Author Archive for: scarey

Smart Networks are the Future of Post-Acute Care: 3 Ways Providers Can Stay Ahead

As the rest of health has transitioned towards some form of value-based or quality-contingent payment (whether through the Readmissions Reduction Program, Hospital Value-Based Purchasing, Physician Quality Reporting System or Meaningful Use), post-acute care has anxiously waited on the sidelines. No longer. With the passage of the IMPACT Act, the extensive growth of ACOs and Bundled Payment for Care Improvement pilots, and growing sophistication of quality measures and data analytics, post-acute care providers are finding themselves increasingly in the spotlight to prove they can offer higher value outcomes over alternative providers or lower-cost settings.

For the past few years, both healthcare networks and consumers have relied heavily on the CMS Five Star Rating, which, as I and others have written about before, is an imperfect guide to quality. For hospital-led systems, rehospitalization measures are increasingly becoming an important marker of quality. In a recent Mcknight’s article, Steven Littlehale of Pointright describes the challenge of narrow networks based on just a few measures. Instead, he proposes using “smart networks” based on several outcome and process measures. Careport Health, a start-up based in Boston, is attempting to do just that.

With the impending transformation towards value-based payment models and smart referral and partner networks, along with growing sophistication on outcomes and measures, how can post-acute care providers remain competitive? Here are three areas to consider:

1. Build a high-reliability, outcome-based organization.

The days of focusing on RUG rates and pushing length of stay as high as possible are over. The five star rating system, while still important, will no longer be the key to acceptance by partner networks. Providers instead need to develop strong, consistent systems to provide high-quality care as effectively and efficiently as possible. Not only does this require a competent therapy team, but providers must also have engaged staff, from CNAs to housekeeping aides, who all contribute to the well being and satisfaction of guests. The need for resiliency means providers must adopt a holistic view of their operations, rather than relying on a few heroes to steer the ship. Information will need to flow continuously and seamlessly through the organization, enabled by technology but driven (and utilized) by capable employees. A culture of continuous improvement and rigorous root cause analysis is essential, which requires deep organizational investment in learning, problem solving, and engagement.

Investments in culture and institutional capacity will have a rollover effect as well: post-acute care providers  who position themselves as meaningful, exciting and challenging places to work will help stem the tide of turnover that has long plagued the sector, and provide a buffer against the growing shortage of direct care workers.

2. Invest in long-term relationship management.

Providers can no longer forget about guests after a discharge is complete– nor should they wait until admission before forming relationships. Instead, providers need to become sources of information about aging and care options for the entire community. They should also invest in interactive care coordination and follow-up technologies to ensure emergent needs and care challenges can be addressed before they become more costly. From call center-based coordination to remote monitoring technologies, the options are quickly growing.

This change to long-term relationship management is both a new challenge—and new opportunity—for providers. Utilizing their existing social services, recreation and transportation infrastructure, skilled nursing providers can quickly and effectively provide low cost, high value assistance to keep elders in their homes after discharge from a skilled facility.

Providers can also take the lead on facilitating care coordination between a guest’s primary care team and other needed resources, such as social services and supports offered through Area Agencies on Aging. Engaging elders in the community also provides natural referral networks for long-term or community-based care services the organization also provides.

3. Expand service lines to target newly available revenue streams.

Many senior housing providers have long stayed away from Medicare services because of the onerous regulations and increased complexity. Bundled payment and ACO models provide innovative opportunities to partner with or build home health agencies and provide high quality, inclusive rehab services in lower-cost-of-care settings. For senior housing providers, this can open up lucrative revenue streams while also providing needed resources to build clinical care capacity and resident offerings. By contracting directly with innovative ACO programs, providers can also avoid the hassle and uncertainty of Medicare billing, as well.

For hospitals and health networks, partnering with senior housing communities provides an ideal way to support a targeted, high risk population with minimal investment of resources. Using analytics and care coordination services like Care at Hand, Life2 and Caremerge, providers can seamlessly integrate expanded services into existing workflows and structures. Non traditional senior housing providers, such as HUD 202 buildings, can also tap into these new opportunities to expand revenue while reducing overall healthcare costs. For instance, housing organizations are partnering with ACOs to reduce hospitalizations– and capturing a piece of the savings. Senior housing providers are providing home care and meal delivery services to local neighbors– making money and building brand awareness. Assisted living communities are participating in bundled payment initiatives to manage chronic conditions in the community in exchange for health IT investments and care management support.

Change is quickly coming to the post-acute care space. This includes not only traditional providers, like skilled nursing facilities, but also assisted living and senior housing communities, home health and home care agencies, and ancillary service providers. Organizations should position themselves now to be an integral value-based partner with these new opportunities or risk being left with outdated service offerings— and empty buildings.

You can learn more about how eSSee Consulting helps providers and Health IT companies capture these new opportunities by visiting our Solutions.

Harness the Power of Information with Governance

“[Information governance is] an organization’s coordinated, inter-disciplinary approach to satisfying information compliance requirements and managing information risks while optimizing information value” – The Sedona Conference Commentary on Information Governance

Governance is the practice of aligning an organization’s values and goals with its operations and structures. Like other crucial resources in healthcare, information is a high level asset that requires management and oversight to ensure it can be used effectively. Information governance, a rapidly growing concept in healthcare, allows an organization to create reliable structures and processes to manage, maintain and act upon information in a way that supports organizational goals and ensures compliance with applicable rules and responsibilities.

Most, if not all, healthcare organizations have at least a simple governance structure in place around privacy and security of health information, driven by the requirements of HIPAA. But information governance is a much deeper concept, addressing not only security but also the quality of information and how effectively it can be used and shared (when necessary). As the use of information in and across healthcare organizations grows, the quality, reliability and availability of that information will become almost as important as actual care routines. For long-term and post-acute care organizations, now is the ideal time to think hard about information governance structures.

AHIMA (The American Health Information Management Association) provides a wealth of resources on information governance (, including an excellent primer on the eight principles of information governance. These eight principles (depicted below) offer a framework to understand the full cycle of information use within an organization.

In a 2014 survey of healthcare organizations, AHIMA found a wide range of organizational approaches to information governance:

Tellingly, 34% of organizations either didn’t think there was any need for governance or didn’t know their organization’s position, while another 22% have not started any program. As this survey represented a wide range of healthcare providers, long-term and post-acute care providers can be expected to fall disproportionately in these underdeveloped camps.

An information governance program should begin at the Board level, typically in the form of a Board oversight committee. In smaller organizations, information governance may be adequately situated within the corporate compliance and risk management program. A cross-functional team should be comprised of Board representatives, the CIO, the IT Director, clinical and administrative leadership, and other relevant stakeholders. Once organized, the information governance committee can develop an organizational information governance strategy and structure to address several components:

  • Key roles and responsibilities
    • Who is responsible for program development and oversight?
    • Who will manage training? Auditing? Communication?
    • How will oversight and accountability survive turnover and succession?
  • Information standards, definitions and expectations
    • How will information be used and what requirements are necessary for these uses?
    • What dimensions govern the acceptability of information?
  • Policies and procedures that govern information management
  • An audit and oversight program
    • How will the organization ensure compliance and identify opportunities for improvement?
  • Workforce training
    • How will employees in all job functions and at all levels contribute to the overall governance program?

Given the central place of health information and its importance to operations, the principle of information integrity oftentimes occupies the majority of a governance program’s ongoing work. A large part of information integrity involves ensuring data quality through the dimensions of accuracy, completeness, validity, timeliness and accessibility.

  • Accuracy: Is the information correct?
  • Completeness: Are all required elements present?
  • Validity: Does the information match the rules?
  • Timeliness: Is the information present when needed?
  • Accessibility: Is the information available?

To manage these dimensions, a governance committee should develop standards for each element, training to teach staff how to prepare and store information correctly, and audit mechanisms to verify data quality and identify problems.

As information needs become more complex, the role for information governance will only grow. Organizations should lay the foundation for a strong information governance program now or risk not having the infrastructure required to compete in the future healthcare marketplace. Begin by setting the governance structure, define roles and responsibilities, train all stakeholders, and sustain through oversight and continuous improvement.

For more information on setting up an information governance program, visit AHIMA’s website:

I will also be speaking about the important of information governance, along with EHR adoption and succession planning at the Long-Term Post Acute Care Heath IT Summit in Baltimore June 21st-23rd. This is a fantastic learning conference for all those involved in long-term and post-acute care operations. Learn more at:

Using Lean and PDSA to Reduce Employee Injuries


For many aging services providers, employee injuries are a costly reality of the workplace. In addition to workers compensation costs, however, employee injuries can cause scheduling challenges and lower worker morale. Lakeville Management, a small regional provider of assisted living and memory care communities, decided to tackle employee injuries as part of their commitment to deepening their respect towards employees.

To begin, administrators held several small focus groups to solicit information about the current safety culture, the employee injury reporting process, and barriers to implementing changes. With this initial information, the leadership team was able to construct a company-wide survey and identify opportunities to improve their processes.



The company safety committee (composed of multi-disciplinary representatives from each member community) first examined their current incident reporting process, which was used to report both actual injuries and near misses. Staff reported that the process was somewhat difficult, and, as a result, very few employees bothered to submit near misses. In addition, by examining the type of injuries that occurred most frequently, the committee decided to focus education and interventions on muscle strains, which accounted for almost 60% of all employee injuries.

The committee began by mapping out the incident reporting process. By dialoguing with supervisors tasked with completing parts of the process, the committee identified pain points, unclear forms, and burdensome back-and-forths. Using this knowledge, the committee tested several process and form updates, refining methods after 30 day trials in a single community.

The organization also created a temporary contest to build awareness about the value of near-miss reporting, including incentives for reporting near-misses and a transparent process in each community where near misses and interventions were displayed on a visual control board located in the staff break room. Staff were able see the results of reporting dangers before they led to injuries and could weigh in on interventions to help ensure that proposed changes were realistic within work routines.



After six months of work and four rounds of the PDSA process, Lakeville reevaluated the incident reporting process ease and short-term results. Supervisors reported that the updated processes were much easier to follow, and the leadership team noted a strong increase in the number of near miss reports. After twelve months, the results were dramatic: almost $200,000 in avoided worker compensation costs, 63% fewer lost days, and 15% fewer modified work days. In addition, managers at Lakeville became accustomed to including a review of staff injuries and near misses as part of their daily work, increasing accountability and awareness for the importance of worker safety to the organization.


Learn more about how Lean can help your organization improve performance, including reducing the number and severity of costly employee injuries, here.











Five Qualities of Role-Based Leadership

An important piece of adaptive leadership is the ability to apply different skill-sets to address different types of problems. Just as you (hopefully) wouldn’t use a hammer to fix a leaking pipe, you shouldn’t rely on one style or approach of leadership to meet every challenge. This complex understanding is oftentimes overlooked in leadership literature, where many authors propose more static models of “what a leader looks like.” In contrast, Ester Cameron and Mike Green, in Making Sense of Leadership: Exploring the Five Key Roles Used By Effective Leaders, propose a five quality leadership model that I find very helpful in understanding adaptive approaches. The five qualities they propose are:

  • The Edgy Catalyzer: Creates discomfort to promote change

    This quality is crucial when the status quo is an impediment to change or when an organization has become too complacent with its current structure and processes. By asking uncomfortable questions and pushing employees to examine held beliefs, the edgy catalyzer can help create a sense of unease that leads to a desire for change.

  • The Visionary Motivator: Focuses on engagement and buy-in to energize people

    A great deal of leadership literature focuses on the role of the visionary motivator in leading teams. This quality builds engagement and participation from team members and helps to create a coalition capable of moving change forward. Communication and positivity are essential traits of this quality.

  • The Measured Connector: Promotes a sense of purpose and connectivity between people

    Measured connectors work to align people with stated goals and targets. At times change can move uncomfortably fast, and this quality focuses on keeping team members together and committed. As organizations and care delivery systems become more complex, the importance of aligning not only internal employees but also external stakeholders grows.

  • The Tenacious Implementer: Focuses on projects, timelines, deliverables and targets

    In the article “What Leaders Really Do,” John Kotter creates a useful distinction between management work and leadership work. One common trap that leaders fall into, however—especially those skilled at building visionary coalitions– is failing to stick around and ensure that goals and projects are actually implemented. The quality of tenacious implementer is particularly important when managing the change required to implement regulatory fixes and large-scale IT projects, like EHRs.

  • The Thoughtful Architect: Envisions frameworks and system design to support needed change

    When working on system change or long-term strategic planning, leaders need to understand how to construct structural and process-oriented objectives to bring into existence an engaged vision. Indeed, many thought leaders are exceptional at building a strong coalition around a hopeful vision for the future, but then struggle to actually redesign an organizational structure or business line that brings this vision to life. The thoughtful architect quality is the most introverted of the qualities, and benefits from time to reflect and consider.

Cameron and Green constructed the following chart around some basic questions to highlight the differences between the qualities:

In considering the challenges facing your organization, different qualities of leadership are necessary in differing amounts to enable the organization to deliver the best results. Like many models of leadership, these five qualities are all considered “positive,” in the sense that they are all necessary to accomplish goals, though, as shown above, the amounts of each quality can vary considerably based on the specific aim. Put into the context of aging services, I’ve offered a visual depiction of the relative amounts of each quality useful in responding to the following challenges:

For each quality, too, there is a risk of using too much or too little of it, and it’s for this reason that I find the model most useful. The problems and challenges facing healthcare organizations today are myriad and diverse, and a one-size-fits-all model of leadership risks sacrificing the particular advantages of skills that might be necessary on one project but not on another. By understanding and embracing this complexity, adaptive leaders are much more effective in responding to a wide assortment of challenges and much more successful in leading a diverse range of change initiatives.

Using Plan-Do-Study-Act to Remove Alarms from a Skilled Nursing Home


Since the late 1980’s, nursing homes nationwide have taken dramatic steps to reduce the use of physical restraints among their residents. For many, this meant replacing lap belts and limb ties with bed and pull-tab alarms. These alarms attempt to alert staff to a resident about to fall, although studies of their effectiveness are inconclusive, at best. Many professionals now consider alarms to be unneeded, anachronistic, and disruptive to a resident’s wellbeing and quality of life—although removing them can be challenging, as Greenville Manor discovered.


When administrators at Greenville first proposed the idea of removing alarms, staff, family members and even some residents worried about the effect on resident safety and security. Although they were excited about eliminating the alarms to improve the atmosphere in the nursing home, the administrative team decied to utlize a Plan-Do-Study-Act (PDSA) cycle to test whether alarms could safely be removed without jeopardizing residents. A small, interdisciplinary team convened to work on the problem. By talking with staff and residents, and conducting online research, the team determined a number of root causes behind resident falls. The team also examined the process by which a nurse added an alarm to a resident’s care plan, and noted that very little investigation typically occurred. By organizing fall causes in a Pareto chart, the team was able to target the top 3 reasons and develop an education program to address those causes.


The team developed a test plan to remove an alarm from one resident and measure the results. After two weeks of no increased falls, the test was expanded to include seven additional residents (one nursing section). The team met frequently to analyze fall data and check in with staff involved in the test pilot. During the test, an alarm was discovered on one of the residents. The team quickly investigated and discovered that one of the night shift employees had been absent from a recent team meeting and did not receive the pilot notice in her mailbox. After correcting the issue, the team made a note to follow-up with a night shift focus group to talk about communication challenges and ways to better communicate between shifts.


After one month, the team determined that removing the alarms had actually resulted in a slight decrease in the number of falls in that section. (Later, the team learned that this result was not uncommon in communities that were successful in removing alarms.) The team decided to move forward with expanding the pilot, but to adjust the communication plan to ensure all staff and other stakeholders received adequate notice of the change.


At the next all-staff meeting, the team shared the results of the test, and solicited reactions from other team members. Staff who were involved in the pilot, along with the project team, responded to questions and helped to allay remaining fears about removing alarms throughout the community. Over the next three months, successive neighborhoods removed alarms while staff carefully monitored fall data. A community-wide party celebrated the removal of alarms, and a record of the before and after fall data was prominently displayed in the staff conference room.

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