1 An Introduction to Transitional Care, Polypharmacy and Health Literacy Developed by Jennifer Heffernan MD
2 Outline Define transitional care Appreciate the impact of discharge quality and outcome on older patients, their caregivers and physicians who care for them Review interventions to improve transitional care Discuss how polypharmacy and health literacy affect the quality of transitional care
3 Outline Avoiding pitfalls: Nursing home to hospital Hospital to home Hospital to another institution
4 Transitional Care A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different health care settings Source: Coleman and Berenson. Lost in Transition. Ann Intern Med 2004;140:
5 Different Healthcare Settings Different locations or different levels of care within the same location Hospitals Rehabilitation Facilities Assisted Living Long-Term Care Hospice Physician s Offices Patient s Home
6 Why does it matter? Patients get lost in transition Adverse events are common Medical errors are newsworthy
7 #1 IOM report To Err is Human - Extrapolated from 2 studies which found % rate of adverse events during hospital admission (53-58% preventable) - Based on 33.6 million admissions 44-98K deaths due to medical errors (More than 8 th leading cause of death) - Defined types of errors as diagnostic (error or delay in dx), therapeutic (procedure, drug error), preventive (inadeq f/u), and other - Included ADEs, surgical injuries, restraint injuries, falls, pressure ulcers - *ALTHOUGH MOST INJURIES ARE MINOR, 1 in 10 RESULTS IN DEATH - Concluded that majority of errors due to system problem 2000
8 Scope of Issue Hospital admission = first of multiple care transitions for older patients At least 25% of hospitalized patients over 65 are D/Cd to another institution 12% D/C with home care services Of those transferred from hosptial to rehab/snf, nearly 50% have 4 or more additional care transitions in next 12 mths. Multiple opportunities for miscommunication and insufficient care
9 #2 IOM report Crossing the Quality Chasm Further emphasized problems with the system failure to translate knowledge into practice health care settings as silos of care 2001
10 # 4 IOM report Preventing Medication Errors Concluded at least 1.5 million preventable ADEs in US each year at cost of $3.5 billion/year Equated to a hospitalized pt being subjected to 1or more medication errors each day *Defined medication errors as errors in procuring, prescribing, dispensing, administering and monitoring a patient s response Occurs most often in prescribing and administering stages Hospital setting is most studied *Doesn t include errors of omission e.g. failing to prescribe a beta blocker 2006
11 How often do transitions occur? After hip fracture pts underwent an average of 3.5 relocations Medicare beneficiaries see a median of 2 PCPs and 5 specialists yearly! 33% changed their PCP every year
12 Show me the numbers Almost 1 in 5 patients suffers an adverse event during the transition from hospital to home 1/3 of adverse events are preventable 2/3 of adverse events are medicationrelated Drugs for which reguire outpt monitoring to prevent acute toxicity account for >50% of hospitalizations in those age >65. 1/4 of patients are re-admitted to the hospital
13 Types of adverse events Medication-related Procedure-related Nosocomial infection Falls Other
14 What were the identified deficits in the system? The most common deficit was poor communication Inadequate pt education Poor communication between pt and physician Poor communication between hospital and community providers
15 Other deficits that lead to system failure Inadequate monitoring No emergency contact information Difficulty obtaining prescriptions Inadequate home services Delayed follow-up care Premature discharge
16 What are the key components of good transitional care? A comprehensive care plan Medication reconciliation Patient preparation Patient education Communication of the plan to receiving professionals
17 Medication Reconciliation How to do it When to do it Why to do it: It s not just about JCAHO! (Joint Commission on the Accreditation of Healthcare Organizations)
18 5 Steps to Constructing the Reconciled Medication List 1. Stop prophylaxis and prn meds if no longer indicated (eg, PPI, sleepers, SQ heparin) 2. If drug was changed to another in its calss because of hospital formulary (not medical indication), change back to previous drug 3. Indicate all new, stopped or changed drugs 4. Provide prescriptions for all new or changed drugs 5. For SNF/rehab D/C: all IV meds & unusual abx need to be called to facility the day before D/C; otherwise could be delay in care
19 Data on Discharge Summaries: JAMA 2007 review of communication deficits between hospital physicians revealed critical information missing from discharge summaries: Responsible hospital MD (Missing 25%) Main diagnosis (17.5%) Discharge medications (21%) Specific follow-up plans (14%) Diagnostic test results (38%) Tests pending at discharge (65%!!!!) Counseling provided to patients or families (91%) Kripalani et al. JAMA 2007;297:
20 Side Effects of Poor Transitional Care Inappropriate plan Conflicting recommendations Incorrect medication regimen Inadequate follow-up Insufficient patient education Patient frustration and dissatisfaction Increased health care utilization
21 Challenges to Improving Transitional Care Lack of provider awareness/familiarity Multiple isolated providers Unprepared patients
22 Challenges Continued Isolated institutions Lack of financial incentives to collaborate
23 Interventions work! Can be patient or provider centered Involve a team approach! Decrease readmission rates Decrease costs Decrease mortality One intervention for CHF pts results in a 30% reduction in mortality and re-admission EQUAL TO EFFECT OF BEING ON A BETA BLOCKER!!!! Stewart et al. Circulation 2002;105:
24 News you can use How can you ensure a safe transition? Decrease polypharmacy Assess health literacy
25 Polypharmacy 73% of seniors with chronic illnesses take 5+ medications daily Causes Complications Interventions
26 Causes of Polypharmacy chronic conditions multiple symptoms (prescribing cascade) multiple providers multiple pharmacies multiple routes of administration
27 Complications of Polypharmacy ADEs non-adherence increased costs
28 Interventions for Polypharmacy Patient: one pharmacy, updated list, inform PMD of changes, throw away outdated meds, avoid sharing meds Physician: use each encounter/admission as opportunity to decrease polypharmacy, ask about adherence, know which medications are inappropriate, education re: changes/names/side effects/instructions
29 Medication Non-Adherence Study of seniors with chronic illness: 20% skipped doses or stopped a med b/c of side effects 20% stopped meds they believed were not helping 25% did not fill a Rx due to cost Age itself is not predictive of non-adherence (#of medications is!)
30 Health Literacy 50% of US adults lack the reading and numerical skills necessary to understand and act on health information What can you do?
31 What can you do? Assess literacy skills educational level is not sufficient Pay attention to behaviors that suggest limited literacy AVOID MEDICAL JARGON Use pictures Ask pts to demonstrate understanding PLEASE SHOW ME HOW YOU WOULD TAKE THESE PILLS Education materials should be at 6 th grade reading level
32 How can a complete discharge summary improve transitional care? Use the d/c summary to communicate the care plan to the patient and next providers: Complete list of diagnoses Succinct hospital course Relevant labs and test results Complete list of medications Allergies Diet and activity instructions Clear follow-up instructions (including f/u labs!) Warning signs and sx
33 Avoiding pitfalls: Nursing home to hospital Hospital to home Hospital to another institution
34 Medical Errors
35 Patient Should Arrive From the Nursing Home With: Chief Complaint or HPI is the observation that made the nurse request transfer: will be in nursing talk alteration of mental status Advance Directive: may be separate sheet Baseline Functional Status Face sheet NH phone number Next of Kin contact information Name and phone number of PCP Current MAR; diagnoses at bottom of page will not be prioritized or even current. Recent labs: unlikely but can request in the a.m.
36 Frequent Fumbles: Transfer From NH to Hospital Patient rerouted to nearest hospital No records available. Patient unable to give history. Transfer ordered by covering physician not PCP Pressure to transfer high acuity residents Illegible transfer sheets. Incomplete or outdated information. NH nurse doesn t know resident (shift change, RN turn over ~100%/yr). HIPAA confusion
37 Communicate with the Nursing Home Let your fingers do the walking: Day shift nurse for baseline: FAX MDS? PCP for additional history prognostic information give heads up on discharge. It is appreciated. DON if trouble locating above if any major change in status in hospital. They do care.
38 TRANSITIONS FROM THE HOSPITAL Should aim to maximize the chance that patients will maintain the benefits of hospitalization Can reduce the risk of early readmission and the use of emergency services Ideally begins at admission, with a projection of medical, nursing, rehabilitative, and functional support required at the time of discharge Slide 38
39 TRANSITION TO HOME Communicate the following to patients or their caregivers: Follow-up appointments Warning symptoms or signs to watch for, with instructions on whom to contact Clinical disciplines (eg, nursing, physical therapy) contracted for care in the home Reconciled medication list, with clarification of which pre-hospital medications are to be continued Slide 39
40 TRANSITION TO ANOTHER INSTITUTION Orient the patient to the nature of the institution, the identity of the new attending physician, and the expected frequency of physician visits Promptly send a discharge summary that includes: Summary of hospital course with care provided List of problems and diagnoses Baseline physical functional status Baseline cognitive status Medication list (with termination dates for time-limited drugs) Slide 40 Allergies Test results still outstanding Follow-up appointment Goals and preferences Advance directives
41 Once you ve seen one nursing home you ve seen one nursing home. Jim Webster, MD
42 Hospital Discharge Critical Pathway Can this patient go home? 1. Patient walks & performs ADL s without assistance (direct observation)? 2. Willing & able caregiver at home? 3. Required medical treatment covered by outpatient insurance, e.g. IV? 4. Has > 1 daily skilled nursing requirement, i.e. wound care, trach, drains, Foleys, PICC lines, suctioning, IV, injections? 5. Hospitalized for FTT, unsafe at home, dementia, psychiatric or physical frailty? 6. Hospice appropriate & no home caregiver?
43 Critical Pathway If NO to Q. 1-3 Can these supports be brought into the home long enough, often enough and soon enough to make discharge safe? IF NO: Discuss NH transfer: See qualifying stay. IF YES to Q. 4 Is the patient medically stable to continue treatment at a non-acute facility?
44 Medicare Qualifying Stay 72 hours acute stay: 3 midnights. Clock starts with admission to floor not arrival in ER. Medicare qualifying diagnosis (SNF or rehab) Within 30 days of DC after qualifying stay Can go home for a trial if unsure. If they fail, can still go directly to NH with Medicare coverage.) NOTE: Hospital discharge before 3 midnights Days are not cumulative. NHP would require a second 72 hour hospital stay. $$$$?
45 Where to go from here? Therapy - availability Therapy - intensity Acute Rehabilitation Subacute Rehabilitation / Skilled Nursing Facility Long-term care 5-7 days/week 3-5 days/week 1-3 days/week 3-5 hours/day 1-3 hours/day hour/day Length of stay 7-14 days 21 days indefinite MD-visits daily 1-3 times/week once per month Nursing assessments every 8 hours required optional optional
46 Critical Pathway: Discharge What is the goal of NH care for this patient? Complete prolonged course of treatment Can it be provided in another setting? Recovery of previous level of function Is this realistic? Is return home likely or not? Rehab Consult OT, PT on admission! Failure to progress in rehab Medicare will stop; self-pay will kick in. About a 10 day grace period.* *Respite Giving an exhausted caregiver a break may deflect future social admissions.
47 Critical Pathway Medically stable for NH transfer if Could cruise on your discharge orders for up to 48 hrs. May not be seen by MD for hrs. Will be seen by MD generally hrs, 5 days, 14 days then monthly. Has been hemodynamically stable on present medical management > 24 hrs. Can tolerate a possible 24 hr lapse in medication. Does not require telemetry, daily or stat labs.
48 If no or not sure to any of the above: Consider delaying discharge a day or two Evaluate for chronic hospital (e.g. vent unit, LTAC. ) Call the DON of the NH you are considering to discuss whether THIS facility is ready this patient. Yourself. Include your med-surg floor RN in this discussion.
49 Medication Errors Most are unintentional discontinuations. Up to 36% of discharges in one series had a potentially dangerous transcription error. Bookvar K. et al Adverse events due to discontinuation in drug use and dose changes in patients transferred between acute and long term care facilities. Arch Int Med 2004;164:
50 Code status Hospital code status remains the same after NH transfer 49% if the physicians talk to each other. Otherwise 9%. Ghusn HF, Teasdale TA, Jordan D. Continuity of the do not resuscitate orders between hospital and nursing home settings. J Am Geriatric Soc. 1997;45:
51 Frequent Fumbles Transition From Hospital to NH Late discharges to evening shift nurse who has 50 patients On-call MD does not know patient Transfer sheet illegible or incorrect Misspellings, wrong doses (decimal slide) No active problem list or goals of therapy Sparse, poor quality or no records
52 Frequent Fumbles Transition From Hospital to NH Not sending MD name or pager Discharging RN gone, chart off the floor Hospital refuses to provide records HIPAA Inappropriate orders ( Wean dopamine drip. ) Unstable conditions (Foley dc d on the way to the elevator, no trial of voiding, no record of this in transfer.) Prn s, especially analgesics should be scheduled.
53 Transfer Don ts Sugar coat the information to the patient or family about sub-acute rehab. Sub-acute rehab is a nursing home. Expect the NH physician to optimize an unstable condition: Titrate CPAP to RR. Expect stat labs; NH STAT = 24 hrs. Expect > 2/d IVPB, IV push, IV drip or wean anything except at a chronic acute facility. We tried to wean her for 11 days so my attending thought she would do better with a slow taper in a subacute.
54 Transfer Do's Encourage family to visit LTCF before transfer. As early in day as possible...write orders day before anticipated discharge. If >1 major change, reconsider. Senior team member reviews discharge sheet: LEGIBLE, prioritized diagnoses. Legible CURRENT orders. Legible name & pager of MD, nursing unit. Advance directives. Flag conditions to be monitored. Order and flag labs needed within 3 days. Avoid IV; Change to p.o. if possible. If IV necessary, provide secure PICC access.
55 Transfer Do s Copy the whole chart AND send the dictation when available. Remove unused IV, PICC, Foley etc. Call DON ahead on drugs that cannot be late; special equipment (e.g. CPAP)
56 Poorly managed transitions of care cause Poor patient care Increased morbidity and mortality Further disruption in continuity of care Higher individual and system costs Angry patients, angry families Poor relationships between institutions and professionals
57 Summary Improving the complex process of transitional care will require a multi-factorial approach including changes in the: Health Care Delivery System Technology Health Policy Research
58 Special Thanks: The Reynold s Foundation Karin Ouchida, MD Division of Geriatric Medicine Montefiore Medical Center, NY Miriam B. Rodin, MD, PhD Division of Geriatric Medicine St. Louis University CHAMP: Care of the hospitalized aging medical patient
Discharge Planning Heidi White, MD Associate Professor of Medicine Yvonne Spurney, RN Associate Chief Nurse Cristina C. Hendrix, DNS, GNP-BC Associate Professor of Nursing Objectives Describe challenges
Community Care of North Carolina CCNC Transitional Care Management Jennifer Cockerham, RN, BSN, CDE Director, Chronic Care Programs & Quality Management 1 Chronic Care Population Within the NC Medicaid
Eliminating the Pitfalls and Barriers to Reducing Rehospitalizations Evelyn Thompson RN,CMC Director of Care Transitions Genesis Healthcare October 2013 Barriers to Care Coordination System level barriers
Discharge Planning Barry K. Bennett, LCSW Adjunct Assistant Professor Department of Surgery WHO ARE SOCIAL WORKERS? Licensed professionals who help individuals, families, and communities understand the
Post Discharge Pharmacy Phone Calls Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist St. Mary s Medical Center Member of Ascension Health Number of Available Beds: 509 Admissions:
RED, BOOST, and You: Improving the Discharge Transition of Care Jeffrey L. Greenwald, MD, SFHM Massachusetts General Hospital - Clinician Educator Service Co-Investigator Project RED & Project BOOST The
CASE A: FROM HOSPITAL TO HOME WITH HOME HEALTH CARE Claudia M. Chaperon, PhD, APRN, BC-GNP CASE A 78-year year-old man with advanced COPD, alcoholism, bipolar is discharged home from hospital late Friday
Key Elements and Formatting Discharge Instructions Mark V. Williams, MD, FACP, MHM Professor & Vice Chair, Dept. of Internal Medicine Interim Chief, Division of Hospital Medicine Director, Centerfor HealthServicesResearch
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
47 th Annual Meeting August 2-4, 2013 Orlando, FL Fundamentals of Transitions of Care (TOC) Rebecca R. Prevost, B.S., Pharm.D., PSO Medication Safety Officer Florida Hospital Disclosure I do not have a
Ensure Timely Post-Hospital Care Follow-Up Peg Bradke and Eric Coleman February 3, 2011 These presenters have nothing to disclose. Session Objectives Participants will be able to: Provide an overview of
Medication Reconciliation Transfer of medication information across settings keeping it free from error. By Jane H. Barnsteiner, PhD, RN, FAAN Medication error is the most common type of error affecting
UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review Updated May 2015 Introduction The UnitedHealthcare Medicare Solutions
KENTUCKY ADMINISTRATIVE REGULATIONS TITLE 201. GENERAL GOVERNMENT CABINET CHAPTER 9. BOARD OF MEDICAL LICENSURE 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances.
AGS REHABILITATION/ POST-HOSPITAL CARE OF THE GERIATRIC FRACTURE PATIENT Egan Allen, MD University of Rochester THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving
my health care notebook Why? Being an active part of your health care team helps you feel better and helps you get even better care. Starting on Day 1, you can keep track of important information and questions.
The Ideal Hospital Discharge Alayne D. Markland, DO, MSc UAB Department of Medicine Division of Geriatrics, Gerontology, & Palliative Care Why is discharge planning important? Surging interest from professional
Complex Continuing Care Restorative Care (Combined Functional Enhancement and Restorative Care Programs) Description: The Restorative Care program provides a moderate to low intensity goal-oriented rehabilitation
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
Why aren t they called Doctor s Homes? or The Role of the Physician in the Nursing Home Mary Ann Forciea MD Kathleen Walsh, DO Division of Geriatric Medicine November 2008 Format of visit Opening seminar
Adverse Drug Events and Medication Safety: Diabetes Agents and Hypoglycemia Date: October 20, 2015 Presented by Mike Crooks, PharmD., PCMH-CCE Pharmacy Interventions, Technical Lead 11/9/2015 1 Objectives:
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
Risk Tools in Predicting Rehospitalization from Home Care VNAA Best Practice for Home Health Learning objectives The participant will be able to: Discuss the need for risk assessment for home health patients
THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM Wednesday, June 02, 2010 As A Provider Of Continuing Nursing Education, Triumph Healthcare Is Required By Texas Nurses Association
GRACE Team Care Integration of Primary Care with Geriatrics and Community-Based Social Services Aged, Blind and Disabled Stakeholder Presentation Indiana Family and Social Services Administration August
Stroke Transitions of Care Hospital Environment to Home Disclosures NONE Objectives Understand the importance of effective transitional care from the acute hospital to home in the stroke population Discuss
Attachment A Minnesota DHS Community Service/Community Services Development Applicant Organization: First Plan of Minnesota Project Title: Implementing a Functional Daily Living Skills Assessment to Predict
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
Depression Support Resources: Telephonic/Care Management Follow-up Depression Support Resources: Telephonic/Care Management Follow-up Primary Care Toolkit September 2015 Page 29 Role of the Phone Clinician
Iatrogenesis Suzanne Beyea,, RN, PhD, FAAN Associate Director: Centers for Health and Aging Iatrogenesis Definition from the Greek word, iatros,, meaning healer, iatrogenesis means brought forth by a healer
1 Nancy L. Wilson Department of Medicine-Geriatrics Houston Center for Quality of Care& Utilization Studies Texas Consortium of Geriatric Education Centers Care for Elders Governing Council Acknowledge
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.
0BCHAPTER 15 F 1BI. POLICY The California Department of Corrections and Rehabilitation (CDCR) shall maintain s (CTC) to house inmate-patients who do not require general acute care level of services but
Stroke/VTE Quality Measure Build for Meaningful Use Stage 1 Presented by Susan Haviland, BSN RN Senior Consult, Santa Rosa Consulting Meaningful Use Quality Measures Centers for Medicare and Medicaid Services
GUIDELINES GUIDELINES ON PREVENTING MEDICATION ERRORS IN PHARMACIES AND LONG-TERM CARE FACILITIES THROUGH REPORTING AND EVALUATION Preamble The purpose of this document is to provide guidance for the pharmacist
A Guide to Understanding Your Discharge Options After Hospitalization DHMC Care Management: (603) 650-5789 Table of Contents Hospital to Home with Home Care... 3 Hospice Care... 5 Skilled Nursing Facility*...
Referral Form Admissions Office 415.682-5683 Fax 415.682-5689 firstname.lastname@example.org 375 Laguna Honda Blvd. San Francisco, CA 94116 www.lagunahonda.org Please fill out this form completely. Parts A, B,
Seven 1. Medications Management Ensuring the safe use of medications by patients and their families and based on patients plans of care a. Assessment of patient s medications intake b. Patient and family
A Guide for Transitioning to Home After a Rehab Stay Transitioning home after a rehab stay can present unique challenges for patients and/or their caregivers. Patients who have had a debilitating illness
1. Medications Management Ensuring the safe use of medications by patients and their families and based on patients plans of care a. Assessment of patient s medications intake b. Patient and family education
SafetyFirst Alert Massachusetts Coalition for the Prevention of Medical Errors January 2001 This issue of Safety First Alert is a publication of the Massachusetts Coalition for the Prevention of Medical
May 7, 2012 Submitted Electronically Secretary Kathleen Sebelius Department of Health and Human Services Office of the National Coordinator for Health Information Technology Attention: 2014 edition EHR
Measure #130 (NQF 0419): Documentation of Current Medications in the Medical Record National Quality Strategy Domain: Patient Safety 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION:
Transitions in Care: Optimizing Intern Resources DeeDee Hu PharmD, MBA Clinical Specialist Critical Care and Cardiology PGY1 Program Director Memorial Hermann Memorial City Medical Center Medication Error
GUIDE TO SUB-ACUTE AND LONG TERM CARE Frequently Used Words and Phrases...2 Understanding Your Care Options...3 The Transition from Hospital to Nursing Facility...5 Paying for Care...6 Choosing Wisely...8
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
Decreasing 30 day Readmissions on a Medical Surgical Telemetry Unit Presented By: Dr. Micah Beachy, Rickelle Collins and Nicole Turille Context As part of healthcare reform, hospitals are being challenged
1900 K St. NW Washington, DC 20006 c/o McKenna Long Centers for Medicare & Medicaid Services U. S. Department of Health and Human Services Attention CMS 1345 P P.O. Box 8013, Baltimore, MD 21244 8013 Re:
Overview of emar Electronic Medication Administration Record March 2006 WHAT IS emar? emar Electronic Medication Administration Record - Replaces the paper MAR MAK Medication Administration Check (Siemens)
Process Description: Medication Reconciliation is the process of making a good faith attempt to obtain a patients prior to admission medication history, which is eventually reconciled against a patients
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
RN Care Manager Assessment: The 4 Domains Access to Care Experience with Provider(s) Getting Needed Services Coordination of Care Medical Home / Services Risk Medical Neighborhood Social Support Home Environment
HOSPICE INFORMED CONSENT PATIENT NAME: INSTRUCTIONS: This form is used to acknowledge receipt of our Orientation Booklet and confirm your understanding and agreement with its contents. Your signature below
Professional Practice Medical Record Documentation Guidelines INTRODUCTION Consistent and complete documentation in the medical record is an essential component of quality patient care. All Participating
IDENTIFYING INFORMATION MANAGEMENT CHALLENGES FACED BY HOME HEALTHCARE PROFESSIONALS MANAGING OLDER ADULTS TRANSITIONS FROM HOSPITAL TO HOME CARE Alicia Arbaje, M.D., M.P.H. Assistant Professor of Medicine,
Understanding and Improving Medication Reconciliation Between Hospitals and Nursing Homes Patient Safety Risk and Cost in Care Transitions White Paper November 2014 Stratis Health, based in Bloomington,
Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge National Quality Strategy Domain: Communication and Care Coordination 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION:
UNIVERSITY OF WISCONSIN HOSPITAL AND CLINICS DEPARTMENT OF PHARMACY SCOPE OF PATIENT CARE SERVICES FY 2014 October 1 st, 2014 Department Name: Department of Pharmacy Department Director: Steve Rough, MS,
RN Care Manager Assessment: The 4 Domains Access to Care Experience with Provider(s) Getting Needed Services Coordination of Care Medical Home / Services Risk Medical Neighborhood Social Support Home Environment
What to know if Medicare denies coverage What Medicare covers Necessary post-hospital extended care for up to 100 days Extended care: nursing care and rehab provided to a Medicare beneficiary who is an
Kaiser Permanente: Transition Care Performance and Strategies Carol Ann Barnes, PT, DPT, GCS email@example.com April 2009 Netta Conyers-Haynes, October, 2014 Principal Consultant, Communications Agenda
H O T T O P I C S I N H E A L T H C A R E Transitions of Care: The need for a more effective approach to continuing patient care The need for a more effective approach to continuing patient care This paper
Medication Reconciliation Darned if you do, Darned if you don t! 1 Why is Medication Reconciliation Important An estimated 60% of all medication errors occur during times of care transitions. Approximately
NHS FORTH VALLEY Medicines Reconciliation Policy Date of First Issue 13/04/2015 Approved 09/04/2015 Current Issue Date 13/04/2015 Review Date 31/03/2017 Version 1.4 EQIA Yes 13/04/2015 Author / Contact
Follow-Up Visits after Heart Failure Hospitalizations: Impact of a Medication Reconciliation Clinic Sherry K. Milfred-LaForest, PharmD, BCPS Clinical Pharmacy Specialist, Cardiology and Organ Transplantation
Ernest Boyd, R.Ph., MBA Executive Director Ohio Pharmacists Association CDC s Guide for Pharmacist Partnership for Public Health Brief overview of Pharmacists All graduate with 6 to 8 year Doctor of Pharmacy
Emerging Topics in Healthcare Reform Value-Based Purchasing Janssen Pharmaceuticals, Inc. Value-Based Purchasing The Patient Protection and Affordable Care Act (ACA) established the Hospital Value-Based
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
Federal Requirements The AANAC OBRA Timing and Scheduling for MDS 3.0 module includes content as defined in the Long-Term Care Facility Resident Assessment Instrument User s Manual and CMS federal requirements
Update: Medical Necessity Documentation Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013 REMINDER Many claim denials occur because the providers or suppliers do not submit
Evidence-Based Care Transition Programs AoA, CMS, VA Grantee Meeting The GRACE Model Geriatric Resources for Assessment and Care of Elders Steven R. Counsell, MD Mary Elizabeth Mitchell Professor and Director,
Medication Adherence: Development of an EMR tool to monitor oral medication compliance Donna Williams, RN PHN Carol Bell, NP MSN Andrea Linder, RN MS CCRC Clinical Research Nurses Stanford University SOM
CLINICAL PRACTICE GUIDELINE PROFESSIONAL PRACTICE TITLE: Stroke Care Rehabilitation Unit DATE OF ISSUE: 2005, 05 PAGE 1 OF 7 NUMBER: CPG 20-3 SUPERCEDES: New ISSUED BY: TITLE: Chief of Medical Staff ISSUED
Management Case Study: Transitions Trifecta Calibrating the Severity of Drug Related Problems, dherence, and Literacy in a High Risk Population Tuesday, December 10, 2013 2:00 p.m. 2:30 p.m. Management
AACE Endocrine Coding Webinar Welcome to the Brave New World: Billing for Endocrine E & M Services in 2010 Question and Answer Submissions Q: If a patient returns after a year or so and takes excessive
Section 6. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.
Presented By: OHA Insurance Solutions, Inc. GOAL This course is designed to promote awareness of the importance of appropriate electronic medical record (EMR) and non-electronic charting to both professional
Hospice Care in The Nursing Home Perspectives of a Medical Director Carole Baraldi, M.D. Evolution of Nursing Facilities Alms houses began over 1000 years ago Historically serve older people who can no