Emerging Practices You May Not Know That Increase Medical Adherence and Reduce Readmissions

How Organizations Are Reaching Patients Better through Mobile Strategies

GQA Recap: Engaging Employees in Pursuit of World-class Health Care

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Emerging Practices You May Not Know That Increase Medical Adherence and Reduce Readmissions
medication Is there a link between the way people shop and the way they take their prescribed medication? Apparently so.

FICO, the company that develops the score by which lenders determine an applicant’s creditworthiness, has developed an HIPAA-compliant tool using the same predictive analytics.

The FICO Medication Adherence Score ranks all individuals in a patient population according to their risk of nonadherence over the next 12 months. When available, it pulls a patient’s prescription claims history. FICO also compares thousands of variables from publicly available data sources. While age and gender are known to be associated with disease prevalence and adherence trends, FICO interprets the predictive power of other data sources such as retail purchase behavior and income and wealth indicators. The score looks at customer buying behavior — the products, promotions and prices influencing it — and finds useful patterns across these dimensions.

This means of identifying individuals at risk for not adhering to medications is a critical step, enabling health care organizations to assign them more suitable discharge instructions, thereby preventing readmission and decreasing costs.

The new FICO medication program is just one in a series of recent strategies that hospitals are taking to better combat a growing problem.

According to the National Council on Patient Information and Education, as many as half of all patients in the United States do not take their medication as prescribed, 31 percent do not fill prescribed medication, 29 percent stop taking medication before supply runs out, and 24 percent take less than recommended dosage.

According to a study reported by the New England Journal of Medicine in 2010, the overall cost of non-adherence to the health care system is estimated at $290 billion per year — 13 percent of U.S. health care expenditure — and rising.

Like the FICO score, the World Health Organization has devised its own categories of factors that help predict medication adherence. Such factors are related to a patient’s knowledge and beliefs about his illness, motivation to manage it, confidence in his ability to engage in illness-management behaviors, and expectations regarding the outcome of treatment and the consequences of poor adherence.

Health care organizations wishing to create their own pre-discharge questionnaire to identify patients at higher risk for non-adherence should consider the interplay among the following five sets of factors, or dimensions, as set by the WHO:

1. Social and Economic Dimension
  • Limited English language proficiency
  • Low health literacy
  • Lack of family or social support network
  • Unstable living conditions or homelessness
  • Limited access to health care facilities
  • Lack of insurance
  • Inability or difficulty accessing pharmacy
  • Medication cost
  • Cultural beliefs about illness and treatment
2. Health Care System Dimension
  • Provider-patient relationship
  • Provider communication skills
  • Patient information materials written at too high of a literacy level
  • Restricted formularies
  • High drug costs, copayments, or both
  • Missed appointments
  • Long wait times
3. Condition-Related Dimension
  • Chronic conditions
  • Lack of symptoms
  • Severity of symptoms
  • Depression
  • Psychotic disorders
  • Developmental disability
4. Therapy-Related Dimension
  • Complexity of medication regimen (number of daily doses; number of concurrent medications)
  • Treatment requires mastery of certain techniques (injections, inhalers)
  • Duration of therapy
  • Frequent changes in medication regimen
  • Medications with social stigma attached to use
  • Actual or perceived unpleasant side effects
  • Treatment interferes with lifestyle or requires significant behavioral changes
5. Patient-Related Dimension
  • Visual, hearing or cognitive impairment
  • Impaired mobility or dexterity
  • Perceived risk/susceptibility to disease
  • Perceived benefit of treatment
  • Confidence in ability to follow treatment regimen
  • Fear of possible adverse effects
  • Feeling stigmatized by the disease
  • Frustration with health care providers
  • Psychosocial stress, anxiety, anger
  • Alcohol or substance abuse

For more information, click here.

Telephone reminders to refill or pick up prescriptions have also been found to improve medication adherence. For example, Database Systems Corp. created the CARE (Call Reassurance) (http://www.medication-reminders.com/) phone service as a community service program that calls seniors and individuals who live alone. Using CARE phone systems, community organizations can automatically call individuals, reminding them to take their medications at their proper times.

Similarly, Script Your Future (http://www.scriptyourfuture.org) offers free medicine reminders via text message.

Using Records to Reduce Readmissions

medication Regardless of the method used, improving medical adherence ultimately means reducing readmissions, which is a critical goal of health care organizations. While the FICO Medication Adherence Score gleans information from public records, the Bridge Model employed in Illinois aims to reduce readmissions by better leveraging hospital and medical records.

The Illinois Transitional Care Consortium is a consortium of community-based organizations, hospitals, University of Illinois at Chicago School of Public Health, and health and medicine policy research groups that developed the Bridge Model. ITCC formed to more effectively address the needs of older adults transitioning from hospital to community by linking hospital-based services with the existing aging network through intensive care coordination.

Research revealed that older adults were particularly vulnerable to poor transition outcomes for a variety of reasons, including multiple medical conditions, medications and care providers; physical and cognitive limitations; health literacy; and burdened caregivers.

According to the ITCC, in the hospital to home transition:
  • 19.6% of Medicare beneficiaries readmitted in 30 days,
  • 19% of patients experienced an adverse event within three weeks of discharge, and
  • 76% of 30-day readmissions were highly preventable.”

The overall goal is to reduce the rate of readmissions by 2014, and the consortium recognizes that improving transitional care is one way to do that.

The model hinges on a Bridge Care Coordinator — a social worker with expertise in geriatric social work, strong clinical and advocacy skills, experience in hospital and community settings, and the ability to tap into community resources. According to the research, 40% to 50% of readmissions are linked to psychosocial issues such as social isolation, depression, financial stress and language and health literacy barriers, as well as a lack of community resources. By connecting hospitals and older adults to the community’s existing aging network — which offers such resources as home care, household care, food, transportation and caregiver support — the risk of adverse events diminishes as do re-hospitalizations.

The Bridge Model is patient focused and community specific, but is applicable to urban, suburban and rural settings.

The target patient population in the model meets the following criteria:
  • Older than 65,
  • Returning home after discharge, and
  • Prescribed more than seven medications.

The following are examples of additional criteria, at least one of which must apply to the patient:
  • Lives alone,
  • High-falls risk,
  • Inpatient hospitalization within past 12 months, or
  • High-risk medication prescribed.

Connecting to Resources

In the Bridge Model sample study at Rush University Medical Center, more than half of older adults seen at the hospital by a Bridge Care Coordinator had yet to get connected to resources available through their community. The Bridge Care Coordinator connects older adults to the aging network. In the study, 49% utilized services for the first time after their encounter with a Bridge Care Coordinator

These are the results after implementing the Bridge model:

Since Discharge Readmission %(Using Bridge) Readmission % (Before Bridge)
30 days 13.6% 16.1%
60 days 20.8% 26.4%
90 days 26.4% 34.2%
120 days 30.8% 36.5%
180 days 36.1% 42.5%

The study also revealed that 83% of the patients in the intervention group had problems identified by the Bridge Care Coordinator during the assessment at two days post-discharge. For 75% of these individuals, problems did not emerge until after discharge.

Whether it’s a score based on predictive analytics or a social worker connecting a patient to available resources, any technology or process that can help identify those at risk for post-discharge problems can have a great impact on reducing readmissions.
How Organizations Are Reaching Patients Better through Mobile Strategies
mobile tech For some time now, doctors have been utilizing mobile technology such as smartphones and tablets to streamline certain processes in the care continuum in the US and abroad. But recently, initiatives aimed at enhancing patient care hinge on a phone in the patient's hands.

In June, Medic Mobile announced the development of the first SIM Application for healthcare. SIM apps can operate on 80% of the world’s phones — from $15 handsets to Android smartphones — and Medic’s new implementation of this technology brings data collection to a new level of accessibility and affordability

Medic Mobile made the official announcement at the Mobile Health Summit in Cape Town, South Africa. Malawi, Africa, is where the pilot program began, based on Stanford student Josh Nesbit’s research on pediatric HIV. Two doctors were attempting to diagnose and treat 250,000 people. Nesbit provided Java-run $10 mobile phones to community health workers to decentralize the care and create an SMS text-messaging patient coordination network. The phones helped medical workers efficiently gather health data and follow up with patients.

Nesbit described the success to blogger Lauren Drell, which she reported on Mashable’s Global Innovation Series.

In six months, our pilot in Malawi saved the clinical staff 1,200 hours of follow-up time and more than $3,000 in motorbike fuel, Nesbit said. It also doubled the number of patients who were treated for tuberculosis. Once treated, patient follow-ups were completed by text message instead of an in-person exam, which saved time, transportation and money.

Using text messages, Medic Mobile also tracks vaccines for pregnant women and infants, sending out reminder messages and information for mothers to bring their babies to the clinic.

Such technology also has great application for rural regions in the United States. The University of Virginia’s Infectious Disease Clinic ran a text-messaging pilot program in 2009 to remind rural HIV patients about appointments and medication regimens. The program was launched after Mary Rafaly, a university social worker who does outreach with HIV patients, noticed that patients in rural areas were less likely to keep appointments and adhere to treatment regimens than those living in urban areas.

In the University of Virginia program, rural patients were issued cell phones that limited them to receiving texts reminding them about medication regimens and upcoming appointments, and to calling their health care providers and emergency contacts. The study is now in the clinical trial phase, with an estimated completion date of June 2013.

Public Health Turns to SMS Solutions

Starting this fall, two major U.S. metropolitan areas — Detroit and New Orleans — will launch new public health campaigns leveraging mobile health technology to help individuals assess their risk of type 2 diabetes and provide them with timely, relevant health information and access to local health and wellness resources.

The campaign will make a texting-based risk assessment available to anyone with a cell phone, promoting the access number through traditional public health channels.

Here’s how it works:
1. Through their cell phones, individuals will be asked brief questions that assess their risk for diabetes and instructed to respond via text message.
2. Based on their responses to this text-based assessment, individuals will be connected with the best possible resources for their needs. This may be an online social forum, a discount for a check-up at a local pharmacy, or the phone number for a local health care provider.

The hope is that an individual who may not have not seen a doctor in the past 10 years because of the perceived financial burden will be made aware of his diabetes risk, and — through the ease of the texting process on his cell phone —could be connected to potentially life-saving resources he might not have known about. For someone who has a doctor but has been unable to effectively manage his condition, the campaign could prompt him to get back in touch with his doctor and participate in a follow-up visit.

The benefit of using mobile technology this way is that it allows engagement with a much larger population than the health system can manage on its own, while simultaneously tailoring information and resources to the individual.

The program is a collaboration between the American Diabetes Association and the Centers for Disease Control and Prevention, which are working with the Office of the National Coordinator for Health Information Technology in an effort to increase the use of health information technology. ONC grantees Detroit and New Orleans are also communities where the diabetes epidemic is particularly critical. Both cities are partnering with mobile health provider Voxiva to develop and provide these services.

The collaboration will include the design of tools and interventions, as well as the development of effective communications that help get the word out about the campaign. All these design elements are being done with an eye toward easy replication and scale across other communities.

The model for the type 2 diabetes project is the national Text4Baby campaign that delivers evidence-based health tips via text message to pregnant women and new moms. Text4Baby started small but grew quickly; more than 500 health organizations in all 50 states have joined the Text4Baby partnership, and it has enrolled more than 185,000 women across the country and delivered more than 15 million text messages to help keep mothers and their babies healthy.

In addition to the general public health benefit, text messaging is also proving to be good business.

Kaiser Permanente’s success with automated text message appointment reminders has been widely touted. A one-month pilot study that sent reminders to individuals the day before their appointment concluded that 1,800 missed appointments were prevented. At $150 per missed appointment, the initiative yielded a savings of $270,000 for the company.

Updating Websites to Be Mobile-Friendly

Just as health care organizations are reaching out to cell phone users in the form of text messages, they are also realizing that many of those consumers are also using their phones to browse the Internet

Visiting a website on a cell phone is a very different experience than navigating with a personal computer. It can be time consuming, slow and overwhelming, especially for a site as complex as a hospital's.

A recent study by the Pew Trust reveals the increasing relevance of adapting websites for mobile browsers — 59 percent of U.S. adults age 18 and older now access the Internet wirelessly using a laptop or mobile device. Of those, 61 percent are searching for health-related information.

That’s where people start now, Rebecca Climer, chief communications officer at Saint Thomas Health Services, told the Nashville Business Journal in a Sept. 10, 2010 article titled, Nashville hospitals take websites mobile to reach patients.

A lot of times, by the time the patient comes to us, they have not only researched the various procedures, but they know the specific doctor that they want, she said.

Saint Thomas spent $11,000 to launch a mobile version of its website last summer that allows users to easily access hospital directions and phone numbers from their mobile device, such as a Blackberry, iPhone or Droid

The mobile site goes beyond simply listing contact information for physicians and facilities; it also features a health information section where users can search medical terms or conditions, such as bee sting or cardiothoracic surgery, and receive information on symptoms and treatments as well as descriptions of medical procedures and their risks.

The same article also reported on HCA Inc.’s TriStar Division, which operates seven hospitals in Middle Tennessee, and also launched a mobile version of its website last fall. The organization had already been delivering emergency room wait times at nearby TriStar hospitals to users’ cell phones via text message. With the mobile website, users can search for events and classes at TriStar hospitals, find physicians by insurance type and zip code, or request an appointment.

Best Practices for Mobile Sites

Lisa M. Rickard of AVID Design, which specializes in hospital website design, offers suggestions for mobile sites. It’s important to realize that your hospital’s mobile site should not mirror your regular site, as there are different challenges that need to be addressed when designing. The point of having a mobile site is for quick and easy access to information. What works solely on your regular site oftentimes will not work in your mobile site.

She suggests that users be able to quickly locate the following:
  • Hospital news
  • Doctor locations
  • Appointment scheduling
  • Facility locations and directions
  • Important phone numbers
  • Social media site connections
  • Patient and visitor information (facility hours, designated parking areas, etc.)

Rickard also offered other best practice guidelines to consider when developing a mobile site:
  • Offer a “go to top” link in the footer for easy navigation
  • Limit text on your site and include only the most pertinent.
  • List your most used mobile site features at the top for easy user access.
  • Avoid using Flash since not all mobile devices are capable of viewing
  • Avoid horizontal scrolling because of certain display modes on various mobile devices.
  • Use minimal images. No one wants to wait for several images to load
  • Use the same font on every screen to ensure legibility and not have to worry about screen resolution
GQA Recap: Engaging Employees in Pursuit of World-class Health Care
Gov quality award In June, American Data Network co-sponsored the Governor’s Quality Award 2011 Healthcare Challenge Seminar, Leading Your Organization to Excellence: A Baldrige Perspective.

Sonja Wulff, vice president of Poudre Valley Health System Center for Performance Excellence in Fort Collins, Colo., spoke to a group of Arkansas health care professionals on the improvement process as outlined by the Malcolm Baldrige National Quality Award. PVHS is in the top 10% of health care organizations in the nation for clinical outcomes, patient and employee satisfaction, physician loyalty and financial performance.

Below is a recap of Wulff’s presentation, which focused on actionable tips for hospitals to follow in order to deliver the highest quality of care and work in the Baldrige frame of mind. Much of audience probed Wulff about how to fully engage employees in helping to champion change across the entire health system.

PVHS’s Center for Performance Excellence was formed in response to requirements of the Baldrige National Quality Program, a presidential award recognizing high-performing organizations in manufacturing, service, small business, education, health care and nonprofit. Its categories for evaluating performance excellence include leadership, strategy, customer focus, knowledge management, workforce focus, operations focus and results.

The Baldrige Process calls on the organization to perform a self-assessment based on those criteria, submit an application for review and receive a feedback report to drive improvement.

PVHS, a private, locally owned non-profit, offers a full spectrum of health care services including two tertiary hospitals with a total of 420 beds, an outpatient campus, numerous physician practices and outpatient facilities.

When PVHS began the Baldrige process in 1997, the hospital’s service area was limited to Fort Collins. The system – which had 1,500 employees, 300 independent physicians and 575 volunteers – was led by five CEOs in four years and suffered a 24 percent employee turnover rate. Annual revenue was $250 million. Today, PVHS’s service area covers Northern Colorado, Wyoming and Nebraska. The hospital touts 5,300 employees, 600 physicians and 1,000 volunteers as well as $1.4 billion in annual revenue and a voluntary employee turnover rate around 7%.

The Hidden Value

Wulff admitted that initially, the category teams designated to work on the Baldrige Award met just to write the application. Their goal was simple — win the award. They looked for warm-fuzzy stories and lists of accomplishments. Their results selection was based on what looked good and where they had benchmarks

But along the way — the hospital applied seven times before it won — PVHS discovered that the real value of the Baldrige award lies in the application process. By applying, PVHS was not only forced to scrutinize key performance indicators, but their application essentially resulted in many free consultation hours from the Baldrige judges.

By 2004, the hospital had adopted the Baldrige framework as its business model and established a quality improvement department to maintain a year-round focus on performance excellence, as well as seven performance excellence teams — one for each of the Baldrige criteria, which the hospital used to identify and address gaps.

Employee Involvement

Workforce satisfaction and engagement are the foundations of a successful, sustainable organization and PVHS began building a culture of engagement in 1997. Based on a best practice from a Baldrige recipient, PVHS surveyed employees as customers and asked:

1. What makes you want to jump out of bed and come to work?
2. How do we build a culture that supports that?
Now referred to as the Employee Culture Survey, this survey tool asks staff members if their needs are being met and prompts adjustments, if indicated by results.

PVHS strategic plan is presented to all employees, who in turn have individual metrics tied to the key objectives. Performance is rewarded through an Optional Performance Plan (OPP), an incentive program designed to engage staff and reinforce high performance and establish a patient focus line to achieve the goals. Payout is based on financial performance, customer satisfaction and employee survey participation. All staff members share equally in the OPP, with individual payout amounts determined by the number of hours worked, not organizational rank.

Senior leaders devote significant time and resources to communicating with and engaging the workforce. Staff engagement and frank, two-way communication between senior leaders and staff begins on an employee’s first day on the job, when the PVHS CEO addresses attendees in New Employee Orientation: “It is my job to make this the best place you have ever worked. If I’m not doing my job, tell me.” To support this invitation, the CEO and other senior leaders have an open-door policy, encourage e-mail and provide their home phone and cell numbers.

Poudre Valley strongly believes in team culture to engage their staff. They create interdisciplinary teams based on their function: patient care, process/facility design, and quality improvement. To determine the team members, PHVS uses the Thomas Concept, which is a program that evaluates a person’s strengths, tendencies and communication styles in order to better understand and strengthen relationships and teams.

PVHS invests significantly to engage the workforce in a culture of appreciation. Specifically, budgets for Reward and Recognition and special events continue to increase. Managers may request an R&R Certificate for staff who demonstrate the following qualities:

1. High performance, innovation and patient/customer focus toward achievement of the SOs; or
2. Behavior standards and values.
The certificates are redeemable for $10 to $500 at a diverse list of area businesses that support the PVHS Foundation. Three peer-to-peer coupons are provided quarterly, redeemable for $3, to allow staff, volunteers, and physicians to reward each other for actions supporting Behavior Standards and values.

To recognize high-performing individuals, senior leaders host an annual Employees of the Year dinner and a Service Awards celebration. They also write personal thank you notes and publicly share patient letters of commendation.

To show general workforce appreciation, senior leaders support celebrations, such as Grill Days, holiday events/gifts, summer picnic, PVHS nights at Colorado State University athletic events, and Hospital Week with free meals, Hospital Bucks, and activities such as the annual medical terminology Spelling Bee, PVHS night at the drive-in movie theater, and Colorado Rockies baseball game.

PVHS also holds the annual Quality Festival, which invites members of the workforce to highlight quality improvement projects and promotes and rewards sharing and implementation of innovations across the organization.

Staff career progression begins with goal setting at performance review, when managers and employees may discuss and plan for growth opportunities within PVHS. Support processes to accomplish employee goals include scholarships/tuition reimbursement, mentoring, coaching, shadowing, conference attendance and interdepartmental secondary job codes that allow staff to train and gain experience in other positions. PVHS regularly promotes from within. Directors rotate VP coverage during absences to gain experience at the senior management level.

Wulff encourages hospital leaders who are interested in pursuing world-class health care as modeled by Baldrige to be persistent. PVHS continues to focus on performance excellence – not the award – as it celebrates achievements along the way

Click here for the 2011-2012 Malcolm Baldrige Criteria for Performance Excellence.
Upcoming Events
Calendar NAHQ Annual Educational Conference

When: Sept. 15 – 18, 2011
Where: Sacramento Convention Center, Sacramento, CA

For a full list of featured speakers and workshops or for more information about the conference, click here. And, don't forget to swing by American Data Network's booth. We have some awesome things in store you won't want to miss.

Healthcare Quality Foundation Wine Tasting

When: September 17, 5:15 – 6:45 p.m.
Where: Sacramento Convention Center, Sacramento, CA

Enjoy the flavors for California’s famous wines. Sample vintage varieties from two Sacramento-based vineyards while networking with fellow quality professionals. Your support of this even provides funds for the foundation’s future grant awards.Sponsored by American Data Network.

Click here for more information.

AAHQ's 7th Annual CPHQ Review Course

When: Wednesday, Sept. 28, 2011, 8 a.m. - 5 p.m.
Where: Westlake Corporate Park, Searcy Building (Ground floor conference room), Little Rock, AR

This workshop is geared toward quality professionals at all levels – a tutorial for those preparing for the certification exam, a robust introduction for anyone new to healthcare quality, and a review for more seasoned professionals. Due to AAHQ’s partnership with American Data Network, the course is offered at a fraction of the cost of other national workshops utilizing the same instructors and course content. AAHQ members pay just $50, representing a HUGE savings when compared to fees of up to $300. Speaker: Dr. Susan Mellott. 7.3 CE hours pending approval.Click here for more information.

Arkansas Hospital Association 81st Annual Meeting

When: Oct. 5 – 7, 2011
Where: Peabody Hotel and Statehouse Convention Center, Little Rock, AR

For registration information or the program brochure, click here. Also, don't forget to swing by the American Data Network booth!

Rollin' On The River of Healthcare Quality

When: Oct. 13 – 14, 2011
Where: Vicksburg Convention Center, Vicksburg, MS

Don't miss the Mississippi Association of Healthcare Quality's educational conference. American Data Network's own Director of Products and Services Stephanie Iorio and Director of Business Development Sherry Bird will be leading the "Healthcare Quality Boot Camp" from 8:30 a.m. - noon on day 1. Click here for more information.