PREVENTING HEART FAILURE READMISSIONS
|
|
|
- Jessie Carr
- 8 years ago
- Views:
Transcription
1 PREVENTING HEART FAILURE READMISSIONS Tanya Sprinkle, BSN, RN, CCM Patient and Family Services Coordinator Michelle Roseman, NHA, MBA Chief Operating Officer/Catawba Regional Hospice Juanita Zwiener, RN, CCM, CRRN CareLink Navigator IREDELL HEALTH SYSTEM! Not-for-profit hospital located in Statesville, N.C.! 199 acute care beds! 48 skilled nursing beds! Home Health Agency Iredell Home Health! Iredell Physician Network, LLC STEP 1 Established Community Coalition! October 2012 Kick-off meeting! 30+ participants (HH, SNF, 3 rd Party Payers, Community Agencies)! Reviewed Community-wide Demographics and Readmissions data! Obtained commitment from participants to engage in Root Cause Analysis! Established Steering Team! Added 2 nd Hospital in Community to Coalition December
2 STEP 2 Conducted Root Cause Analysis! Focus Groups (Community Service Providers, Hospital Discharge Planners, Beneficiaries, Hospital Executives, Hospital Clinical Teams, Community Physicians, Palliative Care Providers, Community Care Coordinators)! Hospital Patient Tracers! Chart Reviews (Hospital 55 reviews, HH 40 reviews, SNF 20 reviews)! Analysis of Medicare Claims-based Data STEP 3 Shared / Analyzed RCA Findings! RCA Findings presented to Community Coalition April 2013! 30+ participants (HH, SNF, 3 rd Party Payers, Community Agencies)! Follow-up Steering Team Meeting to review RCA findings and determine initial area(s) of focus RCA FINDINGS! Lack of Patient & Family Education on Disease Process! Lack of Resources and Services! The need to improve the Discharge Planning Processes! Lack of Communication across the Continuum of Care! Lack of Access / MD Follow Up 2
3 STEP 4: Improvement Strategies Developed RCA Finding #1 Lack of Patient & Family Education on Disease Process! Transition from lengthy Education booklets to Easy-to- Read 1-3 pg. educational materials from Cerner EHR to address low literacy level! Staff Education on education techniques, including Teach-back! Emphasis on ongoing education instead of discharge instruction.! Engaged Respiratory Care staff in education of respiratory patients (i.e., COPD, Pneumonia)! Launching Pulmonary Rehabilitation program. RCA Finding #2 Lack of Resources and Services! Established bi-weekly meetings with Medicaid Managed Care representatives to develop individualized care plans for patients with 30-day readmissions and/or high Emergency Dept. utilization! Community Agencies invited to perform inservice education for Case Management / SW staff.! Working with Blue Medicare to provide patient discharge information day after discharge to facilitate case mgmt. 3
4 RCA Finding #3 Need to Improve Discharge Planning Processes! Restructured Case Mgmt./SW Dept. to separate Utilization Review & Discharge Planning functions and increase discharge planning resources.! Increased Weekend staff coverage! Standardized documentation in EHR! Established new performance expectations for Discharge Planning staff including expectations for initial assessment, prioritization of patients, and follow-up assessment.! Implemented Discharge Risk Assessment Screening Tool to prioritize patients RCA Finding #4 Lack of Communication Across the Continuum of Care! Worked with IS Dept to improve processes for communicating patient information to post-acute care providers. (Ongoing)! Established process for Nurse-to-Nurse report for patients transferred to extended care facilities.! Communicating with Medicaid AccessCare to initiate case mgmt. services for high risk patients proactively instead of waiting until readmission has occurred.! Notifying PCPs of high-risk patients and need for f/u within 7 days of discharge.! Continue with Community Coalition meetings / data sharing quarterly. RCA Finding #5 Lack of MD Access / Follow-up! Placed increased emphasis on Discharge Planner identifying PCP for unattached patients.! Placed increased emphasis on Discharge Planner scheduling follow-up appointments for Community Clinic patients! Discharge Planner entering Follow-up Within 7 days into EHR Discharge Instructions when high-risk patient identified.! Provided MD education on importance of early follow-up.! Partnered with CareLink to initiate Nurse Navigation program July
5 CareLink Referrals Readmission Rate Comparison Readmission Rate Summary Oct Oct CareLink Readmission Rate 16.85% (45/267) Excluding Pts. Not Seen Before Readmitted 14.94% (39/261) Pts. D/C'd to Other Providers 26.50% (31/117) Pts Unable to Contact / Refused 19.83% (23/116) Overall Readmission Rate 19.80% (99/500) THE RESULTS: OBSERVED TO EXPECTED READMISSION RATES 5
6 LESSONS LEARNED! It takes a village!! There is no magic bullet.! There s no need to re-invent the wheel.! You can t undo systems in six months that took years to create.! Slow and steady wins the race. QUESTIONS? tanya.sprinkle@iredellmemorial.org mroseman@pchcv.org jzwiener@pchcv.org
Care Transitions: Success Stories and Lessons Learned
Care Transitions: Success Stories and Lessons Learned Kim McCoy, Stratis Health Kris Garman, Redwood Area Hospital Joleen Johnson, Redwood Area Hospital June 29, 2015 Objectives Learn strategies for implementation
Care Coordination at Frederick Regional Health System. Heather Kirby, MBA, LBSW, ACM Assistant Vice President of Integrated Care
Care Coordination at Frederick Regional Health System Heather Kirby, MBA, LBSW, ACM Assistant Vice President of Integrated Care 1 About the Health System 258 Licensed acute beds Approximately 70,000 ED
Joan Carroll RN, CDMS, CCM Director of Care Transitions Lee Memorial Health System
Joan Carroll RN, CDMS, CCM Director of Care Transitions Lee Memorial Health System 1 Explain how patients experience transitions of care Identify variables that affect transitions due to lack of patient
COPD 30 Day Readmission Project SAINT THOMAS RUTHERFORD MURFREESBORO, TN SEPTEMBER 15, 2015 DAVID M. SELLERS, MD, MBA
COPD 30 Day Readmission Project SAINT THOMAS RUTHERFORD MURFREESBORO, TN SEPTEMBER 15, 2015 DAVID M. SELLERS, MD, MBA USA COPD Data 24 Million Americans under the age of 65 with COPD Almost 20% readmit
Population Health Management: Banner Health Network s Perspective. Neta Faynboym, Medical Director Banner Health Network
Population Health Management: Banner Health Network s Perspective Neta Faynboym, Medical Director Banner Health Network 29 Acute Care Hospitals BANNER AT A GLANCE Banner Health Network with 400K lives
Coordinating Transitions of Care: It Takes a Village
Coordinating Transitions of Care: It Takes a Village Ken Laube RN, BSN, MBA: Vice President Clinical Excellence Situation/Background Patients face significant challenges when moving from one health care
How To Reduce Hospital Readmission
Reducing Hospital Readmissions & The Affordable Care Act The Game Has Changed Drastically Reducing MSPB Measures Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE
Transitions of Care: The need for collaboration across entire care continuum
H O T T O P I C S I N H E A L T H C A R E, I S S U E # 2 Transitions of Care: The need for collaboration across entire care continuum Safe, quality Transitions Effective C o l l a b o r a t i v e S u c
Readmissions as an Enterprise Priority. Presenters 4/17/2014
Readmissions as an Enterprise Priority April 24, 2014 Presenters Vincent A. Maniscalco, MPA, LNHA Administrator Middletown Park Rehabilitation and Health Care Center Vmaniscalco@parkmanorrehab.com Eileen
Using Root Cause Analysis to Determine Why Readmissions are High. Presentation Objectives. Background Information 11/30/2011
Using Root Cause Analysis to Determine Why Readmissions are High Nancy Seck RBN, BSN, MPH, CPHQ Director, Quality Management Glendale Memorial Hospital and Health Center Presentation Objectives Identify
A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates. April 11, 2014
A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates April 11, 2014 About the QIO Program Leading rapid, large-scale change in health quality: Goals are bolder. The patient is at
Plenary Session 1. Health Dimensions Group. 2010 Health Dimensions Group
Plenary Session 1 Kathleen M. Griffin, PhD Health Dimensions Group March 31, 2011 Hospital, Post Acute and Long-Term Care Collaboration in Health Care Reform: Critical Success Factors National Summit:
Erlanger s Care Transitions. Working Together. UT Resident Orientation June 26, 2015
Erlanger s Care Transitions Working Together UT Resident Orientation June 26, 2015 WHAT IS CARE TRANSITIONS? What is Care Transitions? A program that has been formed to meet and exceed CMS changes from
Get With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15
Get With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15 Date and time first seen by ED MD: The time entered should be the earliest
ACO Operational Innovations Featuring the Winners of NAACOS Call for Innovation
ACO Operational Innovations Featuring the Winners of NAACOS Call for Innovation January 14, 2014 Brian Silverstein, MD Managing Partner HC Wisdom briansilverstein@hcwisdom.com April 24,2014 AGENDA INNOVATION
Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management
Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management According to AARP, about 8000 people turn 65 every day The Medicare Trustees have estimated that Medicare will run out of money
Optum s Role in Mycare Ohio
Optum s Role in Mycare Ohio What is MyCare Ohio? New opportunities generated by the Affordable Care Act have allowed Ohio to implement the MyCare Ohio program. MyCare Ohio is a demonstration project that
Atrius Health Pioneer ACO: First Year Accomplishments, Results and Insights
Atrius Health Pioneer ACO: First Year Accomplishments, Results and Insights Emily Brower Executive Director Accountable Care Programs Emily_Brower@AtriusHealth.org November 2013 1 Contents Overview of
Collaborations. from the Field
Care Transitions Community Wide Collaborations Best Practices and Experiences Best Practices and Experiences from the Field CCTP Monthly Webinar: July 2012 This webinar focused on the topic of engaging
CASE MANAGEMENT F R O M A C U T E C A R E T O T H E C O M M U N I T Y A C R O S S T H E C O N T I N U U M O F C A R E
CASE MANAGEMENT F R O M A C U T E C A R E T O T H E C O M M U N I T Y A C R O S S T H E C O N T I N U U M O F C A R E CASE MANAGEMENT Case Management is a collaborative process of assessment, planning,
Parkview Health s Population Health Journey
Parkview Health s Population Health Journey Susan McAlister DNP, RN Director Enterprise Care Management Christine Howell BSN, RN Community Based Registered Nurse Objectives: By the completion of the webinar
RT AS PROJECT MANAGER:
RT AS PROJECT MANAGER: IMPROVING CARE TRANSITIONS DECREASES UNPLANNED READMISSIONS TAMMY JARNAGIN, BHS, RRT DIRECTOR CARDIOPULMONARY SERVICES, NEURODIAGNOSTICS, HOME MEDICAL EQUIPMENT Objectives Recognize
Post-Acute Care Transitions: An Essential Component of Accountable Care
: An Essential Component of Accountable Care Bruce C. Smith, MD, FACP Associate Medical Director, Strategy Deployment Group Health Physicians, Seattle, WA Smith.bc@ghc.org AMGA 2012 Institute for Quality
Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services
Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services Objectives Understand the new consequences to hospitals for discharged clients being re-admitted within selected time
Reducing Avoidable Readmissions Effectively (RARE) Kathy Cummings, RN, BSN, MA Institute for Clinical Systems Improvement
Reducing Avoidable Readmissions Effectively (RARE) Kathy Cummings, RN, BSN, MA Institute for Clinical Systems Improvement Martha and James Acute Episodes Family Doctor Life Expectancy from chronic diseases
Patient to Person. Transitions of Care. Colby Bearch, MA-SF, MA-M, BA, RN, CDONA Sharyn King, RN, BSN, CCM
Patient to Person Transitions of Care Colby Bearch, MA-SF, MA-M, BA, RN, CDONA Sharyn King, RN, BSN, CCM Transitions of Care Transitioning from school to adult services (vocational, medical day, etc.)
Understanding Care Transitions as a Patient Safety Issue
Article reprinted from Patient Safety & Quality Healthcare, May/June 2011 Understanding Care Transitions as a Patient Safety Issue By Sara Butterfield RN, BSN, CPHQ, CCM; Christine Stegel, RN, MS, CPHQ;
Accountable Care Fundamentals for Medical Practice Executives
Accountable Care Fundamentals for Medical Practice Executives Nathan Anspach, FACMPE Senior Vice President and Chief Executive Officer John C. Lincoln Accountable Care Organization and John C. Lincoln
Call-A-Nurse Location
Call-A-Nurse A 24-hour medical call center, specializing in registered nurse telephone triage, answering service, physician and service referral, and class registration. Call-A-Nurse Location Call-A-Nurse
UCare provides case management for all UCare members not affiliated with one of the above listed care systems. 2011 UCare for Seniors
Case Requirements Updated 3/16/2011 According to the Case Society of America (CMSA), Case Model Act of 2009, Case management is a collaborative process of assessment, planning, facilitation, care coordination,
Henry Ford Health System Care Coordination and Readmissions Update
Henry Ford Health System Care Coordination and Readmissions Update September 2013 BACKGROUND Most hospital readmissions are viewed as avoidable, costly, and in some cases as a potential marker of poor
Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015
Leveraging the Continuum to Avoid Unnecessary Utilization While Improving Quality Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015 Karim A. Habibi, FHFMA, MPH, MS Senior
Medicare Savings and Reductions in Rehospitalizations Associated with Home Health Use
Medicare Savings and Reductions in Rehospitalizations Associated with Home Health Use June 23, 2011 Avalere Health LLC Avalere Health LLC The intersection of business strategy and public policy Table of
#Aim2Innovate. Share session insights and questions socially. UCLA Primary Care Innovation Model 6/13/2015. Mark S. Grossman, MD, MBA, FAAP, FACP
UCLA Primary Care Innovation Model Mark S. Grossman, MD, MBA, FAAP, FACP Chief Medical Office, UCLA Community Physicians & Specialty Care Networks June 16, 2015 DISCLAIMER: The views and opinions expressed
Reducing Readmissions with Predictive Analytics
Reducing Readmissions with Predictive Analytics Conway Regional Health System uses analytics and the LACE Index from Medisolv s RAPID business intelligence software to identify patients poised for early
5/10/13 HEALTH CARE REFORM LONGITUDINAL CARE COORDINATION HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO WHY WHAT HOW WHEN WHO
TRANSITION CARE TRANSITION CARE WHY WHAT HOW WHEN WHO HEALTH CARE REFORM HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO Cost/Quality equation Higher cost care has not/does not equate with higher
Connect4 Patients CCCM Primary Care Community. Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM
Connect4 Patients CCCM Primary Care Community Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM September 17, 2015 Objectives: Describe innovative care management
Coaching Patients to Improve Care Transitions in Pennsylvania. May 26, 2010
Coaching Patients to Improve Care Transitions in Pennsylvania Naomi Hauser, RN, MPA, CLNC Director Care Transitions Quality Insights of Pennsylvania Dr. Eric Coleman, MPH Professor of Medicine University
Learning Collaborative
Care Transitions Intervention Model to Reduce 30-Day Readmissions for Chronic Cardiac Conditions Learning Collaborative Dr. Norma Jean-Francois, DNP, APN-C Dr. Mary Anne Marra, DNP, MSN, RN, NEA-BC 1 OVERVIEW
The Trinity Pioneer Story ACO SETTLERS THE PIONEER JOURNEY TO THE TRIPLE AIM. Sue Thompson Chief Executive Officer
The Trinity Pioneer Story ACO SETTLERS THE PIONEER JOURNEY TO THE TRIPLE AIM Sue Thompson Chief Executive Officer 2 UnityPoint Health: Organizational Profile 3 4 UnityPoint Health Fort Dodge: Organizational
Kick off Meeting November 11 13, 2015. MERCY CLINIC EAST COMMUNITIES Management of Patients with Heart Failure (HF)
Kick off Meeting November 11 13, 2015 MERCY CLINIC EAST COMMUNITIES Management of Patients with Heart Failure (HF) Team Composition Justin Huynh, MD Internal Medicine, Physician Champion Mary Laubinger,
PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT. Norris Vivatrat, MD Associate Medical Director Monarch HealthCare
PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT Norris Vivatrat, MD Associate Medical Director Monarch HealthCare 2 Agenda Pioneer ACO basics, performance and challenges Monarch HealthCare Post-acute network
PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT
PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT Norris Vivatrat, MD Associate Medical Director Monarch HealthCare 2 Agenda Pioneer ACO basics, performance and challenges Monarch HealthCare Post-acute network
MERCY-CR/UI HEALTH CARE ACCOUNTABLE CARE ORGANIZATION Dan Fick, M.D. Timothy Quinn, M.D.
MERCY-CR/UI HEALTH CARE ACCOUNTABLE CARE ORGANIZATION Dan Fick, M.D. Timothy Quinn, M.D. November, 2012 Accountable Care Organization An ACO is a group of health care providers who agree to take on a shared
Quality Provisions Ordered by Implementation Date
1 3006, 10301 2 1311 3 3006, 10301 by Secretary 10/1/2011 Ambulatory Surgery Centers 10/1/2011 Providers in HBE shall be accredited with respect to local performance on clinical quality measures (e.g.,
What is the prior authorization process for Skilled Nursing Facility Admission?
MyCare Long Term Care (LTC) Nursing Facility FAQs The nursing facility network is an essential part of the health care delivery system and we value your partnership. We appreciate the compassion you offer
Southern California Patient Safety Collaborative
Southern California Patient Safety Collaborative Track II: Care Transitions March 6 th, 2012 Markus Mettler, NHA, PT : REDUCING SNF TO ACUTE RE-HOSPITALIZATIONS Markus Mettler, NHA, PT 20 years in Healthcare
Nurse Transition Coach Model: Innovative, Evidence-based, and Cost Effective Solutions to Reduce Hospital Readmissions
Nurse Transition Coach Model: Innovative, Evidence-based, and Cost Effective Solutions to Reduce Hospital Readmissions Leslie Becker RN, BS Jennifer Smith RN, MSN, MBA Leslie Frain MSN, RN Jan Machanis
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Discharge Planning
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services ICN 908184 October 2014 This booklet was current at the time it was published or uploaded onto the web. Medicare policy
UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services
UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services Call us: 1-888-898-7969, Option 1, then Option 4 Fax us: 1-800-594-7404 Business hours: Monday Friday (excluding holidays), 8:30 a.m. to
2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF)
2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) Project Objective: Skilled nursing facilities (SNFs) will implement the evidence based INTERACT program developed
How Will Hospital Readmission Penalties Impact Skilled Nursing Facilities?
How Will Hospital Readmission Penalties Impact Skilled Nursing Facilities? Patrick V. Trotta, CPA Director of ElderCare Provider Services Glass Jacobson patrick.trotta@glassjacobson.com 410 356 1000 Presentation
High Rehospitalization Rates: Evaluation and Impact
High Rehospitalization Rates: Evaluation and Impact May 29, 2009 Denise Remus, PhD, RN Chief Quality Officer, BayCare Health System BayCare Health System BayCare is the largest full-service, community-based
PCMH and Care Management: Where do we start?
PCMH and Care Management: Where do we start? Patricia Bohs, RN, BSN Quality Assurance Manager Kelly McCloughan QA Data Manager Wayne Memorial Community Health Centers Honesdale, PA Wayne Memorial Community
Preparing for the Hospital Readmission Reduction Program
Preparing for the Hospital Readmission Reduction Program Hospital readmission rates have been rising throughout the years, and the cost of healthcare with them. According to a study conducted by Vincent
David Eubanks, RN, MSN Billie Papasifakis, RN-BC, MSN, AACC. Describe model of care most appropriate
THE BRIDGE PROGRAM David Eubanks, RN, MSN Billie Papasifakis, RN-BC, MSN, AACC Pamela Teenier, RN, MBA, COC-C, C HCS-D HCSD 1 Objectives Describe model of care most appropriate for a Bridge program from
3/11/15. COPD Disease Management Tackling the Transition. Objectives. Describe the multidisciplinary approach to inpatient care for COPD patients
Faculty Disclosures COPD Disease Management Tackling the Transition Dr. Cappelluti has no actual or potential conflicts of interest associated with this presentation. Jane Reardon has no actual or potential
Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation
How Does CMS Measure the Rate of Acute Care Hospitalization (ACH)? Until January 2013, CMS measured Acute Care Hospitalization (ACH) through the Outcomes Assessment and Information Set (OASIS) reporting
Medical Necessity & Charting Guidelines
Medical Necessity & Charting Guidelines 1 In most cases we are told the rules up front - or will be told if we ask Like most games, the one who knows the rules the best WINS 4 2 Nationally Recognized Industry
3/16/2016. Preventing Readmissions Through Compliant Patient Transitions. Transition of Care Statistics. Care Transitions The Regulatory Environment
Preventing Readmissions Through Compliant Patient Transitions Deborah L. Carlino, RN, MBA, CHC, CHRC Director of Healthcare Compliance and Audit - Rutgers, The State University of New Jersey Melanie A.
WHITE PAPER. How a multi-tiered strategy can reduce readmission rates and significantly enhance patient experience
WHITE PAPER How a multi-tiered strategy can reduce readmission rates and significantly enhance patient experience Vocera Communications, Inc. June, 2014 SUMMARY Hospitals that reduce readmission rates
PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems
PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems By Kathleen M. Griffin, PhD. There are three key provisions of the law that will have direct impact on post-acute care needs
5/13/2011. ACO Partnerships A Case Study. Contents: The Strategic Imperative for Accountable Care
ACO Partnerships A Case Study Bob Edmondson, MPH Vice President, Innovation West Penn Allegheny Health System Pittsburgh, PA 1 Contents: 1. The Strategic Imperative for Accountable Care 2. Population Health
RIH Transitions of Care Collaboration with Coastal Medical To Improve Transitions for Patients Discharged Hospital To Home
RIH Transitions of Care Collaboration with Coastal Medical To Improve Transitions for Patients Discharged Hospital To Home Sergio Petrillo, PharmD Clinical Pharmacist Specialist, Rhode Island Hospital
With New Models of Value-Based Care. September 1, 2015
With New Models of Value-Based Care September 1, 2015 Using Community Care Coordination and Mobile Technology to Impact Health Outcomes and Reduce Avoidable Hospital Encounters Presenters: Chris Parsons,
ACO CASE STUDY CATHOLIC MEDICAL PARTNERS: BUFFALO, NEW YORK
ACO CASE STUDY CATHOLIC MEDICAL PARTNERS: BUFFALO, NEW YORK January 2011 ACO CASE STUDY CATHOLIC MEDICAL PARTNERS: BUFFALO, NY Prepared by: Keith D. Moore / kmoore@mcmanisconsulting.com & Dean C. Coddington
Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed
Care Coordination The Embedded Care Manager Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed Goals of Care Management The goals of care Management are consistent with the Triple Aim: Improve population
10/16/2013. Partnering with Skilled Nursing Facilities & Home Health Agencies to Prevent Hospital Readmissions. Cedars-Sinai Health System
Partnering with Skilled Nursing Facilities & Home Health Agencies to Prevent Hospital Readmissions Kelley Hart, LVN, Katie Gurvitz, MHA, Michelle Hofhine, RN Turning on the High Beams October 10, 2013
Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment
Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Donna Zazworsky, RN, MS, CCM, FAAN Vice President: Community Health and Continuum Care Carondelet Health
It Takes Two to ACO A Unique Management Partnership
AMGA 2014 Annual Conference, April 4, 2014 It Takes Two to ACO A Unique Management Partnership Scott Hayworth MD, President & CEO Mount Kisco Medical Group Alan Bernstein MD, Senior Medical Director Mount
September 2008 Update
Improving Transitions Transitions of Care Measures of Care September 2008 Update THE VISION OF THE NATIONAL TRANSITIONS OF CARE COALITION Paper by the NTOCC Measures Work Group, 2008 www.ntocc.org MAY
Be Careful What You Ask For A Predictive Model That Really Works
Be Careful What You Ask For A Predictive Model That Really Works Rod Christensen, MD President, Allina Health Clinics Cheryl Hermann, RN, MBA Vice President, Clinic Operations & Patient Care Services Karen
Homeward Bound. Amanda Melvin, MSW Emily Hartman, BSN, RN Tiffany Curtis, BSN, RN, CRRN Cindy Regan, MSN, RN - BC
Homeward Bound Amanda Melvin, MSW Emily Hartman, BSN, RN Tiffany Curtis, BSN, RN, CRRN Cindy Regan, MSN, RN - BC Objectives Identify and differentiate the levels of stroke rehabilitation care. Identify
Developing Successful Hospital Partnerships
Developing Successful Hospital Partnerships Michael Logan, MHA Director of Operations Services Publication Date: May 2013 2013 Sawgrass Partners, LLC DEVELOPING SUCCESSFUL HOSPITAL PARTNERSHIPS Those aging
ST JOHN S LUTHERAN MINISTRIES. Kent Burgess President & CEO
ST JOHN S LUTHERAN MINISTRIES Kent Burgess President & CEO WHAT S CHANGING MAYBE? -The way we get paid (Reduce Cost) -The way we get measured (Better Care) -What will be required of us (More) -Partnerships/Affiliations
ACOs and Post-Acute Care:
ACOs and Post-Acute Care: Implications and Strategies for Providers Partner and Managing Director Leavitt Partners Michelle L. Templin Vice President Strategic Business Development Managed Health Care
BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM?
BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM? Uniform Data System for Medical Rehabilitation Annual Conference August 10, 2012 Presented by: Donna Cameron Rich Bajner
Eastern Massachusetts Pioneer Accountable Care Organization (ACO) Quality Standards COMMON EXPECTATIONS FOR SKILLED NURSING FACILITIES.
Eastern Massachusetts Pioneer Accountable Care Organization (ACO) Quality Standards COMMON EXPECTATIONS FOR SKILLED NURSING FACILITIES Draft 12-5-12 General: 1. Staffing: a. Low staff turnover rate. b.
Ann Hablitzel, RN, BSN, MBA Hospice Care of California
Ann Hablitzel, RN, BSN, MBA Hospice Care of California Objectives Describe the creations of new community based palliative care programs Identify criteria for admission Discuss philosophy and goals Analyze
ACO & Medicare Shared Savings Program
ACO & Medicare Shared Savings Program Office Manager and Front Desk Staff Training Maureen Pence RN BSN CCM mpence@npnwa.net 253 627 1151 February 2013 Agenda All slides and attachments will be e mailed
How to Survive and Grow Your Rehabilitation Program Through 2013
How to Survive and Grow Your Rehabilitation Program Through 2013 Rebecca H. Crouch, PT,DPT,MS,CCS,FAACVPR Coordinator of Pulmonary Rehabilitation Duke University Medical Center North Carolina Cardiopulmonary
Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases
Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases Epidemiology Over 145 million people ( nearly half the population) - suffer from asthma, depression and other chronic
THE SAN DIEGO CARE TRANSITIONS PARTNERSHIP
THE SAN DIEGO CARE TRANSITIONS PARTNERSHIP Transforming Care Across the Continuum Julianne R. Howell, Ph.D. Senior Health Policy Advisor County of San Diego Health and Human Services Agency SAN DIEGO COUNTY
Care Transitions Training Videoconference December 17, 2009 Questions and Answers
1. Q: Will the transition log be sent to the counties and care systems electronically? A: It will be available on each health plan s Web page. If a website is not available, the plan will send the form
Bridging the IT Functionality Divide in Care Coordination
Bridging the IT Functionality Divide in Care Coordination April 15, 2015 Anne Meara AVP, Network Care Management Dave Kim Strategy Advisory Service Line Executive DISCLAIMER: The views and opinions expressed
Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care
Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care Charley P. Starnes, RRT, RCP Clinical Respiratory Specialist- COPD Education Important Milestones July 2011-
High Desert Medical Group Connections for Life Program Description
High Desert Medical Group Connections for Life Program Description POLICY: High Desert Medical Group ("HDMG") promotes patient health and wellbeing by actively coordinating services for members with multiple
Get With The Guidelines Best Practices: A look at reducing 30-day heart failure readmission rates
Get With The Guidelines Best Practices: A look at reducing 30-day heart failure readmission rates Thank you for joining the webinar! The presentation will begin shortly. *Please make sure your computer
UTILIZING ADT NOTIFICATIONS TO SUPPORT POPULATION HEALTH MANAGEMENT 2015 Michigan Rural Health Conference, April 20, 2015
UTILIZING ADT NOTIFICATIONS TO SUPPORT POPULATION HEALTH MANAGEMENT 05 Michigan Rural Health Conference, April 0, 05 Paula Hedlund, Chief Innovation Officer Anne Levandoski, Chief Quality Officer The Overriding
HealthCare Partners of Nevada. Heart Failure
HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with
9/23/2014. Mission To improve the health of the people in the communities we serve.
Big Data & Reduced Readmissions Chris Myers, MS, RN, CCM, Director of Care Transitions, Texas Health Harris Methodist Hospital Hurst-Euless- Bedford Anand Shah, MD, Vice President, Parkland Center for
Care Coordination among DSRIP Partners
Care Coordination among DSRIP Partners John F. Skip Williams, Jr., MD, EdD, MPH Maureen Fahey, RN, MBA Thursday, June 25, 2015 3:00-3:30 pm OVERVIEW OF PRESENTATION New York State DSRIP Overview Brooklyn
10 Key Concepts for Higher Sales into ACOs
By Michelle O Connor President and CEO By Michelle O Connor President and CEO CMR Institute Healthcare providers are under significant pressure from government payers, commercial health plans, and patients
March 19, 2008 Team San Diego GMU Module 1 Draft 2
2 March 19, 2008 Team San Diego GMU Module 1 Draft 2 2 THE LEVEL OF COMPETITION THE LEVEL OF COOPERATION White Space (No Network) Love-Fest Rumble in the Jungle Co-opetition (San Diego County) Community-based
Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION
Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION At the end of this session, you will be able to: Identify ways RT skills can be utilized for
The Solution to your Rehab Needs
The Solution to your Rehab Needs E R G O S O L U T I O N S N E W S L E T T E R Visit our website goergorehab.com June 2011 Volume 1 The Solution to your Rehab Needs ERGO SOLUTIONS NEWSLETTER Volume 1 Ergo
Blueprint for Post-Acute
Blueprint for Post-Acute Care Reform Post-acute care is a critical component within our nation s healthcare system and an essential aspect of care for many patients making a full recovery possible after
Transitional Care at Mount Sinai The PACT Program
Transitional Care at Mount Sinai The PACT Program Maria Basso Lipani, LCSW Program Director, PACT Mount Sinai Hospital Mount Sinai Medical Center Founded in 1852 1,171-bed tertiary-care teaching and research
Best Practices in Managing Patients With Chronic Obstructive Pulmonary Disease (COPD)
Best Practices in Managing Patients With Chronic Obstructive Pulmonary Disease (COPD) Geisinger Health System Case Study Organization Profile Geisinger Health System is a physician-led, fully integrated
Home Care s Pivotal Role in Patient Transitions from Acute to Post Acute Care Settings:
Home Care s Pivotal Role in Patient Transitions from Acute to Post Acute Care Settings: Experiences of a Successful CCTP Program And So Much More! Jane Pike-Benton Senior Director, Home Health & Post Acute