Implementing Care Management for Complex Patients in Primary Care Best Practices from Successful Programs
|
|
|
- Jeffry Franklin
- 10 years ago
- Views:
Transcription
1 Implementing Care Management for Complex Patients in Primary Care Best Practices from Successful Programs Clemens Hong MD, MPH California Association of Public Hospitals December 5, 2014
2 Sources: Cohen, Steven B. and Namrata Uberoi Differentials in the Concentration in the Level of Health Expenditures across Population subgroups in the U.S., Agency for Healthcare Research and Quality.
3 Using complex care management teams to improve care & reduce costs One proposed solution to address healthcare cost problem Specially trained multidisciplinary, complex care management teams
4 Program/Population Utilization/Cost Quality Admit / Readmit ED Use Cost Quality Provider Experience Patient Experience/ QOL GENERAL TREND Source: Hong CS, Ferris TG. CMWF Brief 2014 (Pending Publication) 4
5 Challenges for CCM Programs: Drops in Potential Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Adapted from J Eisenberg JAMA Realized improvement
6 Family/Caregivers CCM Team Patient CM
7 Social Service Agencies Government Service Agencies Health Delivery System Family/Caregivers CCM Team Acute & Post-acute Facilities Specialty Care Providers Patient CM Payers & Purchasers Public Health Agencies Behavioral Health Home Health & VNA
8 Social Service Agencies Government Service Agencies Health Delivery System Acute & Post-acute Facilities Specialty Care Providers Patient- Centered Medical Home PCMH Team PCP CM CCM Team Payers & Purchasers Public Health Agencies Behavioral Health Home Health & VNA
9 Social Service Agencies Government Service Agencies Health Delivery System Acute & Post-acute Facilities Specialty Care Providers Patient- Centered Medical Home PCMH Team PCP CM CCM Team CCM Hub Payers & Purchasers Behavioral Health Public Health Agencies Home Health & VNA
10 Scope of Work & Key Tasks Central task to build relationships with patients, primary care teams & hospital/community partners Touches Twice weekly to monthly Telephonic, office, in-home Patient case load: Depends on training, resources, & intensity of intervention Use of teams, risk stratification & IT enable larger case loads
11 Scope of Work & Key Tasks Comprehensive assessment & creation of care plans Address behavioral health & social service needs Address barriers to access/care Care coordination focus on transitions of care Health coaching/self-management support Medication Management support Advanced illness management support Patient advocacy & activation Facilitate Practice Change Outpatient Specialist Care Emergency Department & Acute Inpatient Care CARE MANAGEMENT & PRIMARY CARE SNF & Rehab Care
12 1. Quantitative Patient Selection Applying risk prediction software to claims data Acute care utilization focused High risk condition focused 2. Qualitative Referral Physician/Staff or Patient 3. Hybrid approaches
13 Effective Targeting of Care Management Population Volume Healthy Area of Greatest Opportunity? Chronic Illnesses Area of Greatest Opportunity? Medically Complex/ High Utilizers Area of Greatest Opportunity?
14 Patient engagement Connection to primary care Face-to-face interaction Longitudinal relationships Traits of team matters Motivational interviewing Sell it to patients Ensure early successes Making the right pitch to patients is important Tailored approach at Camden 1.Reach out to patients during hospitalization or ED visit 2.Personalized introduction 3.Open-ended questions to identify patients needs 4.Use understanding of needs to tailor presentation of services Mobile workforce & technology 14
15 Primary care integration Co-location Face-to-face interactions Education on CM role/benefits Enhancing integration Champions Data/ EMR Access Early successes/trust building 15
16 Engaging Other Critical Partners Ties to inpatient facilities/eds Communication with inpatient CMs Communication with skilled nursing facilities CM team members embedded at hospital sites Ties to community-based agencies Home health agencies Hospice Elder Resource Centers Community Centers Social Service Agencies
17 Important concepts for ensuring efficient CCM Build strong relationships with patients, primary care teams, hospitals/specialists and other community care partners A good CM doesn t do everything Allocate CM resource to high-yield activities Complement existing services Focus on mutable issues Work in multi-disciplinary teams Use HIT infrastructure to enhance CM efficiency
18 Important concepts for ensuring efficient CCM No perfect model Start with the best approach for the context/population Then use continuous quality improvement to improve CCM is evolving rapidly so we will need to continue to share learning and evaluate different approaches
19 Los Angeles County Department of Health Services Care Connections Program Anansi Health
20 Serving 5-10% of LAC DHS s Patients CCM Panel within a Panel Complex biopsychosocial needs Hard to engage High utilization of health care High cost of care 19,000-38,000 out of 380,000 primary care patients 15-30X growth possible
21 Aims $ $ Admit/ ED CCP
22 Social Service Agencies Government Service Agencies Patient- Centered Medical Home Health Delivery System PCMH Team CCM Team PCP PCP CHW RN Acute & Post-acute Facilities Specialty Care Providers Central CCM Hub Payers & Purchasers Public Health Agencies Behavioral Health Home Health & VNA
23 Care Connections Team CHW PCMH Embedded
24 Patient Engagement Social Support Comprehensive Assessment & Care Planning Health System Navigation CHW Role Care Transition Support Advanced Illness management support Chronic Disease Support & Health Coaching
25 66 year old man h/o Stroke X4 left sided paralysis & seizures Heart Disease - planned bypass surgery Prescribed 15 pills daily - trouble affording Smoker wants to quit with hypnosis Patient Has caregiver personal care attendant Admits for rectal bleeding & stroke in past year Frequent ED Visits for pain management Multiple specialists 4 appointments/week Wheelchair transportation issues Depression evaluated for self-neglect
26 Acknowledgements Principal Investigator: Timothy Ferris RAs: Allie Siegel, Powell Perng, Paola Miralles Funding: o Tom Bodenheimer o Randy Brown o Nancy McCall o Melanie Bella o Rushika Fernandopulle o Steven Kravet o Joanne Sciandra o Annette Watson Steering Committee: * No conflicts of interest to report *
27 Questions? Thank you! Contact:
28 Tiering Tiering the Total Population Quantitative approaches Tiering High-Risk Patients Clinical Tiering by CMs Care Gaps, Chronic Conditions, Utilization trigger-based Individualized Care Plan Automated Tiering Risk score, time in program, health risk assessment or utilization trigger-based Iora health s Worry Score
Implementing Care Management for Complex Patients in Primary Care Best Practices from Successful Programs
Implementing Care Management for Complex Patients in Primary Care Best Practices from Successful Programs Clemens Hong MD, MPH Maine Community Care Teams Summit November 14, 2013 Health Care Costs Concentrated
Implementing Care Management for Complex Patients
Implementing Care Management for Complex Patients Timothy Ferris, MD, MPH SVP, Population Health Management, MGH, MGPO and Partners HealthCare Ohio Perinatal Quality Collaborative September 28, 2015 Thinking
Pushing the Envelope of Population Health
Pushing the Envelope of Population Health Timothy Ferris, MD, MPH Senior Vice President, Population Health Management, Partners HealthCare May 15, 2014 DISCLAIMER: The views and opinions expressed in this
GRACE Team Care Integration of Primary Care with Geriatrics and Community-Based Social Services
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
Dual RFI Response Summary
Dual RFI Response Summary Improving Care through Integrated Medicare and Medi- Cal Delivery Models Stuart Levine, MD., MHA. Keith Wilson, MD Robert Margolis, MD. Stakeholder Meeting August 30, 2011 1 Organization
5/13/2011. ACO Partnerships A Case Study. Contents: The Strategic Imperative for Accountable Care
ACO Partnerships A Case Study Bob Edmondson, MPH Vice President, Innovation West Penn Allegheny Health System Pittsburgh, PA 1 Contents: 1. The Strategic Imperative for Accountable Care 2. Population Health
Population Health Management: Banner Health Network s Perspective. Neta Faynboym, Medical Director Banner Health Network
Population Health Management: Banner Health Network s Perspective Neta Faynboym, Medical Director Banner Health Network 29 Acute Care Hospitals BANNER AT A GLANCE Banner Health Network with 400K lives
Community Health Worker Led Diabetes Coaching within the Medical Home
Community Health Worker Led Diabetes Coaching within the Medical Home Christine Snead, RN Erin Kane, MD Baylor Scott & White Health www.alliancefordiabetes.org Objectives Identify tools, resources and
Parkview Health s Population Health Journey
Parkview Health s Population Health Journey Susan McAlister DNP, RN Director Enterprise Care Management Christine Howell BSN, RN Community Based Registered Nurse Objectives: By the completion of the webinar
Nancy L. Wilson Department of Medicine-Geriatrics Houston Center for Quality of Care& Utilization Studies Texas Consortium of Geriatric Education
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
Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management
Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management According to AARP, about 8000 people turn 65 every day The Medicare Trustees have estimated that Medicare will run out of money
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
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
Patient to Person. Transitions of Care. Colby Bearch, MA-SF, MA-M, BA, RN, CDONA Sharyn King, RN, BSN, CCM
Patient to Person Transitions of Care Colby Bearch, MA-SF, MA-M, BA, RN, CDONA Sharyn King, RN, BSN, CCM Transitions of Care Transitioning from school to adult services (vocational, medical day, etc.)
Kick off Meeting November 11 13, 2015. MERCY CLINIC EAST COMMUNITIES Management of Patients with Heart Failure (HF)
Kick off Meeting November 11 13, 2015 MERCY CLINIC EAST COMMUNITIES Management of Patients with Heart Failure (HF) Team Composition Justin Huynh, MD Internal Medicine, Physician Champion Mary Laubinger,
Opportunities for Home Care Providers in Working with Medical Homes October 2014. EMHS Vice President Continuum of Care Chief Advocacy Officer
How to Establish Partnerships and Opportunities for Home Care Providers in Working with Medical Homes October 2014 Lisa Harvey-McPherson, RN, MBA, MPPM EMHS Vice President Continuum of Care Chief Advocacy
Connect4 Patients CCCM Primary Care Community. Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM
Connect4 Patients CCCM Primary Care Community Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM September 17, 2015 Objectives: Describe innovative care management
Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services.
Domain 3 Projects 3.a.i Integration of Primary Care and Behavioral Health Services Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination
PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT. Norris Vivatrat, MD Associate Medical Director Monarch HealthCare
PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT Norris Vivatrat, MD Associate Medical Director Monarch HealthCare 2 Agenda Pioneer ACO basics, performance and challenges Monarch HealthCare Post-acute network
What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company?
What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company? Lisa Harvey McPherson RN, MBA, MPPM EMHS Vice President Continuum of Care & Chief Advocacy Officer Disclosures
Atrius Health Pioneer ACO: First Year Accomplishments, Results and Insights
Atrius Health Pioneer ACO: First Year Accomplishments, Results and Insights Emily Brower Executive Director Accountable Care Programs [email protected] November 2013 1 Contents Overview of
Be Careful What You Ask For A Predictive Model That Really Works
Be Careful What You Ask For A Predictive Model That Really Works Rod Christensen, MD President, Allina Health Clinics Cheryl Hermann, RN, MBA Vice President, Clinic Operations & Patient Care Services Karen
Building an Accountable Care Organization. Jean Malouin, MD MPH University of Michigan Health System September 21, 2012
Building an Accountable Care Organization Jean Malouin, MD MPH University of Michigan Health System September 21, 2012 Agenda UMHS overview PGP demo ACO precursor Current efforts underway Role of primary
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
INTRO TO THE MICHIGAN PIONEER ACO 101: THE BASICS. Karen Unholz, RN, BSN
INTRO TO THE MICHIGAN PIONEER ACO 101: THE BASICS Karen Unholz, RN, BSN Origins of the Accountable Care Organization ACOs originated from the Patient Protection and Affordable Care Act (Healthcare Reform)
Joan Carroll RN, CDMS, CCM Director of Care Transitions Lee Memorial Health System
Joan Carroll RN, CDMS, CCM Director of Care Transitions Lee Memorial Health System 1 Explain how patients experience transitions of care Identify variables that affect transitions due to lack of patient
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
Commercial ACOs: Trials and Tribulations
Commercial ACOs: Trials and Tribulations June 12, 2015 Agenda: John Jenrette, MD, CEO, Sharp Community Medical Group Moderator Nancy Greenstreet, MD, Medical Director, Physicians Medical Group of Santa
CMS Innovation Center Improving Care for Complex Patients
CMS Innovation Center Improving Care for Complex Patients ECRI Institute Dr. Patrick Conway, M.D., MSc CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality Director, Center for
The Collaborative Models of Mental Health Care for Older Iowans. Model Administration. Collaborative Models of Mental Health Care for Older Iowans 97
6 The Collaborative Models of Mental Health Care for Older Iowans Model Administration Collaborative Models of Mental Health Care for Older Iowans 97 Collaborative Models of Mental Health Care for Older
December 23, 2010. Dr. David Blumenthal National Coordinator for Health Information Technology Department of Health and Human Services
December 23, 2010 Dr. David Blumenthal National Coordinator for Health Information Technology Department of Health and Human Services RE: Prioritized measurement concepts Dear Dr. Blumenthal: Thank you
Stuart Levine MD MHA Corporate Medical Director, HealthCare Partners Assistant Clinical Professor, Internal Medicine and Psychiatry, UCLA David
Stuart Levine MD MHA Corporate Medical Director, HealthCare Partners Assistant Clinical Professor, Internal Medicine and Psychiatry, UCLA David Geffen School of Medicine 1 HealthCare Partners Delivery
DSRIP QUARTERLY REVIEW PROCESS: Project Requirement - Timeframe. Project Requirement - Unit Level Reporting
DSRIP QUARTERLY REVIEW PROCESS: PPSs will submit a quarterly report to the Independent Assessor throughout the DSRIP program via the automated MAPP tool which includes Domain 1 DSRIP Requirement Milestone
Get With The Guidelines Best Practices: A look at reducing 30-day heart failure readmission rates
Get With The Guidelines Best Practices: A look at reducing 30-day heart failure readmission rates Thank you for joining the webinar! The presentation will begin shortly. *Please make sure your computer
Population Health Management Innovation Payer and Provider Collaboration. Population Health Management Innovation Payer and Provider Collaboration
Population Health Management Innovation Payer and Provider Collaboration Population Health Management Innovation Payer and Provider Collaboration Agenda Strategic Context Population Health Journey Key
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
#Aim2Innovate. Share session insights and questions socially. UCLA Primary Care Innovation Model 6/13/2015. Mark S. Grossman, MD, MBA, FAAP, FACP
UCLA Primary Care Innovation Model Mark S. Grossman, MD, MBA, FAAP, FACP Chief Medical Office, UCLA Community Physicians & Specialty Care Networks June 16, 2015 DISCLAIMER: The views and opinions expressed
Disease Management Identifications and Stratification Health Risk Assessment Level 1: Level 2: Level 3: Stratification
Disease Management UnitedHealthcare Disease Management (DM) programs are part of our innovative Care Management Program. Our Disease Management (DM) program is guided by the principles of the UnitedHealthcare
Proven Innovations in Primary Care Practice
Proven Innovations in Primary Care Practice October 14, 2014 The opinions expressed are those of the presenter and do not necessarily state or reflect the views of SHSMD or the AHA. 2014 Society for Healthcare
High Desert Medical Group Connections for Life Program Description
High Desert Medical Group Connections for Life Program Description POLICY: High Desert Medical Group ("HDMG") promotes patient health and wellbeing by actively coordinating services for members with multiple
Accountable Care Organizations: What Are They and Why Should I Care?
Accountable Care Organizations: What Are They and Why Should I Care? Adrienne Green, MD Associate Chief Medical Officer, UCSF Medical Center Ami Parekh, MD, JD Med. Director, Health System Innovation,
Scope and Standards Formation Task Force... 2. Introduction... 5
Table of Contents Scope and Standards Formation Task Force... 2 Introduction... 5 Scope of Practice for Registered Nurses Care Coordination and Transition Management... 6 Historical Evolution... 6 Definitions
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
Realizing ACO Success with ICW Solutions
Realizing ACO Success with ICW Solutions A Pathway to Collaborative Care Coordination and Care Management Decrease Healthcare Costs Improve Population Health Enhance Care for the Individual connect. manage.
RIH Transitions of Care Collaboration with Coastal Medical To Improve Transitions for Patients Discharged Hospital To Home
RIH Transitions of Care Collaboration with Coastal Medical To Improve Transitions for Patients Discharged Hospital To Home Sergio Petrillo, PharmD Clinical Pharmacist Specialist, Rhode Island Hospital
PREVENTING HEART FAILURE READMISSIONS
PREVENTING HEART FAILURE READMISSIONS Tanya Sprinkle, BSN, RN, CCM Patient and Family Services Coordinator [email protected] 704-878-4534 Michelle Roseman, NHA, MBA Chief Operating Officer/Catawba
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
Partnerships in Primary and Behavioral Health Care ACO Survival Integrated Care
Partnerships in Primary and Behavioral Health Care ACO Survival Integrated Care Ensuring Success for ACOs September 22 23 Joyce Wale LCSW Vice President, Institute for Behavioral Healthcare Improvement
DRIVING VALUE IN HEALTHCARE: PERSPECTIVES FROM TWO ACO EXECUTIVES, PART I
DRIVING VALUE IN HEALTHCARE: PERSPECTIVES FROM TWO ACO EXECUTIVES, PART I A firm understanding of the key components and drivers of healthcare reform is increasingly important within the pharmaceutical,
Identifying High-Risk Medicare Beneficiaries with Predictive Analytics
Identifying High-Risk Medicare Beneficiaries with Predictive Analytics September 2014 Until recently, with the passage of the Affordable Care Act (ACA), Medicare Fee-for-Service (FFS) providers had little
Nursing Home to Community Program: A Discharge Planning Manual
Nursing Home to Community Program: A Discharge Planning Manual March 2006 Portions of this Manual may be cited on condition that proper credit is given to: Broome County Community Alternative Systems Agency
ST JOHN S LUTHERAN MINISTRIES. Kent Burgess President & CEO
ST JOHN S LUTHERAN MINISTRIES Kent Burgess President & CEO WHAT S CHANGING MAYBE? -The way we get paid (Reduce Cost) -The way we get measured (Better Care) -What will be required of us (More) -Partnerships/Affiliations
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
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
Performance Measurement in CMS Programs Kate Goodrich, MD MHS Director, Quality Measurement and Health Assessment Group, CMS
Performance Measurement in CMS Programs Kate Goodrich, MD MHS Director, Quality Measurement and Health Assessment Group, CMS Mind the Gap: Improving Quality Measures in Accountable Care Systems October
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
Collaborative Onsite Medical Care in the Workplace
Collaborative Onsite Medical Care in the Workplace Sue Dierksen, MPH,RN, COHN-S/CM, CSP Director of Business Health- Aspirus Clinics Holly Bauer, RN BSN Health Services Supervisor, Sentry Insurance Objectives
What do ACO s and Hospitals want from SNF s and CCRC s
What do ACO s and Hospitals want from SNF s and CCRC s Presented to the Institute of Senior Living, April 11, 2013 A Division of Kindred Healthcare 1 Assessing the match: What hospitals and ACO s currently
Five Myths Surrounding the Business of Population Health Management
Five Myths Surrounding the Business of Population Health Management Joan Moss, RN, MSN Robert Sehring Chief Nursing Officer and Chief Ministry Services Officer, Senior Vice President, Sg2 OSF HealthCare
Sharp HealthCare ACO. Pioneer Introduction to the FSSB November 8, 2012
Sharp HealthCare ACO Pioneer Introduction to the FSSB November 8, 2012 Sharp HealthCare Not-for-profit serving 3.1 million residents of San Diego County Grew from one hospital in 1955 to an integrated
Relative patient benefits of a hospital-pcmh collaboration within an ACO to improve care transitions:
Relative patient benefits of a hospital-pcmh collaboration within an ACO to improve care transitions: Lessons learned from the PCORI grant application experience Jeffrey L. Schnipper, MD, MPH, FHM Director
HEDIS 2012 Results
Capital District Physicians Health Plan, Inc. Nonprofit Health Plan Albany, New York Capital District Physicians Health Plan, Inc. (CDPHP ) is featured as a high performer in cardiovascular care, identified
Care Management: Reducing Risks. Project ECHO Consultation. Amy J. Khan, MD, MPH. Mia McCallum-Crawford, RN
Care Management: Improving Health & Reducing Risks Project ECHO Consultation February 19, 2015 Amy J. Khan, MD, MPH Lisa Moreno, RN Mia McCallum-Crawford, RN Objectives 1. Consider patient factors and
Game Changer at the Primary Care Practice Embedded Care Management. Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012
Game Changer at the Primary Care Practice Embedded Care Management Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012 Objectives To describe the recent evolution of care management at
Patient Centered Medical Home: An Approach for the Health Plan
: An Approach for the Health Plan By Marissa A. Harper and JoAnn E. Balara Excellence in healthcare consulting The Medical Home Concept Works Recent Medicare demonstration projects on Patient Centered
Arkansas Health Care Payment Improvement Initiative
Arkansas Health Care Payment Improvement Initiative Joseph W. Thompson, MD, MPH Arkansas Surgeon General Director, Arkansas Center for Health Improvement Arkansas System Transformation Strategy Workforce
A Sustainable Source for Services through Health Home Legislation: What it Means for Supportive Housing
A Sustainable Source for Services through Health Home Legislation: What it Means for Supportive Housing The Source for Housing Solutions Sharon Rapport, CSH Lezlie Murch, Exodus Recovery Brenda Goldstein,
Readmissions as an Enterprise Priority. Presenters 4/17/2014
Readmissions as an Enterprise Priority April 24, 2014 Presenters Vincent A. Maniscalco, MPA, LNHA Administrator Middletown Park Rehabilitation and Health Care Center [email protected] Eileen
Nursing in a Transformed Health Care System: New Roles, New Rules
RESEARCH BRIEF June 2015 Nursing in a Transformed Health Care System: New Roles, New Rules Key takeaway message: Although the supply of nurses is likely to meet overall demand, the nature of a nurse s
POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk
POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk Julia Andrieni, MD, FACP Vice President, Population Health and Primary
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
The Montefiore ACO and Behavioral Health Integration: A Work in Progress. Henry Chung, MD Bruce Schwartz, MD
The Montefiore ACO and Behavioral Health Integration: A Work in Progress Henry Chung, MD Bruce Schwartz, MD Agenda Describe the Montefiore Medical Center delivery system and experience in managing vulnerable
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
3/11/15. COPD Disease Management Tackling the Transition. Objectives. Describe the multidisciplinary approach to inpatient care for COPD patients
Faculty Disclosures COPD Disease Management Tackling the Transition Dr. Cappelluti has no actual or potential conflicts of interest associated with this presentation. Jane Reardon has no actual or potential
THE ROLE OF HEALTH INFORMATION TECHNOLOGY IN PATIENT-CENTERED CARE COLLABORATION. 2012 Louisiana HIPAA & EHR Conference Presenter: Chris Williams
THE ROLE OF HEALTH INFORMATION TECHNOLOGY IN PATIENT-CENTERED CARE COLLABORATION 2012 Louisiana HIPAA & EHR Conference Presenter: Chris Williams Agenda Overview Impact of HIT on Patient-Centered Care (PCC)
MODULE 11: Developing Care Management Support
MODULE 11: Developing Care Management Support In this module, we will describe the essential role local care managers play in health care delivery improvement programs and review some of the tools and
WellSpan Health Care Management Strategy. October, 2013
WellSpan Health Care Management Strategy October, 2013 We will realize a fundamental, yet gradual, shift in how we deliver and receive payment for care From: A system that treats people mostly when they