1. health and fitness
2. disease
3. diabetes

Athena Forum Institute
®
ACO Workforce Performance
21st Century Training for Healthcare Professionals
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 & Publisher
Senior Fellow, Jefferson School of Population Health
[email protected]
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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
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Baldrige National Quality Program in Healthcare
• 
A healthcare organization that values its staff is committed to their satisfaction, development, and
well-being.
• 
Baldrige Award recipients are focused on creating and maintaining a productive learning and
caring work environment for all staff.
• 
Example: Bronson Methodist Hospital -- Baldrige Recipient -- for workplace excellence.
• 
Example: Baptist Hospital, Inc. -- Baldrige Recipient -- for building a systematic approach to
building patient relationships through staff empowerment training.
• 
Source: National Institute of Standards & Technology, U.S. Dept of Commerce. www.baldrige.nist.gov
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Define Management!
• 
Management is getting work done through others.
RN Care
Coordinators
ACO Care Director
SW Care
Coordinators
Pharmacist Care
Coordinators
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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.
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ACO Workforce Performance
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Design
Athena Forum Institute® was designed in 2008 by dozens of population health managers from:
Aetna, CIGNA, Humana & WellPoint. Before the “ACO” was invented.
Athena Forum has 3 features -- to improve team performance:
1. Management Tool:
Directors assign courses to steer the team to ACO priorities.
2. CE Machine for Staff:
Staff love Athena Forum for 600 CE accessible from any computer.
3. Clinical Reference Tool:
6,000 page curriculum is searchable ( 21st Century PDR )
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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 for your Medicare seniors,
3. 
Demonstrate measures toward enhancing the patient experience (customer service) of seniors,
4. 
Become the high-quality – low-cost provider in your region.
5. 
Athena Forum s education supports measures 1, 2, & 3.
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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
¨ 
¨ 
¨ 
¨ 
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Diabetes
Hypertension
Ischemic vascular disease
Heart failure
Coronary artery disease
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Athena Forum Care Management Series® Slide 1 of 2
CM Express
Establishing Your Professional Identity
Mod A: Essentials of Case Management
Mod B: Importance of Claims
Mod C: Resource Management
Mod D: Transitions of Care / Patient Experience
Mod A: Essentials
Mod B: Critical Thinking
Mod C: Emotional Intelligence
Mod D: Conflict Resolution
Mod E: Leadership
Discharge Planning
Mod F: Difficult People
Mod A: Philosophy & Standards
Mod B: Patient Centered Approach to DP
Mod C: External Forces in DP
Hospital Revenue Cycle
Mod A: Industry Cash Flow
Mod B: Hospital Cash Flow: Claims, RAC, Avoidable Days
Ethics in Case Management
Mod A: Ethical Standards of Practice
Mod B: CM Ethics in the Hospital Setting
Mod C: Ethics in the Telecare Era
Mod D: Ethics in Large Corporate Cultures
Mod E: Ethics in the Community Health Setting
Patient Advocacy
Mod A: Advocacy & Care Management
Mod B: Right Care Guidelines for our Patients
Mod C: Key Components to Care Success
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Athena Forum Care Management Series®
Part 2 of 2
Population Healthcare
ACO Excellence (autumn 2014)
Mod A: Prior Authorizations
Mod B: Concurrent Review
Mod C: Transitions of Care
Mod A: ACO Preventive Care Programs for Our Medicare Seniors
Mod B: ACO Chronic Care Management Programs for Our Medicare Seniors
Mod C: ACO Excellence in Customer Service (Enhancing the Pt Experience)
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
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Athena Forum Clinical Care Series®
Slide 1 of 3
Asthma
CV Risk: Stroke & MI
Mod A: Prevalence & Pathophysiology
Mod B: Assessment
Mod C: Treatment
Mod D: Care Manager’s Role in Asthma
Mod A: Prevalence & Pathophysiology
Mod B: Stroke & The Care Manager’s Role
Mod C: MI & The Care Manager’s Role
Colorectal Cancer
Diabetes
Mod A: Prevalence & Pathophysiology
Mod B: Symptoms & Management
Mod C: Treatments & Interventions
Mod A: Therapies
Mod B: Assessments & Complications
Mod C: Pharmacologic in Diabetes Care
Mod D: Standards of Medical Care
COPD
EOL & Palliative Care
Mod A: Prevalence & Pathophysiology
Mod B: Assessments & Complications
Mod C: Pharmacologics in COPD
Mod D: Care Manger’s Role
Mod E: Pneumonia
Mod A: The Evolving Role of the Hospital in EOL Care
Mod B: Patient Goals in End-Of-Life Care
Mod C: Symptom Management
Mod D: Regulations & Reimbursements in EOL
Mod E: The Care Manager’s Role in EOL
COPD rates are rising in women.
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Athena Forum Clinical Care Series® Slide 2 of 3
GI Disorders
Obesity Management
Mod A: Ulcerative Colitis
Mod B: Crohn’s Disease
Mod C: Diverticulitis
Mod A: Prevalence & Pathophysiology
Mod B: Assessments & Complications
Mod C: Treatments & Interventions
Mod D: Care Manager’s Role in Obesity Management
Heart Failure
Pain Management
Mod A: Prevalence & Pathophysiology
Mod B: Assessment & Complications
Mod C: The Care Manager’s Role
Mod A: Pathophysiology of Pain
Mod B: Acute Pain
Mod C: Chronic Pain
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
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Athena Forum Clinical Care Series® Slide 3 of 3
Rheumatoid Arthritis
Women’s Health
Mod A: Prevalence & Pathophysiology
Mod B: Assessments & Complications
Mod C: Treatments & Interventions
Mod D: Care Manger’s Role
Mod A: The Perimenopausal Years
Mod B: Complications in Menopause Care
Mod C: Sexuality in Maturity
Mod D: Care Manager’s Role
Sepsis Care
Wound Care
Mod A: Prevalence & Economics
Mod B: Pathophysiology & Assessment
Mod C: Sources & Predispositions
Mod D: Prevention & Treatment
Mod E: Care Manager’s Role in Sepsis
Mod A: Prevalence & Pathophysiology
Mod B: Assessments & Complications
Mod C: Treatments & Interventions
Mod D: Prevention Strategies
Mod E: Care Manager’s Role in Wound Care
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Athena Forum Behavioral Health Series®
Anxiety Disorders
Elder Abuse [summer 2014
Child Abuse [summer 2014]
Harm Risk Behaviors
Cross Cultural Practice [autumn 2014]
HIV/AIDS Counseling [autumn 2014]
Depression: Prevalence & Societal Impact
Medication Errors Preventions [autumn 2014]
Depression: Pathophysiology
Substance Abuse
Depression: Non-Pharmaceutical Treatments
Depression: Pharmaceutical Treatments
Depression: Care Manager’s Role
Domestic Violence [summer 2014]
[BH: 1,000 pages online & in development; CE for SW & RN]
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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%.
Table 4.2. Goals for Glycemic Control
A1C
Goal
Action
Suggested
4%-6%
< 7%
> 8%
< 110
mg/dL
90-130
mg/dL
< 90 / > 150
mg/dL
Plasma Values
Average
preprandial
glucose
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]
Normal
Average
< 120
bedtime glucose mg/dL
110-150 <110 / > 180
mg/dL
mg/dL
Whole Blood Values
Average
preprandial
glucose
< 100
mg/dL
Average
< 110
bedtime glucose mg/dL
80-120
mg/dL
< 80 / > 140
mg/dL
100-140 <100 / > 160
mg/dL
mg/dL
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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]
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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]
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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]
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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]
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Pricing
4 Levels of Educational Subscriptions:
1. Alpha Subscriber (large hospitals > 500 beds):
$5,500.00 year
2. Beta Subscriber (medium hospitals 100 – 499 beds)
$3,500.00 year
3. Charter Subscriber (hospitals < 99 beds) & Med Group & SNF
$ 950.00 year
4. Or Individual Subscribers
$
225.00 year
All benefits are available to all subscribers:
• 
Complimentary Webinars for Management Orientations,
• 
Complimentary Webinars for Staff Orientations,
• 
Unlimited personnel enrollments for Alpha, Beta & Charter Subscribers,
• 
24/7 access to all 600 CE certificates for all (RN, SW, ACM & CCM credentials),
• 
Accessible from all mobile devices (e.g. Nook, Kindle, iPad) from any Wi-Fi location,
• 
All subscribers receive all new courses added to the curriculum (1,000 new pages added yearly).
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ACO Subscription Package Example #1
ACO System #1:
• 
Alpha Subscriber (large hospital 600 beds)
• 
Beta Subscriber (medium hospital 200 beds)
• 
Beta Subscriber (medium hospital 240 beds)
• 
Beta Subscriber (medium hospital 190 beds)
• 
Charter Subscribers (20 medical groups X $950)
• 
2 Trainers from BlueCross (2 RN s X $225)
Total:
$ 5,500
3,500
3,500
3,500
19,000
450
$35,450 year
ACO Personnel Training Costs = $11.14 per person, per year.
• 
All hospital care coordinators enrolled = 100
• 
All hospital floor nurses enrolled (bonus for clinical courses) = 3,000 floor nurses
• 
All medical group care coordinators enrolled = 80
• 
Total enrolled personnel = 3,180 / $35,450 = $11.14 training cost per person per year.
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ACO Subscription Package Example #2
ACO System #2:
• 
Alpha Subscriber (large hospital 600 beds)
• 
Beta Subscriber (medium hospital 200 beds)
• 
Beta Subscriber (medium hospital 240 beds)
• 
Beta Subscriber (medium hospital 190 beds)
• 
Beta Subscriber (medium hospital 201 beds
• 
Charter Sub (small hospital 90 beds)
• 
Charter Sub (small hospital 65 beds)
Total:
$ 5,500
3,500
3,500
3,500
3,500
950
950
$21,400 year
ACO Personnel Training Costs = $10.34 per person, per year.
• 
All hospital care coordinators enrolled = 68
• 
All hospital floor nurses enrolled (bonus for clinical courses) = 2,000 floor nurses
• 
Total enrolled personnel = 2,068 / $21,400 = $10.34 training cost per person per year.
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Return-On-Investment Discussion
Dear CFO,
“As mentioned, I would like to request a new training budget of $25,000 from our ACO contract to train our 100 care
coordinators, as well as about 2,000 floor nurses under this flat rate contract. Our training costs can be expressed as
training 2100 clinical personnel for $12.00 per person, per year, including all CE certificates. Bargain.
“The online training vendor is Athena Forum Institute and they specialize in supporting ACO companies comply with
Medicare’s patient quality measures on diabetes, heart failure, coronary artery disease and others.
“ROI: Training our clinical teams: helps increase our Medicare scores – our increased scores improves the probability
of Medicare renewing our $200M contract next year.
Thank you.
Vice President
ACO Care Management Operations
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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
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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).
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Sample ACO Implementation Memo 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.
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:
AUG:
SEP:
OCT:
NOV:
DEC:
COPD: Mod B: Assess & Manage
No assignment. At the beach.
Professional ID: Conflict Resolution
Heart Failure: Mod C Interventions
Hospital Revenue Cycle Module C
No assignment. Happy Holidays.
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Accreditations: 100% Volume for RN, SW, ACM, CCM • 
Athena Forum offers 600 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 48 states.
• 
Social Work in California: Approved CE Provider by the California Board of Behavioral Sciences.
• 
ACM: Approved Provider by the ACMA (American Case Management Association)
• 
CCM: Approved Provider of CCM CE by the CCMC (Certified Case Managers Commission)
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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.
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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.”
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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.
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Sample Workforce Development Plan
Staff Performance Plan for 2014:
Advancing My Practice:
• 
JAN 2014: Ischemic Vascular Disease
Mod B: CV Risk: Stroke & CM Role
This course supports the Medicare Patient Quality Measure
on improving care on ischemic vascular disease.
• 
FEB 2014: Professional Identity
Mod C: Emotional Intelligence
Learn how to control your emotions to make better decisions.
• 
MAR 2014: Diabetes
Mod A: Diabetes Therapies
Supporting the Medicare Patient Quality Measure on diabetes.
• 
APR 2014: COPD
Mod E: CM Role in COPD Care
Enhancing the patient-centered approach in COPD care.
Instructs on motivational interviewing for behavior mod.
• 
MAY 2014: Professional Identity
Mod F: Interacting with Difficult People
News Flash! Sometimes there are difficult people in our work.
This course instructs on getting the job done with less stress.
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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
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Contact us:
Healthcare Sales
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]
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