The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: patient engagement (page 1 of 2)

McLaren- Lansing: Using Change as an Opportunity for Optimizing Palliative Care

Kim Hecksel

McLaren- Lansing Palliative Care nurses from left to right: Kim, RN, Paula, CNP and Carol, RN

Although the palliative care program at McLaren- Lansing has been around for about a decade, health care organizations are constantly changing and evolving to meet patient and family needs. The MVC Coordinating Center had the opportunity to speak to the team of case managers and nurses from McLaren- Lansing to hear about the different successes and barriers to palliative care at this facility. One distinct characteristic of this palliative care program is that patients and families are seen by and interact with consistent faces, rather than different clinicians, each time they visit. McLaren uses this consistency as leverage through transitions of care, especially at a time when clinician duties and health organizations are constantly changing.

The palliative care program at McLaren- Lansing also keeps up with the constant changes in health care by utilizing different online resources. One resource available to hospitals interested in palliative care programs is the Center to Advance Palliative Care (CAPC). CAPC offers a platform to help provide different health care organizations across the nation the tools and resources needed to advance palliative care programs in their respective institutions. For example, some CAPC resources help palliative care teams set up and develop a business plan for their respective palliative care programs. CAPC resources are helping guide the McLaren- Lansing team in creating a business model that illustrates the financial impact of a palliative care program on the health system. For more information on CAPC and the resources they can provide, visit www.capc.org.

The palliative care team also looks at the big picture of the care provided to patients and consequently putting together different pieces of information to ultimately develop a course of treatment that best meets the needs of the patients and the family involved. One of the barriers McLaren- Lansing has with their palliative care program is working with patients, family members and other health care providers on understanding the value of palliative care and what it really offers. When met with this resistance, the palliative care team works in different ways on learning about and discussing the care plan and goal setting to find the right format for communication and understanding a diverse patient population. For example, the palliative care team engages with physicians one-on-one and attends presentations on the benefits of palliative care to better understand and work with patients and their families about their diagnosis and individualized care plan. Taking advantage of different resources available, such as CAPC, and instilling a strong support system among the palliative care team and liaising teams are factors that aid in instituting a successful palliative care program.

If you are interested in learning more about the palliative care program at McLaren- Lansing, please feel free to reach out to Deby (debevans@med.umich.edu) or Abeer (abeery@med.umich.edu) for more information and contact.

Managing High-Needs Patients can Help Improve Outcomes at Michigan Hospitals

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Only about 5% of patients are considered high-need, yet these patients constitute nearly 50% of total healthcare costs. High-need patients typically have more complex diagnoses and significant barriers to accessing healthcare that impacts the self-management of their condition(s) outside of the hospital. In a recent, pre-publication report, Effective Care for High-Need Patients, the National Academy of Medicine (NAM) outlines various characteristics of high-need patients, patient taxonomy models, along with care models. This report is a compilation of feedback from relevant workshops, presentations, discussions, and literature and stresses the importance of identifying and managing care delivery to high-need patient populations.

High-Need Patients Characteristics

To better create targeted initiatives in a hospital setting for high-need patients, there needs to be better identification of characteristics using data. Although there is not one, specific definition of “high-need patients”; functional limitations, complexity of care/disease, and health care costs are all characteristics that can be used to identify and analyze these patient populations. These characteristics not only impact the care that is delivered within the clinical setting, but also the ability for that patient to self-manage their health outside of the hospital.

High-Need Patient Taxonomies

NAM reviewed two patient taxonomy models in use by the Harvard T.H. Chan School of Public Health and The Commonwealth Fund to better segment patients for improved identification of high-need populations. Using a taxonomy model can guide health systems to more suitable integration of behavioral, social, and functional characteristics in the patient care plan outside of the clinical setting. What is unique about the taxonomy developed by NAM is that it builds upon clinical and medical characteristics to identify behavioral health and social factors that affect care delivery decisions. More detail about this starter taxonomy and a conceptual model can be found here.

Successful Care Models for High-Need Patients

This NAM report also uncovered common characteristics among care models that are successful in managing high-need patient populations. The report mentions that successful care models typically expand upon domains related to health and well-being, care utilization, and costs. Furthermore, these care models include details on dimensions related to service setting focus, care attributes, delivery features, and organizational culture. By targeting a specific high-need patient population (ex: age group), health systems are better able to create care models and initiatives geared towards improved, more integrated care delivery. The report also outlines an analytic framework that helped NAM identify successful care models for high-need patients.

The MVC Coordinating Center can help member hospitals identify domains and care utilization of high-need patients.  If you are interested in identifying these populations within your hospital, please reach out to Deby (debevans@med.umich.edu) or Abeer (abeery@med.umich.edu).

Interested in learning more about optimizing care delivery for high-need patient populations? More information and a copy of Effective Care for High-Need Patients can be found below:

https://nam.edu/effective-care-for-high-need-patients/

https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf

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