THE SAN DIEGO CARE TRANSITIONS PARTNERSHIP
|
|
|
- Quentin Flynn
- 10 years ago
- Views:
Transcription
1 THE SAN DIEGO CARE TRANSITIONS PARTNERSHIP Transforming Care Across the Continuum Julianne R. Howell, Ph.D. Senior Health Policy Advisor County of San Diego Health and Human Services Agency
2 SAN DIEGO COUNTY DEMOGRAPHICS 4,261 square miles (larger than 21 U.S. States; same size as Connecticut) 5 th largest U.S. County, 2 nd largest in CA 18 municipalities; 36 unincorporated towns 18 tribal nations 42 school districts 2013 Estimates 3.1 million population 48% White 32% Latino 11% Asian/PI 4.7% African American 0.5% American Indian Region is very diverse Over 100 languages Large military presence Largest refugee resettlement site in CA Busiest international border crossing in the world (San Ysidro/MX)
3 SAN DIEGO COUNTY GOVERNMENT Board of Supervisors 5 elected by District 5 Major Groups Health and Human Services Agency (HHSA) Created in 1998, Integrated Delivery System Public-private partnership emphasis o Long tradition as a community convener o No County-owned acute-care hospital ~ $2 billion annual budget 6,000 FTEs, 185 advisory boards ~ 1 million clients womb to tomb Public Safety Group Land Use and Environment Group Community Services Group Finance and General Government 3
4 Background: SDCTP A strategic partnership between Palomar Health, Scripps Health, Sharp HealthCare, the UCSD Health System 11 hospitals/13 campuses, and AIS/County of San Diego HHSA Goals of the federal Community-based Care Transitions Program (CCTP): Improve transitions from the inpatient hospital setting to community Improve quality of care Reduce readmissions for high risk beneficiaries Document measureable savings to the Medicare program
5 Opportunity
6 Opportunity continued Design and implement a patient-centered system of care across the continuum Share data and best practices to realize the Triple Aim Demonstrate to the rest of the country how to: Scale up a comprehensive care transitions program to serve a large, diverse population of high risk patients Test new care transition interventions Improve the health of the community in a predominantly managed care county Innovate with clinical and social service partners who endorsed a shared vision to transform care for FFS Medicare patients across the continuum
7 Structure Steering Committee Planning & Oversight AIS Administration Work Team Operations Partnership Collaboration
8 AGING & INDEPENDENCE SERVICES (AIS) Call Center/ADRC RSVP Veterans Health Promotion Outreach & Education Senior Dining & Home- Delivery Care Mgmt Caregiver Support Care Transitions In-Home Supportive Services (IHSS) APS Ombudsman Project Care PA/PG/PC Senior Team
9 Components of the SDCTP CCTP Model All Systems Patients receive specific services (aka interventions) tailored to their individual needs Available interventions: Inpatient nursing support to coordinate care, the discharge process, and hand-off to downstream providers (called High- Risk Healthcare Coach, Inpatient Navigator, and Transition Nurse Specialist, depending on the system) Pharmacy: medication reconciliation and education Care Transitions Intervention (CTI): using the 4-pillar Eric Coleman model to support health self-management through teach-back and coaching Care Enhancement (CE): identify and meet a patient s immediate and ongoing social support needs (provided by AIS to patients in all systems)
10 Components of the SDCTP CCTP Model Selected Systems Only Available interventions: Post-Acute Navigation (PAN): telephonic CTI (Sharp only) Follow-up Phone Calls: post-discharge phone calls to follow up on important issues and triage new problems (UCSD only)
11 CCTP in Action
12 ALEX: IT System Supporting SDCTP
13 Data in Action: Monthly Dashboard
14 Data in Action: CE Patients Assessed Risk Elderly/Frail Assist with activities of daily living Mental Health Lack of Social Support Primary Care Physician follow-up/transportation PolyPharm/Unable to Manage Meds Demographics 59% of CE patients are female 44% are at or below the Federal Poverty Level 31% receive SSI 53% are Dual Eligible 25% are Hispanic 23% speak Spanish only High ER/Hospital Utilizers Socioeconomic CE Coordinated Services Top Admitting Diagnosis 38% Chest Pain 31% Shortness of Breath 11% Abdominal Pain 11% Congestive Heart Failure 9% Syncope Chore/Homemaker Durable medical equip. Food Voucher Med Co-Pay Personal Care Home Delivered Meals Mental Health Nutrition Counseling Transportation Other
15 CCTP: Impact on Readmission Rate 30-Day All Cause Hospital Readmission Rate 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Medicare Fee-for-Service (FFS) Beneficiaries Reduction in 30-Day All Cause Hospital Readmission Rate San Diego County 2010 to % 2010 Medicare FFS Beneficiaries 17.8% 2013 Medicare FFS Beneficiaries Source: Centers for Medicare and Medicaid Services readmission rates data files.
16 CCTP: Impact on Readmission Rate cont. Community-Based Care Transitions Program (CCTP) Reduction in 30 Day Hospital Readmission Rate January 2013 to January Day Hospital Readmission Rate 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 39.8% 2012 Target Group Baseline 13.9% CCTP Participants 11.7% CCTP Completers Target Group baseline: CCTP participants 30 day readmission rate from 2012 CCTP Participants: Those who completed services (CCTP Completers) and those who did not complete all aspects of the program CCTP Completers: CCTP participants who completed all aspects of the program
17 Trends and Outcomes An increase in the San Diego FFS Medicare population by 8.6% A decrease in hospital admissions from 2010 to 2013 of 3.4% Readmission rate per 1,000 beneficiaries 2010: 11.02/1000 benes/quarter 2013: 8.99/1000 benes/q4 (seasonally adjusted) CCTP contributed to a reduction of 437 hospital readmissions and an overall estimated $2.6 million in Medicare savings
18 Lessons Learned How to work together Time needed to ramp up + expand program footprint How to identify and target the right patients Even simple interventions take time to complete Community relationships are critical for success Extending CCTP services to all patients is ideal We are training the next generation of health care and social service providers
19 What s Next? Improvements in screening / patient selection process Better understanding of why patients readmit and how/if we could have intervened Increased collaborations with community health agencies and SNFs Training the next generation of health care practitioners Expanding CCTP to other patient populations Sustaining the partnership and seeking new opportunities for partnership
20 Coming together is a beginning Keeping together is progress Working together is success - Henry Ford Thank you so much!
How To Help The Elderly
SAN DIEGO COUNTY S AGING & DISABILITY RESOURCE CONNECTION IS A CORE PARTNERSHIP BETWEEN: COUNTY OF SAN DIEGO HEALTH & HUMAN SERVICES AGENCY AGING & INDEPENDENCE SERVICES & ACCESS TO INDEPENDENCE SAN DIEGO
Welcome to San Diego! NAPIPM 2014 34 th Annual Education Conference
Welcome to San Diego! NAPIPM 2014 34 th Annual Education Conference 1 POLICIES, PRACTICES & PEOPLE: PERFORMANCE-BASED CONVERGENCE IN ACTION NICK MACCHIONE, FACHE DIRECTOR COUNTY OF SAN DIEGO HEALTH AND
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
A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates. April 11, 2014
A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates April 11, 2014 About the QIO Program Leading rapid, large-scale change in health quality: Goals are bolder. The patient is at
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
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
Health Care Leader Action Guide to Reduce Avoidable Readmissions
Health Care Leader Action Guide to Reduce Avoidable Readmissions January 2010 TRANSFORMING HEALTH CARE THROUGH RESEARCH AND EDUCATION Osei-Anto A, Joshi M, Audet AM, Berman A, Jencks S. Health Care Leader
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
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
Community Health Needs Assessment Implementation Plan FY 14-16
Community Health Needs Assessment Implementation Plan FY 14-16 South Miami Hospital conducted a community health needs assessment in 2013 to better understand the healthcare needs of the community it serves
Maryland Medicaid Program. Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 15, 2012
Maryland Medicaid Program Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 15, 2012 1 Maryland Medicaid In Maryland, Medicaid is also called Medical Assistance or MA. MA is a joint
Providing and Billing Medicare for Transitional Care Management
PYALeadership Briefing Providing and Billing Medicare for Transitional Care Management Updated November 2014 2014 Pershing Yoakley & Associates, PC (PYA). No portion of this white paper may be used or
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
Empowering Value-Based Healthcare
Empowering Value-Based Healthcare Episode Connect, Remedy s proprietary suite of software applications, is a powerful platform for managing value based payment programs. Delivered via the web or mobile
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
Healing the Homeless:
Healing the Homeless: A Community Collaboration Malynda Mallory Shelter Manager Columbus House, Inc. Michael Ferry Lead Social Worker Yale New-Haven Hospital Creating the Impetus for Change Ryan Greysen
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,
Empowering Value-Based Healthcare
Empowering Value-Based Healthcare Episode Connect, Remedy s proprietary suite of software applications, is a powerful platform for managing value-based payment programs. Delivered via the web or mobile
Improving Service Delivery Through Administrative Data Integration and Analytics
Improving Service Delivery Through Administrative Data Integration and Analytics Getty Images David Mancuso, PhD October 2, 2015 1 Analytics in the Social and Health Service Environment Program costs are
Second Forum on Health Care Management & Policy November 28 30, 2012. Discussion Report. Care Management
Second Forum on Health Care Management & Policy November 28 30, 2012 Discussion Report Care Management Thomas G. Rundall Henry J. Kaiser Emeritus Professor of Organized Health Systems School of Public
Response to Serving the Medi Cal SPD Population in Alameda County
Expanding Health Coverage and Increasing Access to High Quality Care Response to Serving the Medi Cal SPD Population in Alameda County As the State has acknowledged in the 1115 waiver concept paper, the
Understanding Care Transitions as a Patient Safety Issue
Article reprinted from Patient Safety & Quality Healthcare, May/June 2011 Understanding Care Transitions as a Patient Safety Issue By Sara Butterfield RN, BSN, CPHQ, CCM; Christine Stegel, RN, MS, CPHQ;
Telemedicine in the Patient Protection and Affordable Care Act (2010)
Telemedicine in the Patient Protection and Affordable Care Act (2010) The new national health insurance reform legislation contains several advances for telemedicine that are listed below. There are numerous
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
CARE MANAGEMENT SERIES Part 6 Developing a Staffing Model That Works
CARE MANAGEMENT SERIES Part 6 Developing a Staffing Model That Works We will get to staffing but let s start by reviewing core functions. Care Management As we have discussed previously, Care Management
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
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
The Best of New Jersey: Care Transitions Communities
The Best of New Jersey: Care Transitions Communities June 25, 2014 H e a l t h c a r e Q u a l i t y S t r a t e g i e s, I n c. 557 Cranbury Road Suite 21 East Brunswick, NJ 08816-5419 Phone: 732-238-5570
How To Reduce Hospital Readmission
Reducing Hospital Readmissions & The Affordable Care Act The Game Has Changed Drastically Reducing MSPB Measures Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE
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
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Discharge Planning
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services ICN 908184 October 2014 This booklet was current at the time it was published or uploaded onto the web. Medicare policy
Maximizing Partnerships in the Changing Healthcare Delivery System
Maximizing Partnerships in the Changing Healthcare Delivery System Erin Westphal, MSG The SCAN Foundation Goals of Session Opportunities for Partnership Affordable Care Act California Duals Integration
Safe Transitions Best Practice Measures for
Safe Transitions Best Practice Measures for Hospitals Setting-specific process measures focused on cross-setting communication and patient activation, supporting safe patient care across the continuum
PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems
PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems By Kathleen M. Griffin, PhD. There are three key provisions of the law that will have direct impact on post-acute care needs
The Future of Home Health Care Project MAY 2014
The Alliance for Home Health Quality & Innovation The Future of Home Health Care Project MAY 2014 About the Alliance The Alliance for Home Health Quality & Innovation is a 501(c)(3) foundation with a mission
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
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
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
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
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
Home Care s Pivotal Role in Patient Transitions from Acute to Post Acute Care Settings:
Home Care s Pivotal Role in Patient Transitions from Acute to Post Acute Care Settings: Experiences of a Successful CCTP Program And So Much More! Jane Pike-Benton Senior Director, Home Health & Post Acute
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
Medicare Advantage Plans: An Overview
Medicare Advantage Plans: An Overview June 2014 Prepared by: Penny Finch, Benefits Consultant Copyright 2014 by The Segal Group, Inc. All rights reserved. 5432273.1 CONTENTS Medicare 101 Understanding
MANITOWOC COUNTY CARE TRANSITION PROGRAM
MANITOWOC COUNTY CARE TRANSITION PROGRAM A U G U S T 1 5, 2 0 1 3 Judy Rank Director Cathy Ley Supervisor Care Transitions Coach MANITOWOC COUNTY CARE TRANSITION PROGRAM Julie Place, Director of Nursing
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
HOW TO UNDERSTAND YOUR QUALITY AND RESOURCE USE REPORT
HOW TO UNDERSTAND YOUR QUALITY AND RESOURCE USE REPORT CONTENTS A BACKGROUND AND PURPOSE OF THE MID-YEAR QUALITY AND RESOURCE USE REPORTS... 1 B EXHIBITS INCLUDED IN THE MID-YEAR QUALITY AND RESOURCE USE
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.)
Addictions Services Refers to alcohol and other drug treatment and recovery services.
APPENDIX E GLOSSARY: MOU GUIDANCE This Glossary is a communication tool which attempts to provide informal explanations of terms which may be used in discussions regarding the MOU. These terms should not
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
Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: February 19, 2014
Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: February 19, 2014 Introduction The Office of Mental Health (OMH) licensed and regulated Assertive Community
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
Maximizing Limited Care Management Resources to Improve Clinical Quality and Ensure Safe Transitions
Maximizing Limited Care Management Resources to Improve Clinical Quality and Ensure Safe Transitions Scott Flinn MD Deborah Schutz RN JD Fritz Steen RN Arch Health Partners A medical foundation formed
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
Maryland Data as of July 2003. Mental Health and Substance Abuse Services in Medicaid and SCHIP in Maryland
Mental Health and Substance Abuse Services in Medicaid and SCHIP in Maryland As of July 2003, 638,662 people were covered under Maryland's Medicaid/SCHIP programs. There were 525,080 enrolled in the Medicaid
Patient Protection and Affordable Care Act [PL 111-148] with Amendments from 2010 Reconciliation Act [PL 111-152] Direct-Care Workforce
![Patient Protection and Affordable Care Act [PL 111-148] with Amendments from 2010 Reconciliation Act [PL 111-152] Direct-Care Workforce](/thumbs/25/6872632.jpg "Patient Protection and Affordable Care Act [PL 111-148] with Amendments from 2010 Reconciliation Act [PL 111-152] Direct-Care Workforce")
DIRECT-CARE WORKFORCE AND LONG-TERM CARE PROVISIONS AS ENACTED IN PATIENT PROTECTION AND AFFORDABLE CARE ACT AND HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010 Key Provisions Direct-Care Workforce
IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis
IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis CHANGE LOG Medicaid Chapter Policy # Effective Date Chapter 535 Health Homes 535.1 Bipolar and
2013 ACO Quality Measures
ACO 1-7 Patient Satisfaction Survey Consumer Assessment of HealthCare Providers Survey (CAHPS) 1. Getting Timely Care, Appointments, Information 2. How well Your Providers Communicate 3. Patient Rating
2014 Model of Care Training SHP_2014838A
2014 Model of Care Training SHP_2014838A 1 Model of Care Training This course is offered to meet the CMS regulatory requirements for Model of Care Training for our Special Needs Plans. It also ensures
Frequently Asked Questions Regarding At Home and Inpatient Hospice Care
Frequently Asked Questions Regarding At Home and Inpatient Hospice Care Contents Page: Topic Overview Assistance in Consideration Process Locations in Which VNA Provides Hospice Care Determination of Type
Care Transition Bundle Seven Essential Intervention Categories
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
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:
Transitions of Care: The need for a more effective approach to continuing patient care
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
Care Transition Bundle Seven Essential Intervention Categories. Examples of Transition of Care Interventions
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
Health Home Program (Section 2703) Iowa Medicaid Enterprise. Marni Bussell Project Manager December 13, 2013
Health Home Program (Section 2703) Iowa Medicaid Enterprise Marni Bussell Project Manager December 13, 2013 1 Two Health Home Programs: Same Triple Aim Goals Chronic Condition Health Home: Primary Care
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
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
Analysis of Care Coordination Outcomes /
Analysis of Care Coordination Outcomes / A Comparison of the Mercy Care Plan Population to Nationwide Dual-Eligible Medicare Beneficiaries July 2012 Prepared by: Varnee Murugan Ed Drozd Kevin Dietz Aetna
Medicare: 2015 Model of Care Training 04/2015
Medicare: 2015 Model of Care Training 04/2015 1 Model of Care Training This course is offered to meet the CMS regulatory requirements for Model of Care Training for our Special Needs Plans. It also ensures
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
Implementation of 1115 Waiver/Transition of Seniors and Persons with Disabilities. Frequently Asked Questions
Healthy San Diego Many Medi-Cal beneficiaries are mandated to enroll in a Medi-Cal Managed Care Plan. The benefit of being on a Medi-Cal Managed Care Plan is improved access to health care including specialists
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
Ohio s strategy to enroll primary care practices in the federal Comprehensive Primary Care Plus (CPC+) Program
Ohio s strategy to enroll primary care practices in the federal Comprehensive Primary Care Plus (CPC+) Program Greg Moody, Director Governor s Office of Health Transformation Webinar for Primary Care Practices
Affordable Care Act Opportunities for the Aging Network
Affordable Care Act Opportunities for the Aging Network The Affordable Care Act (ACA) offers many opportunities for the Aging Network to be full partners in health system reform. These include demonstration
Passport Advantage Provider Manual Section 10.0 Care Management Table of Contents
Passport Advantage Provider Manual Section 10.0 Care Management Table of Contents 10.1 Model of Care 10.2 Medication Therapy Management 10.3 Care Coordination 10.4 Complex Case Management 10.0 Care Management
Coaching Patients to Improve Care Transitions in Pennsylvania. May 26, 2010
Coaching Patients to Improve Care Transitions in Pennsylvania Naomi Hauser, RN, MPA, CLNC Director Care Transitions Quality Insights of Pennsylvania Dr. Eric Coleman, MPH Professor of Medicine University
2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF)
2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) Project Objective: Skilled nursing facilities (SNFs) will implement the evidence based INTERACT program developed