nor can they write messages in Spanish to patients on behalf of providers. Green Management Consulting Group, Inc. 18

19 What does the future look like?  Video visits with patients via the portal.  Availability of educational videos- i.e. “how to breast feed or how to administer insulin”.  Transparency with the use of “open notes”, allowing the patient to see their progress notes.  Home monitoring to support independence of elderly patients  Chronic Conditions Management.  Facebook teams considering “patient condition support groups” and preventive care apps to help promote healthy lifestlye changes  New Orleans-based Ochsner Health System has announced it is the first to fully integrate Apple's new mobile health platform with its Epic EHR system. Green Management Consulting Group, Inc. 19

20 Legal Considerations CA AB2253 Unless the patient requests the disclosure, the health care professional deems this disclosure as an appropriate means, and a health care professional has first discussed in person, by telephone, or by any other means of oral communication, the test results with the patient, in compliance with any other applicable laws, none of the following clinical laboratory test results and any other related results shall be disclosed to a patient by Internet posting or other electronic means: (1) HIV antibody test (2) Presence of antigens indicating a hepatitis infection. (3) Abusing the use of drugs. (4) Test results related to routinely processed tissues, including skin biopsies, Pap smear tests, products of conception, and bone marrow aspirations for morphological evaluation, if they reveal a malignancy. Green Management Consulting Group, Inc. 20

21 Credentialed Medical Assistants  Who can enter orders into the EHR technology in order to meet the Stage 1 & Stage 2 Meaningful Use?  Under the 2012 CMS ruling, now “any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of computerized provider order entry (CPOE) if they can originate the order per state, local and professional guidelines.”  How does CMS define ‘Credentialed Medical Assistants’?  “Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.” Commonly, medical assistants turn to nationally recognized certification organizations, such as the National Healthcareer Association (NHA) to obtain the necessary credentials.  Requirements for creditionaling  CMA (AAMA) not for profit Graduated from a Commission on Accreditation of Allied Health Education Programs (CAAHEP) accredited program and passed the national examination.  A California Certified Medical Assistant (CCMA) is a member of an organization that is specific to California and is not affiliated with the national medical assisting organization. The California Medical Assisting Association (CMAA) grants the CCMA credential after passing their examination. It’s hrough for profit National Healthcare Association https://questions.cms.gov/faq.php?faqId= Green Management Consulting Group, Inc. 21

22 Scope Who can enter medication orders in order to meet the measure for the computerized provider order entry (CPOE) meaningful use objective under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and when must these medication orders be entered?  Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the numerator for the measure of the CPOE objective if they can enter the order per state, local, and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. Green Management Consulting Group, Inc. 22

23 How can chronic care patients be engaged? Make an invisible disease visible Know everyone is motivated to live a long healthy life, but obstacles get in the way Understand obstacles from the patients perspective Give personalized results Accept that managing a chronic illness is WORK for the patient too! Green Management Consulting Group, Inc. 23

24 Group Exercises Remember: You can’t be patient- centered without both patient engagement and patient involvement in the way care is provided. Green Management Consulting Group, Inc. 24

25 Exercise Get in your group Read your scenario Agree on a facilitator and a spokesperson Brainstorm ideas Summarize Present Assignment:  Describe specific strategies to engage the population  e.g. Identification, target sign up, tools, education, where/how would you “advertise”?  How would you engage staff in this process?  e.g. roles for various staff levels, motivators  What rewards would you expect?  For staff & patients & business Green Management Consulting Group, Inc. 25

26 Target Population: Adult Type 2 Diabetics Background: Most common form of diabetes affecting almost 26 million Americans, chronic illness, can damage the nerves and small blood vessels of the eyes, kidneys, and heart causing increased risk of heart attack, stroke, neuropathies, kidney damage, eye damage. Expensive. Risk Factors: Over age 45History of gestational diabetes (diabetes while pregnant) Obese or overweightHave family members who have type 2 diabetes Don't exerciseHave low HDL (good) cholesterol or high triglycerides Have high blood pressureAfrican Americans, Latinos, Native Americans, Asian Americans/Pacific Islanders Assignment: Describe specific strategies to engage the population e.g. Identification, target sign up, tools, education, where/how would you “advertise”? How would you engage staff in this process? e.g. roles for various staff levels, motivators What rewards would you expect? For staff & patients & business Green Management Consulting Group, Inc. 26

27 Target Population: Adult patients who are overweight or obese Definition: An adult who has a BMI between 25 and 29.9 is considered overweight. An adult who has a BMI of 30 or higher is considered obese. Background: Obesity is common (1/3 of our population), serious (Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death), and costly (estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight),. Non-Hispanic blacks have the highest age-adjusted rates of obesity (47.8%) followed by Hispanics (42.5%), non-Hispanic whites (32.6%), and non-Hispanic Asians (10.8%) Assignment: Describe specific strategies to engage the population e.g. Identification, target sign up, tools, education, where/how would you “advertise”? How would you engage staff in this process? e.g. roles for various staff levels, motivators What rewards would you expect? For staff & patients & business Green Management Consulting Group, Inc. 27

28 Target Population: Teenage patients who are overweight or obese Definition: Overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex. Background: Most obese teenagers become obese adults. Obesity now affects 20.5% of 12- to 19-year-olds, has almost quadrupled in the past 30 years. Obese adolescents are: more likely to have prediabetes, a condition in which blood glucose levels indicate a high risk for development of diabetes; are at greater risk for bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem; and more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. Assignment: Describe specific strategies to engage the population e.g. Identification, target sign up, tools, education, where/how would you “advertise”? How would you engage staff in this process? e.g. roles for various staff levels, motivators What rewards would you expect? For staff & patients & business Green Management Consulting Group, Inc. 28

29 Target Population: Adult patients who are hypertensive Definition: Hypertension is defined as a systolic blood pressure of 140 mm Hg or more, or a diastolic blood pressure of 90 mm Hg or more, or taking antihypertensive medication. [2] Background: Hypertension affects approximately 75 million adults in the United States. Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, end- stage renal disease, and peripheral vascular disease. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), released a report in 2003 which noted that approximately 30% of adults were unaware of their hypertension; up to 40% of people with hypertension were not receiving treatment; and, of those treated, up to 67% did not have their BP controlled to less than 140/90 mm Hg Assignment: Describe specific strategies to engage the population e.g. Identification, target sign up, tools, education, where/how would you “advertise”? How would you engage staff in this process? e.g. roles for various staff levels, motivators What rewards would you expect? For staff & patients & business Green Management Consulting Group, Inc. 29

30 Appendix

31 NCQA Recognition  The patient is encouraged to select a personal clinician and to collaborate in the development and management of individual care plans to include treatment goals. Care teams are expected to be trained on effective patient communication, particularly with vulnerable populations, to assess the cultural and linguistic needs of patients and families and to provide interpretation or bilingual services and materials in languages of its population. Another element requires a practice to develop and document self-management plans in collaboration with patients, their families and or/caregivers and to provide resources to support patient/family self-management. The practice is also expected to request feedback from patients on their experiences with the practice and the way care was delivered and to obtain performance and patient experience data for vulnerable patient groups. (http://www.csi.mt.gov/medicalhomes/StakeholderCouncil/111513Meeting/MGMA%20PCMH% 20Guidelines_Tool%20to%20Compare%20National%20Programs.pdf ) Green Management Consulting Group, Inc. 31

32 Aetna will shutdown its high-profile, health tracking and data aggregation platform CarePass by the end of the year. Green Management Consulting Group, Inc. 32

33 Why did it fail?  Lack of public trust: People don’t trust their personal information with their insurance company  Competition (Apple & Google apps)  User data was low: wasn’t clear what was in it for the consumer  Not easy to use (2.5 stars out of 5)  Didn’t analyze data, emphasis on collecting and storing  Didn’t integrate with the EHR  Aetna didn’t get any ROI  Aetna’s priorities changed – focus on chronically ill who consume most of the health care dollars  Lost the leaders who supported it  Poor outreach to members failed/ Green Management Consulting Group, Inc. 33

34 Resources  Supporting Patient Engagement in the Patient-Centered Medical Home  Patient Centered Primary Care Collaborative  Dr. Dominick Frosch shared-decision-making-with-dominick-frosch/  Credentialed Medical Assistants: https://questions.cms.gov/faq.php?faqId=7693 cma#.VCmntxbCe18 stands-apart.pdf  Facebook getting into healthcare? idUSKCN0HS idUSKCN0HS  Apple’s HealthKit & Epic technology/ochsner-health-system-first-epic-user-to-fully- integrate-with-healthkit.html Green Management Consulting Group, Inc. 34


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