Using Inbound and Outbound Calling Programs

Size: px
Start display at page:

Download "Using Inbound and Outbound Calling Programs"

Transcription

1 timely follow up Clinical Escalation ebook 7 Steps to Successful Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs Care team coordination Reduced readmissions

2 Contents 02 part 1 Why all the fuss about hospital readmissions? 03 part 2 The importance of reaching out to patients post discharge 05 part 3 What is post discharge calling and why do I need it? 07 part 4 7 steps to reducing readmissions with post discharge calling 12 part 5 Some final thoughts 14 About SironaHealth

3 PART 1 Why all the fuss about hospital readmissions? The Center for Medicare and Medicaid Services (CMS) is changing the way we look at readmissions Sparked by healthcare reform, a renewed focus has been placed on managing and reducing hospital readmissions considered to be preventable. Beginning in October 2012, CMS is incorporating pay-for-performance incentives designed to encourage health systems to extend care beyond the hospital setting to ensure their patients are complying with their at home care plans. A LITTLE BACKGROUND In 2007, the Medicare Payment Advisory Commission (MedPAC) reported to congress that, of the Medicare patients who had been rehospitalized within 30 days of discharge in 2005, 13% were for reasons deemed potentially preventable accounting for $12 billion (or $7,000 per beneficiary) in Medicare spending. In 2009, a New England Journal of Medicine study found that 18-20% of Medicare patients were re-hospitalized within 30 days, and a staggering 33% were readmitted within 90 days of discharge. the way forward Congress took notice of these alarming trends and specifically addressed readmissions when drafting their new healthcare legislation. As a result of the March 2010 signing of the Patient Protection and Affordable Care Act, CMS now has the authority to withhold hospital payments for excessive readmissions. Hospitals are now financially at risk for patients re-hospitalized for reasons considered to be preventable and need to move quickly to improve follow up care. Why a wait and see approach won t work As of October 1, 2011, patients discharged from hospitals will have an impact on penalties applied to readmissions in Hospitals need to be actively evaluating their current performance, forecasting what their financial penalties will be, and implementing strategies to reduce these readmissions. CMS will be focusing first on: Congestive Heart Failure (CHF) Acute Myocardial Infarction (AMI) Pneumonia Then in 2014, likely adding: Chronic Obstructive Lung Disease Coronary Bypass Grafting Percutaneous Coronary Interventions Vascular Procedures ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 2

4 PART 2 The importance of reaching out to patients post discharge Developing the right readmission reduction strategy While the Center for Medicare and Medicaid Services has implemented financial penalties for hospitals with excessive readmissions, they haven t provided any instructions on how to successfully reduce them. This leaves many hospitals wondering what the right approach is. And while there are indeed many solutions to consider, there is one universal thing that needs to happen in order to impact readmission rates and that s timely follow up. Leaving the hospital can be a stressful process for patients Patients are tired, nervous about the transition home, concerned that their condition could worsen, and (in far too many cases) unclear as to what they need to do now that they ve left the hospital. Or in other words... They are at risk for readmission. And with all that a patient goes through during their hospital stay, it s not surprising that despite your best efforts some patients won t understand, retain, or follow the home care instructions you provided at the point of discharge. Patients that don t understand / follow their home care instructions are at risk of serious complications with their recovery. In fact, this is a major factor for most hospital readmissions, especially in regards to medication compliance. Health Lit er a cy (noun) An individual s ability to read, understand, and use healthcare information to make decisions and follow instructions for treatment. ~ Wikipedia To avoid readmissions relating to poor health literacy, you need to connect with patients shortly after discharge to ensure they understand what to do and why it s important. KEY TAKEAWAY You need to connect with patients within hours after discharge to make sure they understand and follow their home care instructions. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 3

5 PART 2 The importance of reaching out to patients post discharge Coordinating patient follow up and monitoring is critical Many patients don t see a physician promptly after they have left the hospital. In fact, 50% of Medicare patients had no interaction with a physician between the time they were discharged and when they were readmitted. This constitutes a significant gap in care for the patient. This gap in care allows health deterioration to go unnoticed by the care team until severe complications arise that require readmission. Physician follow up is a critical part of the patient s care plan, but sometimes patients don t have the means (or motivation) to make and keep their appointments. As you build your post discharge follow up programs, appointment reminders and scheduling become key components of a successful hospital readmission reduction strategy. Not only do you need to be able to facilitate the appointment, it s equally important to educate the patient as to why the follow up is needed. Follow up improves the patient experience & HCAHPS scores Patients who don t understand their discharge instructions, or are otherwise unsure of what they need to do to manage their follow up care, are more likely to have an unfavorable perception of their overall hospital experience negatively impacting your HCAHPS scores. Connecting with your patients after discharge not only improves patient safety, but provides your patients with piece of mind that they have a support system in place in the event they have questions or require additional care. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 4

6 PART 3 What is post discharge calling and why do I need it? What is post discharge calling? Post discharge calling services are outbound programs that consist of both clinical and non-clinical professionals who rapidly assess a patient s current health status, offer clinical decision support, schedule appropriate follow up care, and gather feedback on what their overall hospital experience was. Hospitals use post discharge calling to quickly engage patients who have left the hospital, identify patients who are at risk of being readmitted, and initiate support services that will lead to healthy patient outcomes. Post discharge calling services help hospitals cost-effectively manage their patient population beyond their four walls. The best post discharge calling programs serve as front line care coordinators for the hospital, using guideline driven processes to facilitate follow up care across the patient s entire care team. What post discharge calling isn t The goal of post discharge calling programs is to identify what barriers patients are facing with their home recovery, and then connect them to the hospital resource that will help manage their home care appropriately. Post discharge calling is not: A stand-alone satisfaction survey that collects information about the patient experience without providing any escalation to relevant healthcare resources. About reactive service recovery for patients upset about their hospital experience. A one time thing. Continuous follow up engagement is needed to successfully reduce readmission rates. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 5

7 PART 4 What is post discharge calling and why do I need it? While timely follow-up is critical, that alone isn t enough to prevent readmissions. To be effective, you need a care team that can connect, evaluate, and escalate patients to appropriate care and/or administrative resources. Jeff Forbes, President, SironaHealth Why does my hospital need post discharge calling? Roughly 20% of hospitalizations in the United States are readmissions. But which of those readmissions were potentially avoidable? As CMS rolls out their Hospital Readmission Reduction Program, your hospital will need a cost-effective way to reach out to all your discharged patients and identify potentially avoidable readmissions. Telephone based programs are ideally suited to accomplish this task. Catch symptoms early, before they lead to a readmission Patients can develop new symptoms at any time during their recovery. And while many patients (and their care providers) will seek help, others will ignore new symptoms and put off calling their doctor. Calling programs keep you in contact with all your discharged patients, reminding them to seek help when they need it. Essential to assigning appropriate follow up care To avoid a costly readmission, some of your patients may require one-on-one care from a clinical professional. Sending a clinician (doctor, pharmacist, nurse, etc.) to every patient who has been discharged isn t financially feasible for many hospitals. Post discharge calling allows you to identify, segment, and prioritize in person coaching services so that they are delivered only to the patients who need them. CMS financial penalties may just be the beginning We ve seen this before. When CMS implements a new financial incentive or launches a new healthcare pilot program, commercial insurers will likely follow suit. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 6

8 PART 4 7 steps to reducing readmissions with post discharge calling Following up with patients hours after discharge: a critical step in reducing readmission rates Communication is the key to keeping your patients safe. Engaged and informed patients are much more likely to understand and follow their discharge instructions correctly, making it less likely they will need to be readmitted. To help get you started, we ve outlined the 7 steps needed to launch a successful post discharge calling program. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 7

9 PART 4 7 steps to reducing readmissions with post discharge calling 01 Conduct follow up calls hours after the patient s discharge 02 Confirm the patient understands their home care and medication instructions Catching potential complications early is critical to reducing hospital readmissions and the telephone remains the most effective way to connect with patients after discharge. The key is to have a post discharge calling program that not only engages with patients quickly, but can rapidly assess what the next appropriate course of action is. And the next appropriate course of action doesn t automatically mean emergency clinical intervention (although that is important!). What s required is a post discharge follow up program that is tailored to meet the specific needs of each patient and their families. Follow up calling programs that connect with patients quickly after discharge, and can coordinate next steps, are extremely effective in identifying and filling any gaps in care that can lead to readmission. INSIDER TIP Your post discharge follow up calls need to build on the trust your hospital staff has already created. This means having compassionate individuals make the calls, asking relevant questions, and being able to resolve any issues, clinical or otherwise, quickly. One of the first things you need to do during a follow up call is to confirm that the patient understands their post discharge instructions and that they are following them. Why? Because non-compliance with post discharge instructions is a driving factor for preventable readmissions. The goal of your post discharge calling programs should be to identify any misunderstandings and/or risky behaviors early in order to resolve them before they can cause a readmission. We recommend that, at minimum, your post discharge advocates: Confirm that the patient received their post discharge instructions before they left the hospital. Ask the patient if they understand their home care instructions and if they need any clarification on what they need to do. Find out if the patient was able to successfully fill their medication prescriptions. And if they haven t, why not. Ask if the patient has any questions about their medications. Confirm that the patient is taking them as prescribed. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 8

10 PART 4 7 steps to reducing readmissions with post discharge calling 03 Provide clinical decision support and health coaching 04 Facilitate appropriate next steps As you make post discharge follow up calls, you will encounter patients experiencing health issues. For patients experiencing acute symptoms, this means providing them with clinical decision support (e.g. nurse triage) in order to identify what the appropriate next course of action is. If the person conducting the follow up call isn t a clinician, there needs to be a process in place that can escalate them to a licensed professional (like a registered nurse) right away. Using clinical guidelines, the triaging nurse will recommend self-care, physician follow up, urgent care, or emergency services. Some patients may require follow up health coaching Other patients may require additional coaching from a clinical professional (e.g. pain management, medication adherence, exercise). Make sure there s a process in place to trigger additional outreach. Your goal should be to resolve any and all barriers to recovery identified during the follow up call as quickly as possible. As we discussed in Step 3, escalating symptomatic patients to a clinician is a critical part in facilitating appropriate care however, this is not the only type of escalation needed to reduce readmissions. To reduce readmissions, your post discharge follow up service needs to be prepared to: Help the patient schedule their follow up appointment(s). Find the patient a doctor that meets their follow up care needs in the event they do not have a primary care physician. Coordinate patient transportation services as needed. Arrange any additional follow up services (telephonic health coaching, in-home nurse visit, medication management, etc.). INSIDER TIP While many follow up calls can be handled by a non-clinician (that can escalate to a RN when needed), you might consider having clinicians make outbound follow up calls for patient conditions that have a higher risk of complication. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 9

11 PART 4 7 steps to reducing readmissions with post discharge calling 05 Make it easy to reconnect with a registered nurse anytime, day or night 06 Keep all members of the patient s care team in the loop Questions can arise at anytime, and so can symptoms. The ideal post discharge calling program is a blend of both outbound and inbound programs giving patients 24x7 access to your support services. Provide your patients with a telephone based support line that will allow them to immediately connect with a clinician if they have questions. Staff your support line with RNs who have access to telephone triage guidelines in addition to any relevant patient data. And make sure the promotion of your inbound support line is an integral part of your discharge process. Otherwise, patients won t know to use it. Some promotional ideas: Assign a dedicated 800 number for your patient support line. Include promotional materials such as brochures, magnets and key tags with your written discharge instructions. Remind the patient about the nurse support line at the end of the initial post discharge follow up call. When it comes right down to it, reducing readmissions can t be solved by one provider it requires the entire care team. The best way to reduce readmissions is to employ a team approach to providing patient care utilizing physicians, specialists, registered nurses, pharmacists, and other healthcare professionals. Problem is, if the rest of the team isn t in the care loop, they don t know when they need to intervene with the patient. As you take a lead in conducting post discharge follow up calls, you need to be able to share what you learn with the rest of the patient s care team. For health systems that have implemented an Electronic Medical Record (EMR), this means automatically writing call results directly to the EMR. However, for systems that don t currently have an EMR implemented, other provider communications (fax, text, secure , etc.) are needed. When everyone on the care team is on the same page, you can identify and resolve care issues quickly, before they can cause a readmission. INSIDER TIP The same escalation rules outlined in Step 4 should apply to your inbound nurse advice line allowing you to connect patients to the appropriate healthcare resource at the moment of engagement. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 10

12 PART 4 7 steps to reducing readmissions with post discharge calling 07 Use feedback captured during the call to improve the discharge process Have a high number of patients who did not receive their discharge instructions? Are patients not filling their medications? Do patients need help scheduling follow ups? Tracking and trending this data is critical if you wish to reduce readmissions not to mention improve the patient s experience during the discharge process. The key is to have the right reports. Having a clear picture of what causes readmissions allows you to make improvements to your discharge process which could be anything from assigning more clinical resources to working with local taxi companies to coordinate patient travel. The first step in reducing readmissions is to understand why they are occurring, and the best way to do that is to gather and share feedback. INSIDER TIP Share the feedback you gather with your entire hospital team. Your team can t solve problems without knowing what they are. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 11

13 PART 5 Some final thoughts Launching the right post discharge calling program In order to effectively reduce your hospital readmissions, you need to have a process in place that allows you to connect with patients after discharge, and that enables you to manage their health as they transition to a different level of care. The telephone has proven to be a cost-effective and reliable channel for engaging and coaching patients about their health. Your job is to implement a post discharge calling program that is staffed with the right healthcare professionals, utilizes the most appropriate guidelines, can quickly escalate to local clinical and administrative resources, and can automatically keep everyone in the patient s care team up-to-speed on their health status and needs. Readmissions are not primarily about people being re-hospitalized because of mistakes made in the hospital. [Readmissions] are about making transitions effectively. Stephen Jencks, M.D., a former senior clinical adviser to CMS How SironaHealth does it To help you manage and reduce your hospital readmissions, we provide outsource post discharge follow up services. Staffed by registered nurses and specially trained discharge advocates, we help your patients successfully transition home, or to another care facility, by conducting guideline driven outreach calls 24 to 72 hours after discharge. During the post discharge call, our advocates will: Clarify discharge instructions. Remind patients to refill their prescriptions. Schedule follow up care appointments. Escalate the patient to a registered nurse for symptomatic triage or care advice as appropriate. To learn more about how we can help you reduce your hospital readmissions, please visit: sironahealth.com/post-discharge ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 12

14 References Page 2: MedPAC (June 2007) Report to the Congress: Promoting Greater Efficiency in Medicare Page 2, 4: Jencks S, et al. Rehospitalizations among patients in the Medicare fee-forservice program. New England Journal of Medicine Page 2: Patient Protection and Affordable Care Act of 2010, Pub. L. No , 124 Stat. 119 (2010, March 23). Page 6: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National Quality Improvement / Hospitalization Reduction Study. Caring: National Association for Home Care magazine. 2006; 25(2):70. Photo credits SironaHealth greatly acknowledges the following photographers for sharing their original works via flickr and the Creative Commons license. Page 2: Flickr user name jonworth-eu ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 13

15 About SironaHealth Healthcare needs have changed. Most contact centers haven t. That s why we re here. We are a multi-channel health contact center that offers healthcare companies a unified way to coordinate patient care across telephone, web, , and mobile channels. SironaHealth programs help your patients make the appropriate healthcare choices whether it be choosing the proper physician or knowing when they should seek emergency care all while keeping their entire care team in the loop. Our guiding purpose is to deliver healthcare solutions that keep your patients safe by guiding them to the appropriate level of care with compassion and speed. Care Solutions Nurse Advice Line (aka Telephone Triage) ER Decision Support Care Reminders Pre-Admission Assessment Post Discharge Follow Up Engagement Services Physician Referral Services Referral Class Registration Patient Services Custom Survey Automated Voice Software & Support Call Center Software Smartphone Apps Infrastructure Co-source Services Contact us SironaHealth 500 Southborough Drive, South Portland, ME SironaHealth.com twitter.com/sironahealth linkedin.com/company/sironahealth-in facebook.com/sironahealth ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 14

Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation

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

More information

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 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

More information

FINANCIAL IMPLICATIONS OF EXCESS HOSPITAL READMISSIONS JOSESPH B. HENDERSON, J.D.

FINANCIAL IMPLICATIONS OF EXCESS HOSPITAL READMISSIONS JOSESPH B. HENDERSON, J.D. FINANCIAL IMPLICATIONS OF EXCESS HOSPITAL READMISSIONS JOSESPH B. HENDERSON, J.D. Executive MHA Candidate, 2013 University of Southern California Sol Price School of Public Policy Abstract A 2007 Medicare

More information

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 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

More information

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 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

More information

An Integrated, Holistic Approach to Care Management Blue Care Connection

An Integrated, Holistic Approach to Care Management Blue Care Connection An Integrated, Holistic Approach to Care Management Blue Care Connection With health care costs continuing to rise, both employers and health plans need innovative solutions to help employees manage their

More information

Home Health Care: A More Cost-Effective Approach to Medicaid in Illinois Illinois HomeCare & Hospice Council December 2010

Home Health Care: A More Cost-Effective Approach to Medicaid in Illinois Illinois HomeCare & Hospice Council December 2010 Home Health Care: A More Cost-Effective Approach to Medicaid in Illinois Illinois HomeCare & Hospice Council December 2010 As the Illinois Legislature prepares to act on the future of Medicaid, it is important

More information

PCMH and Care Management: Where do we start?

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

More information

Call-A-Nurse Location

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

More information

5/10/13 HEALTH CARE REFORM LONGITUDINAL CARE COORDINATION HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO WHY WHAT HOW WHEN WHO

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

More information

Coordinating Transitions of Care: It Takes a Village

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

More information

hospital readmission rate reduction: building better interfaces within the community.

hospital readmission rate reduction: building better interfaces within the community. hospital readmission rate reduction: building better interfaces within the community. Whitepaper By Ken Taverner, M.Sc. the issue of hospital readmission rates Leaving the hospital after being admitted

More information

Transitions of Care: The need for collaboration across entire care continuum

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

More information

The Role of Telehealth in an Integrated Health Delivery System

The Role of Telehealth in an Integrated Health Delivery System The Role of Telehealth in an Integrated Health Delivery System How Telehealth Can Provide the Bridge Between Patients and Healthcare Providers Against the changing landscape of healthcare reform, healthcare

More information

ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT

ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT Accountable Care Analytics: Developing a Trusted 360 Degree View of the Patient Introduction Recent federal regulations have

More information

Population Health Solutions for Employers MEDIA RESOURCES

Population Health Solutions for Employers MEDIA RESOURCES Population Health Solutions for Employers MEDIA RESOURCES ABOUT MISSIONPOINT MissionPoint s mission is to make healthcare more affordable, accessible and improve the quality of care for our members. MissionPoint

More information

RED, BOOST, and You: Improving the Discharge Transition of Care

RED, BOOST, and You: Improving the Discharge Transition of Care 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

More information

Meeting of the Advisory Panel on Outreach and Education (APOE) Centers for Medicare and Medicaid Services March 27, 2013.

Meeting of the Advisory Panel on Outreach and Education (APOE) Centers for Medicare and Medicaid Services March 27, 2013. 701 Pennsylvania Avenue, Ste. 800 Washington, DC 20004 2654 Tel: 202 783 8700 Fax: 202 783 8750 www.advamed.org Meeting of the Advisory Panel on Outreach and Education (APOE) Centers for Medicare and Medicaid

More information

Achieving Quality and Value in Chronic Care Management

Achieving Quality and Value in Chronic Care Management The Burden of Chronic Disease One of the greatest burdens on the US healthcare system is the rapidly growing rate of chronic disease. These statistics illustrate the scope of the problem: Nearly half of

More information

Medicare Value-Based Purchasing Programs

Medicare Value-Based Purchasing Programs By Jane Hyatt Thorpe and Chris Weiser Background Medicare Value-Based Purchasing Programs To improve the quality of health care delivered to Medicare beneficiaries, the Centers for Medicare and Medicaid

More information

Hospital Quality Initiative Overview CENTERS FOR MEDICARE & MEDICAID SERVICES December 2005

Hospital Quality Initiative Overview CENTERS FOR MEDICARE & MEDICAID SERVICES December 2005 Hospital Quality Initiative Overview CENTERS FOR MEDICARE & MEDICAID SERVICES December 2005 Background Quality health care is a high priority for the Bush administration, the Department of Health and Human

More information

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 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

More information

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. 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

More information

Value-Based Purchasing

Value-Based Purchasing 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

More information

3 Easy Ways to Increase Your Medical Practice Revenue by 25%

3 Easy Ways to Increase Your Medical Practice Revenue by 25% 3 Easy Ways to Increase Your Medical Practice Revenue by 25% 3 Easy Ways to Increase Your Medical Practice Revenue by 25% There are a hundred ways to streamline workflow and improve revenue in a medical

More information

CCNC Care Management

CCNC Care Management CCNC Care Management Community Care of North Carolina (CCNC) is a statewide population management and care coordination infrastructure founded on the primary care medical home model. CCNC incorporates

More information

WHITE PAPER. 9 Steps to Better Patient Flow and Decreased Readmissions in Your Emergency Department

WHITE PAPER. 9 Steps to Better Patient Flow and Decreased Readmissions in Your Emergency Department Communication Solutions WHITE PAPER 9 Steps to Better Patient Flow and Decreased Readmissions in Your Emergency Department Increase patient satisfaction and reduce readmissions all while building loyalty,

More information

Six Communication Best Practices for Transitional Care Management

Six Communication Best Practices for Transitional Care Management WHITE PAPER Six Communication Best Practices for Transitional Care Management In the era of chronic illness and historically long lifespans, patient care transitions to home or another facility have become

More information

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs Idaho Health Home State Plan Amendment Matrix: Summary Overview This matrix outlines key program design features from health home State Plan Amendments (SPAs) approved by the Centers for Medicare & Medicaid

More information

Preventing Readmissions

Preventing Readmissions Emerging Topics in Healthcare Reform Preventing Readmissions Janssen Pharmaceuticals, Inc. Preventing Readmissions The Patient Protection and Affordable Care Act (ACA) contains several provisions intended

More information

Chronic Care Management (CCM) from a Physician Practice Administrator s Perspective

Chronic Care Management (CCM) from a Physician Practice Administrator s Perspective Chronic Care Management (CCM) from a Physician Practice Administrator s Perspective Chronic Care Management (CCM) from a Physician Practice Administrator s Perspective 1 ABOUT THE AUTHOR Dennis Breslin

More information

The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012. Penny S. Milanovich President UPMC Visiting Nurses Association

The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012. Penny S. Milanovich President UPMC Visiting Nurses Association The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012 Penny S. Milanovich President UPMC Visiting Nurses Association Cost of Chronic Conditions An average of 40-50% of healthcare

More information

Tips To Improve 5-Star Performance Ratings

Tips To Improve 5-Star Performance Ratings Tips To Improve 5-Star Performance Ratings Two different patient surveys impact CMS Star ratings: 1. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, typically mailed to plan

More information

Selling Care Transition Services to Hospitals

Selling Care Transition Services to Hospitals Selling Care Transition Services to Hospitals An Ankota White Paper By Ken Accardi, Founder/CEO 2015 Copyright 2015 Ankota LLC - All rights reserved. How to Sell Your Care Transition Services to Hospitals

More information

Modern care management

Modern care management The care management challenge Health plans and care providers spend billions of dollars annually on care management with the expectation of better utilization management and cost control. That expectation

More information

RT AS PROJECT MANAGER:

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

More information

Following Up with Patients Discharged from the Emergency Department: A Look at Voice and UCSF

Following Up with Patients Discharged from the Emergency Department: A Look at Voice and UCSF Following Up with Patients Discharged from the Emergency Department: A Look at Voice and UCSF page 1 Introduction The transition from hospital to home is a sensitive time period for patients and care providers.

More information

HealthCare Partners of Nevada. Heart Failure

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

More information

Narrow network health plans: New approaches to regulating adequacy and transparency. Michael S. Adelberg

Narrow network health plans: New approaches to regulating adequacy and transparency. Michael S. Adelberg Compliance TODAY October 2015 a publication of the health care compliance association www.hcca-info.org Combating healthcare fraud in New Jersey an interview with Paul J. Fishman United States Attorney

More information

Improving Hospital Performance

Improving Hospital Performance Improving Hospital Performance Background AHA View Putting patients first ensuring their care is centered on the individual, rooted in best practices and utilizes the latest evidence-based medicine is

More information

WHAT IS MEDICAL MANAGEMENT? WHAT IS THE PURPOSE OF MEDICAL MANAGEMENT?

WHAT IS MEDICAL MANAGEMENT? WHAT IS THE PURPOSE OF MEDICAL MANAGEMENT? WHAT IS MEDICAL MANAGEMENT? How health plans make decisions to approve payment for medical treatment is a poorly understood part of the healthcare system. One part of the process, known as medical management,

More information

Connected Care Delivers: Telemedicine s Value Proposition. June 8, 2015 National Council of Behavioral Health

Connected Care Delivers: Telemedicine s Value Proposition. June 8, 2015 National Council of Behavioral Health Connected Care Delivers: Telemedicine s Value Proposition June 8, 2015 National Council of Behavioral Health Agenda Introduction U.S. Market Landscape and Outlook Evidence of Cost Savings & Quality Care

More information

caresy caresync Chronic Care Management

caresy caresync Chronic Care Management caresy Chronic Care Management THE PROBLEM Chronic diseases and conditions, including heart disease, diabetes, COPD and obesity, are among the most common, expensive, and preventable health problems in

More information

About NEHI: NEHI is a national health policy institute focused on enabling innovation to improve health care quality and lower health care costs.

About NEHI: NEHI is a national health policy institute focused on enabling innovation to improve health care quality and lower health care costs. 1 Aaron McKethan PhD (amckethan@rxante.com) About NEHI: NEHI is a national health policy institute focused on enabling innovation to improve health care quality and lower health care costs. In partnership

More information

What Providers Need To Know Before Adopting Bundling Payments

What Providers Need To Know Before Adopting Bundling Payments What Providers Need To Know Before Adopting Bundling Payments Dan Mirakhor Master of Health Administration University of Southern California Dan Mirakhor is a Master of Health Administration student at

More information

How Will Hospital Readmission Penalties Impact Skilled Nursing Facilities?

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

More information

Care Management Approach for People Who Are at High Risk

Care Management Approach for People Who Are at High Risk Care Management Approach for People Who Are at High Risk Presented by: Ann Larsen RN, CDE Care Manger - Herefordshire Clinic/Trainer Care Management Plus June 11, 2013 Welcome! Type questions into the

More information

Emerging g Trends in Home Care

Emerging g Trends in Home Care Emerging g Trends in Home Care Dana Sheer, ACNP, MSN Susan Beausoliel, BSN, MS, DNP 1 The Triple Aim Goals Quality Improve Patient Outcomes Goal Readmissions Cost Reduce costs/penalties associated w/ readmissions

More information

Stroke Transitions of Care. Hospital Environment to Home

Stroke Transitions of Care. Hospital Environment to Home 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

More information

The Essential Guide to Using Web Chat in Healthcare

The Essential Guide to Using Web Chat in Healthcare The Essential Guide to Using Web Chat in Healthcare A publication of INTRODUCTION T echnology has revolutionized the way we communicate with one another -- whether it s text messages, e-mails, web chats

More information

2015 Healthcare Call Center Survey Results

2015 Healthcare Call Center Survey Results 27th Annual Conference Of Healthcare Call Centers 2015 Healthcare Call Center Survey Results Executive Summary of Findings, Insights and Ideas June 11, 2015 Healthcare Call Center Times Corporate Healthcare

More information

Support for Presentation

Support for Presentation Purpose of Activity The purpose of this presentation is to demonstrate how Athens Regional Home Health successfully implemented remote telemonitoring as a part of a comprehensive disease management program

More information

Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services

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

More information

Kaiser Permanente: Transition Care Performance and Strategies

Kaiser Permanente: Transition Care Performance and Strategies Kaiser Permanente: Transition Care Performance and Strategies Carol Ann Barnes, PT, DPT, GCS carbarne@gmail.com April 2009 Netta Conyers-Haynes, October, 2014 Principal Consultant, Communications Agenda

More information

Key CompetenCies for reducing readmissions: the Cio perspective

Key CompetenCies for reducing readmissions: the Cio perspective Key CompetenCies for reducing readmissions: the Cio perspective Executive Summary Addressing the challenge of reducing hospital readmissions using manual processes is not a viable long-term solution. With

More information

Root Cause Analysis (RCA) Getting to the Root of the Problem

Root Cause Analysis (RCA) Getting to the Root of the Problem Root Cause Analysis (RCA) Getting to the Root of the Problem DRIVING IMPROVEMENT The focus is on three critical aims to make care better for everyone: Better patient care Better population health Lower

More information

Washington State Medicaid: Implementation and Impact of ER is for Emergencies Program May 4, 2015 l The Brookings Institution

Washington State Medicaid: Implementation and Impact of ER is for Emergencies Program May 4, 2015 l The Brookings Institution THE RICHARD MERKIN INITIATIVE ON PAYMENT REFORM AND CLINICAL LEADERSHIP Washington State Medicaid: Implementation and Impact of ER is for Emergencies Program May 4, 2015 l The Brookings Institution Executive

More information

Erlanger s Care Transitions. Working Together. UT Resident Orientation June 26, 2015

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

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Harmoni - Hanley Health Centre Tel: 03001236759 Date of Inspection:

More information

Adding Value to. Provider Compensation. June 13, 2016. Healthcare Strategy Group OHA Presentation 2016. Adding Value to. Physician Compensation

Adding Value to. Provider Compensation. June 13, 2016. Healthcare Strategy Group OHA Presentation 2016. Adding Value to. Physician Compensation Provider Compensation June 13, 2016 1 Who are We? About (HSG) Hospital-physician integration specialists since 1999 Strategic, best practice approach to employed physician networks and independent physician

More information

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions...

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions... TABLE OF CONTENTS SECTION PAGE NUMBER Background... 2 Policy... 2 535.1 Member Eligibility and Enrollment... 2 535.2 Health Home Required Functions... 3 535.3 Health Home Coordination Role... 4 535.4 Health

More information

IT S TIME! PRIMARIS EHR SOLUTION. Benefits of Operational Efficiency. Why Primaris?

IT S TIME! PRIMARIS EHR SOLUTION. Benefits of Operational Efficiency. Why Primaris? IT S TIME! PRIMARIS EHR SOLUTION For years, Primaris has advocated the use of health information technology to improve patient care. We help providers take full advantage of their electronic health records

More information

Managing Patients with Multiple Chronic Conditions

Managing Patients with Multiple Chronic Conditions Best Practices Managing Patients with Multiple Chronic Conditions Advocate Medical Group Case Study Organization Profile Advocate Medical Group is part of Advocate Health Care, a large, integrated, not-for-profit

More information

The Road to Reform: Out of Chaos Comes Care Coordination. Mark Green, MBA,PMP,LSSBB AVP Transition Management Ochsner Health System

The Road to Reform: Out of Chaos Comes Care Coordination. Mark Green, MBA,PMP,LSSBB AVP Transition Management Ochsner Health System The Road to Reform: Out of Chaos Comes Care Coordination Mark Green, MBA,PMP,LSSBB AVP Transition Management Ochsner Health System Ochsner Health System Ochsner Risk Populations Full risk 34,000 Medicare

More information

Treating Depression to Remission in the Primary Care Setting. James M. Slayton, M.D., M.B.A. Medical Director United Behavioral Health

Treating Depression to Remission in the Primary Care Setting. James M. Slayton, M.D., M.B.A. Medical Director United Behavioral Health Treating Depression to Remission in the Primary Care Setting James M. Slayton, M.D., M.B.A. Medical Director United Behavioral Health 2007 United Behavioral Health 1 2007 United Behavioral Health Goals

More information

1. Executive Summary Problem/Opportunity: Evidence: Baseline Data: Intervention: Results:

1. Executive Summary Problem/Opportunity: Evidence: Baseline Data: Intervention: Results: A Clinical Nurse Leader led multidisciplinary Heart Failure Program: Integrating best practice across the care continuum to reduce avoidable 30 day readmissions. 1. Executive Summary Problem/Opportunity:

More information

Approaches to Asthma Management:

Approaches to Asthma Management: Approaches to Asthma Management: BY CAROL MCPHILLIPS-TANGUM AND CAROLINE M. ERCEG ASTHMA IS A CHRONIC DISEASE that affects millions of people in the United States and disproportionately impacts children,

More information

Advocate Health Partners Clinical Integration Program

Advocate Health Partners Clinical Integration Program Advocate Health Partners Clinical Integration Program A Core Strategy to Enhance Value for Patients, Providers, and Purchasers Lee Sacks, M.D., President Mark Shields, M.D., M.B.A., Senior Medical Director

More information

Hospital readmissions contribute to the increasing. Deployment of Lean Six Sigma in Care Coordination An Improved Discharge Process

Hospital readmissions contribute to the increasing. Deployment of Lean Six Sigma in Care Coordination An Improved Discharge Process Professional Case Management Vol. 19, No. 2, 77-83 Copyright 2014 Wolters Kluwer Health Lippincott Williams & Wilkins Deployment of Lean Six Sigma in Care Coordination An Improved Discharge Process Susan

More information

Plenary Session 1. Health Dimensions Group. 2010 Health Dimensions Group

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:

More information

Reducing Readmissions with Predictive Analytics

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

More information

Preparing for Online Communication with Your Patients

Preparing for Online Communication with Your Patients Preparing for Online Communication with Your Patients A Guide for Providers This easy-to-use, time-saving guide is designed to help medical practices and community clinics prepare for communicating with

More information

Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases

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

More information

Accountable Care Fundamentals for Medical Practice Executives

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

More information

Population Health Management Helps Utica Park Clinic Ease the Transition to Value-Based Care

Population Health Management Helps Utica Park Clinic Ease the Transition to Value-Based Care CASE STUDY Utica Park Clinic Population Health Management Helps Utica Park Clinic Ease the Transition to Value-Based Care The transition from fee-for-service to value-based reimbursement has been a challenge

More information

1900 K St. NW Washington, DC 20006 c/o McKenna Long

1900 K St. NW Washington, DC 20006 c/o McKenna Long 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:

More information

5/6/2014. Physiologic Monitoring Tools & Use with Patients with Chronic Health Conditions. Objectives. The Issue at Hand

5/6/2014. Physiologic Monitoring Tools & Use with Patients with Chronic Health Conditions. Objectives. The Issue at Hand Physiologic Monitoring Tools & Use with Patients with Chronic Health Conditions Kelly Brittain, PhD, RN Assistant Professor MCRH-Nursing Grand Rounds May 8, 2014 Objectives 1. Summarize previous research

More information

I. Current Cardiac Rehabilitation Requirements

I. Current Cardiac Rehabilitation Requirements CLIENT ADVISORY July 24, 2009 CMS Proposes Changes to Cardiac Rehabilitation Program Design and Physician Supervision Requirements The Centers for Medicare and Medicaid Services (CMS) recently published

More information

Using Root Cause Analysis to Reduce All-Cause Readmissions. Howard Dubin, MD

Using Root Cause Analysis to Reduce All-Cause Readmissions. Howard Dubin, MD Using Root Cause Analysis to Reduce All-Cause Readmissions Howard Dubin, MD Test Your Problem Solving Skills If you had two U.S. coins totaling 55 cents and one of the coins was NOT a nickel, what are

More information

Better Communication, Collaboration and Care Coordination

Better Communication, Collaboration and Care Coordination Solutions for Enabling Lifetime Customer Relationships Better Communication, Collaboration and Care Coordination Supporting Care Transitions with Communication Technology WHITE PAPER: HEALTHCARE WHITE

More information

Statement Of. The National Association of Chain Drug Stores. For. U.S. Senate Special Committee on Aging. Hearing on:

Statement Of. The National Association of Chain Drug Stores. For. U.S. Senate Special Committee on Aging. Hearing on: Statement Of The National Association of Chain Drug Stores For U.S. Senate Special Committee on Aging Hearing on: 10 Years Later: A Look at the Medicare Prescription Drug Program 2:30 p.m. 366 Dirksen

More information

I n t e r S y S t e m S W h I t e P a P e r F O R H E A L T H C A R E IT E X E C U T I V E S. In accountable care

I n t e r S y S t e m S W h I t e P a P e r F O R H E A L T H C A R E IT E X E C U T I V E S. In accountable care I n t e r S y S t e m S W h I t e P a P e r F O R H E A L T H C A R E IT E X E C U T I V E S The Role of healthcare InfoRmaTIcs In accountable care I n t e r S y S t e m S W h I t e P a P e r F OR H E

More information

Solutions. Health Advocate Chronic Care Management Program

Solutions. Health Advocate Chronic Care Management Program Solutions Health Advocate Chronic Care Management Program Taking Control Immunizations, preventive screenings and managing chronic conditions are key to controlling costs. Yet physicians often have limited

More information

Goals and Objectives for Electronic Health Record (EHR) Implementation

Goals and Objectives for Electronic Health Record (EHR) Implementation Goals and Objectives for Electronic Health Record (EHR) Implementation Guidelines Provided By: The National Learning Consortium (NLC) Developed By: Health Information Technology Research Center (HITRC)

More information

Medication Adherence: Rx for Success

Medication Adherence: Rx for Success Medication Adherence: Rx for Success Medication Adherence: Rx for Success Introduction Universal concern about rising health care costs combined with historic health care legislation has created an unprecedented

More information

Integrated Care for the Chronically Homeless

Integrated Care for the Chronically Homeless Integrated Care for the Chronically Homeless Houston, TX January 2016 INITIATIVE OVERVIEW KEY FEATURES & INNOVATIONS 1 The Houston Integrated Care for the Chronically Homeless Initiative was born out of

More information

Transforming traditional case management through local provider partnerships

Transforming traditional case management through local provider partnerships Transforming traditional case management through local provider partnerships Introduction The dramatic changes sweeping the health care industry are driving a strong interest in engaging patients at the

More information

Transitions of Care Management Coding (TCM Code) Tutorial. 1. Introduction Meaning of moderately and high complexity 2

Transitions of Care Management Coding (TCM Code) Tutorial. 1. Introduction Meaning of moderately and high complexity 2 Transitions of Care Management Coding (TCM Code) Tutorial Index 1. Introduction Meaning of moderately and high complexity 2 2. SETMA s Tools for using TCM Code 3 Alert that patient is eligible for TCM

More information

Patients Receive Recommended Care for Community-Acquired Pneumonia

Patients Receive Recommended Care for Community-Acquired Pneumonia Patients Receive Recommended Care for Community-Acquired Pneumonia For New Jersey to be a state in which all people live long, healthy lives. DSRIP LEARNING COLLABORATIVE PRESENTATION The Care you Trust!

More information

ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION)

ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION) ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION) Hello and welcome. Thank you for taking part in this presentation entitled "Essentia Health as an ACO or Accountable Care Organization -- What

More information

Kaiser Permanente of Ohio

Kaiser Permanente of Ohio Kaiser Permanente of Ohio Chronic Disease Management Program March 11, 2011 Presenters: Amy Kramer and Audrey L. Callahan 1 Objectives 1. Define the roles and responsibilities of the Care Managers in the

More information

DATA DRIVEN HEALTH CARE TRANSFORMATION

DATA DRIVEN HEALTH CARE TRANSFORMATION DATA DRIVEN HEALTH CARE TRANSFORMATION Population Health Analytics as the Foundation for Primary Care Redesign Sylvia Meltzer, MD, LSSGBC Laura Spurr, MPS, PMP Learning Objectives Organization description

More information

Care Transitions. Provide Your Patients with Effective Transitional Care Without Changing Your Operating Model. Share This

Care Transitions. Provide Your Patients with Effective Transitional Care Without Changing Your Operating Model. Share This Care Transitions Provide Your Patients with Effective Transitional Care Without Changing Your Operating Model Brought to you by Amedisys: Architects of a leading patient-centered Care Transitions network.

More information

Med Sync YOUR STEP-BY-STEP QUICK REFERENCE GUIDE

Med Sync YOUR STEP-BY-STEP QUICK REFERENCE GUIDE Med Sync YOUR STEP-BY-STEP QUICK REFERENCE GUIDE Med Sync: Your Step-by-Step Quick Reference Guide The Med Sync Guide provides a simple, five-step process to implement a medication synchronization program

More information

Coventry Health Care of Florida. Special Needs Plan (SNP) Model of Care Annual Training

Coventry Health Care of Florida. Special Needs Plan (SNP) Model of Care Annual Training Coventry Health Care of Florida Special Needs Plan (SNP) Model of Care Annual Training 1 Course Overview The Centers for Medicare and Medicaid (CMS) require all contracted medical providers to receive

More information

An Introduction to HealthInfoNet s HIE Reporting & Analytics. 6th Annual APS Healthcare Maine Conference May 14, 2015

An Introduction to HealthInfoNet s HIE Reporting & Analytics. 6th Annual APS Healthcare Maine Conference May 14, 2015 An Introduction to HealthInfoNet s HIE Reporting & Analytics 6th Annual APS Healthcare Maine Conference May 14, 2015 Presentation Outline HealthInfoNet Background Current Status of health information exchange

More information

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 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

More information

THE AFFORDABLE CARE ACT ITS EFFECTS ON RESPIRATORY CARE & SLEEP DEPARTMENTS

THE AFFORDABLE CARE ACT ITS EFFECTS ON RESPIRATORY CARE & SLEEP DEPARTMENTS THE AFFORDABLE CARE ACT ITS EFFECTS ON RESPIRATORY CARE & SLEEP DEPARTMENTS SHANE KEENE, DHSC, RRT- NPS, CPFT, RPSGT, RST DEPARTMENT HEAD, ANALYTICAL AND DIAGNOSTIC SCIENCES UNIVERSITY OF CINCINNATI Mr.

More information

Henry Ford Health System Care Coordination and Readmissions Update

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

More information

A Family Caregiver s Guide to Urgent Care Centers

A Family Caregiver s Guide to Urgent Care Centers Family Caregiver Guide A Family Caregiver s Guide to Urgent Care Centers Urgent care centers help fill the gap between a doctor s office and a hospital s emergency room (ER). They provide treatment for

More information