Post Discharge Pharmacy Phone Calls. Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist
|
|
- Janice Clark
- 7 years ago
- Views:
Transcription
1 Post Discharge Pharmacy Phone Calls Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist
2 St. Mary s Medical Center Member of Ascension Health Number of Available Beds: 509 Admissions: 16,880 Outpatient visits: 646,767 (includes Outpatient Surgery) Number of Births: 1,411 Emergency Room Visits: 55,656 Surgical visits: 4,528 (inpatient only) Employees: 3,685
3 Care Transitions Goal: Reduce All Cause Readmissions for patients with a principle diagnosis of heart failure by 2% Steering Committee Approve and facilitate change; provide thought leadership; ensure connections among work groups. Team Members: Cardiac Telemetry, Home Health, OVHC, Case Management, Pharmacy, Social Work, Quality, Priority Care, Medical Nursing, Cardiac Rehab Focus Area Follow Up Care Cindy Whittinghill Focus Area Medication Education/ Compliance Don Julian Focus Area Early Discharge Planning Tracy MacGregor Focus Area Patient/Family Engagement/ Education Dawn Worman Improve home health screening and referral process Update home health plan of care for HF Ensure timely physician follow up appt in 5-7 days Improve coordination of care with SNF and LTC Test coaching methodology using pharmacy students Conduct pre discharge visit for medication reconciliation & education Conduct post DC phone call Identify anticipated DC date & post on whiteboard Trial rounding with physicians Interview Readmissions and intensify DC planning process Implement teach back methodology across CV services: Educate staff using scenarios and modeling Update DC Phone Call Tool Update patient education materials
4 Assemble Team Safety Coordinator (Pharmacy) Clinical Manager (Pharmacy) Student Preceptor Coordinator (Pharmacy) Cardiac Rehab Staff Nurse (Nursing) Director of Cardiac Unit (Nursing) Exec Director Pharmacy / Patient Flow Pharmacy Student
5 Team Education (Understanding Care Transitions & GWTG Models) Define Ideal State Hospital Visit (introduction to program and personal heath record) Follow-up home visit within hours of discharge Three follow-up phone calls (2, 7, and 14 days post discharge) Personal Heath Record Four pillars (patient fills out during home visit) Medication self-management Dynamic patient centered record Follow-up Red flags Coaching patient to take charge of their own healthcare Help smooth the transition from Hospital to home Empower patients to manage their own health care and contact health care providers when needed Support for patient and source of information NOT the care provider Help develop questions and concerns
6 Team Education Barriers to Ideal State Resources, Resources, Resources Define Available Resources Clinical Pharmacists Students Determine Qualifiers Cardiac Unit Patients Only Patients Discharged M TH Only (No Weekend Discharges will be Covered, unless already visited) No nursing home patients or those that are unable to communicate through a phone Current post discharge follow-up process used by Cardiac Rehab Team will not change
7 Develop Pilot Goals Decrease Readmissions (overarching) Calls Made Within 72 hours of Discharge Review Patient Discharge Home Medications Review Follow-up Appointment with Primary Care Physician (date/time) Portability between students (easy training / start-up) Team Meetings Meet regularly to discuss problems identified and ways to improve overall process
8 Tool Kit Concept Two copies Contents Process Overview Forms Scripting Tools Additional Resources
9 Process Review (Identification and Review) Patient Identification Cardiac Rehab Census List Patient Tracking Form Chart Review (15 minutes) Face Sheet H&P Home Medication List Active Pharmacy Drug Profile
10 Process Review In Hospital Visit (15 minutes) Ideally Done on First Full Day of Admission Introduction Purpose of Meeting / Call (prevent readmission) Use of Medication Profile Card Verify Best Time to Call Ask Patient to Gather Lists and Bottles When They Are At Home Commitment to Call
11 Process Review Phone Call (30 Minutes) Ask Patient to Gather Med Related Items Medication Card Prescription Bottles Discharge Summary Info Blank Piece of Paper (for questions) Review Discharge Med List Open Ended Questions Indication How They Take Special Instructions
12 Process Review Phone Call (30 Minutes) General Question and Answer (Counseling if needed) Did They Have Prescriptions Filled, Any Barriers (cost, transportation, etc) Verify Follow-up Physician Appointments Verify Patient checking on weight and what to do for increases When should they call a doctor? Encourage Use of Medication Profile Card
13 Pilot Results Number Of Patients Visited In Hospital: 42 Number of successful calls after discharge: 29 Number of interventions: 40 Number of interventions per patient: 1.37 Follow-up physician appt. made: 15 Patient satisfied with phone call: 27 Readmission within 30 days: 1
14 Pharmacy Related Interventions Missing Prescriptions Discrepancies in Med Start Date and Dose Patient Continuing To Take Contraindicated Medication Counseling on Smoking Cessation Encouraging Use of Weekly Pill Planner Counseling on importance diet (low salt, diabetic) Encouraging Patients to Contact Physician for Issues Potentially Related to Medications (Fatigue, Continuing Specific Meds)
15 Pilot Findings Most benefit when comparing Rx bottles to new home med list Lack of new medication prescribed (either due to cost or lack of prescription) Still taking medication that was discontinued in the hospital either due to name confusion or because still with all other bottles Different doses from hospital to prescription bottles Patients are unaware of indication for medication and need counseling on many home medications Patients may not have scales at home Patients are not making their follow-up appointments
16 Looking Forward Make a continual process to reach more HF patients Include both 6th year pharmacy students and pharmacists (pharmacists to provide gap coverage when no student) Dedicated pharmacy student rotation (Purdue) for three months of the year for Care Transitions (discharge medication management) Expand Program Other Disease States All Patients > 65 yo All Patients (any age) taking > 10 home medications
17 Care Transitions Results Care Transitions Heart Failure Performance Measurement Outcome Measures: Source data: Premier Quality Manager Target Benc hmark s-qio or CMS Jan- Jun 2009 Jul- 09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan day Readmissions- all dx, all cause, all payor < 8.1% 10.4 % 10.3% 10.3% 8.7% 9.1% 8.8% 9.7% 9.4% 30 day Readmissions- all dx, all cause, Medicare <13.5 % 17.6 % 14.5 % 16.8% 16.3% 10.5% 13.7% 13.1% 14.0% 12.4% Number of Patients dc'd with Principal Dx of HF (Premier- pt details) d Readmissions- 1st Adm HF, Readmit all cause, all payor 30d Readmission- 1st Adm HF, Readmit all cause, Medicare <19% 24.5% 23.8 % 25.7% 28.1% 8.7% 36.1% 25.0% 14.0% 18.4% 22.3 % 30.8% 33.3% 11.8% 42.9% 25.0% 14.3% 21.4%
18 Revised Med Rec Forms Implemented New Reconciliation Form on 4/13/10. Designed to be used internally and given to patient Avoids potential errors related to transcription Larger Font, Plain Language replaces Medical Terminology Incorporates Discharge Instruction Forms that were given to patient apart from med reconciliation
19 Revised Med Rec Forms Patient and pharmacy student caller have same form and can discuss specific changes and annotations
20 SMMC Post Discharge Rx Calls Questions?
3/19/2013 2012, American Heart Association 1
3/19/2013 2012, American Heart Association 1 Development of HF Performance Measures: Process, Barriers, and Spinoffs Target: Heart Failure University of New Mexico School of Medicine Division of Cardiology
More informationNewark Beth Israel Medical Center Selected: DSRIP Project #8: The Congestive Heart Failure (CHF) Transition Program
Project Focus Newark Beth Israel Medical Center Selected: DSRIP Project #8: The Congestive Heart Failure (CHF) Transition Program Transitioning Into Transitional Care Program Modeled After Project RED,
More informationUsing 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 informationCare Network of East Alabama, Inc.
Care Network of East Alabama, Inc. Established in 2011 as a not-for-profit organization to promote the medical home and to address the needs of Patient 1st patients in east Alabama Timeline December 2010
More informationPatients 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 informationPopulation 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
More informationRIH 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
More informationBerkshire Medical Center Heart Failure Program
Berkshire Medical Center Heart Failure Program Reducing Readmissions A Multi Disciplinary Approach 1 Project Goals To improve the overall care of Berkshire County Heart Failure Patients Reduce 30 day readmission
More informationCCNC Care Management Standardized Plan
Standardization & Reporting: Why is standardization important? Community Care Networks are responsible for the delivery of targeted care management services that will improve quality of care while containing
More informationCare Coordination at Frederick Regional Health System. Heather Kirby, MBA, LBSW, ACM Assistant Vice President of Integrated Care
Care Coordination at Frederick Regional Health System Heather Kirby, MBA, LBSW, ACM Assistant Vice President of Integrated Care 1 About the Health System 258 Licensed acute beds Approximately 70,000 ED
More informationGet 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
More informationCreating a Hospital Based Bedside Delivery Program to Enhance the Patient Experience at Cleveland Clinic s Community Hospitals
Learning Objectives Creating a Hospital Based Bedside Delivery Program to Enhance the Patient Experience at Cleveland Clinic s Community Hospitals Describe the 5 steps needed to create an effective hospital
More informationDecreasing 30 day Readmissions on a Medical Surgical Telemetry Unit
Decreasing 30 day Readmissions on a Medical Surgical Telemetry Unit Presented By: Dr. Micah Beachy, Rickelle Collins and Nicole Turille Context As part of healthcare reform, hospitals are being challenged
More informationErlanger 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 informationLeadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015
Leveraging the Continuum to Avoid Unnecessary Utilization While Improving Quality Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015 Karim A. Habibi, FHFMA, MPH, MS Senior
More informationMedication Error. Medication Errors. Transitions in Care: Optimizing Intern Resources
Transitions in Care: Optimizing Intern Resources DeeDee Hu PharmD, MBA Clinical Specialist Critical Care and Cardiology PGY1 Program Director Memorial Hermann Memorial City Medical Center Medication Error
More informationPost-Acute Care Transitions: An Essential Component of Accountable Care
: An Essential Component of Accountable Care Bruce C. Smith, MD, FACP Associate Medical Director, Strategy Deployment Group Health Physicians, Seattle, WA Smith.bc@ghc.org AMGA 2012 Institute for Quality
More informationLearning Collaborative
Care Transitions Intervention Model to Reduce 30-Day Readmissions for Chronic Cardiac Conditions Learning Collaborative Dr. Norma Jean-Francois, DNP, APN-C Dr. Mary Anne Marra, DNP, MSN, RN, NEA-BC 1 OVERVIEW
More informationHow To Help A Nursing Home And Hospital Collaborate
Continuum of Care Bridging the Gap between the Hospital and Nursing Home Scott Wells, RN MSN Tiffany Noller, RN MSN Objectives Name key members involved in hospital/nursing home collaborative Identify
More information#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
More informationDavid Glendenning Presentation Title
David Glendenning Presentation Title Education Coordinator Emergency Medical Services New Hanover Regional Medical Center New Hanover Regional Medical Center Emergency Medical Services Our EMS Reality
More information10/16/2013. Partnering with Skilled Nursing Facilities & Home Health Agencies to Prevent Hospital Readmissions. Cedars-Sinai Health System
Partnering with Skilled Nursing Facilities & Home Health Agencies to Prevent Hospital Readmissions Kelley Hart, LVN, Katie Gurvitz, MHA, Michelle Hofhine, RN Turning on the High Beams October 10, 2013
More informationTruth or Consequences, Best Medication List Practices to Deliver Best Care. Leaning & Action Network Session
Truth or Consequences, Best Medication List Practices to Deliver Best Care Leaning & Action Network Session Introduction David Cook (5 minutes) Housekeeping: - In event of a fire? - Restrooms? David R.
More informationRED, 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 informationImproving Care Transitions using PDSA Methodology
Improving Care Transitions using PDSA Methodology Catherine Payne, MD, FHM Care Transitions Physician Champion Medical Director of Clinical Informatics Erlanger Medical Center Chattanooga, Tennessee Objectives
More informationHealth 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
More informationUnderstanding 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;
More informationCare 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 information1. 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 informationRT 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 informationHospital Based Transitions of Care Program. Dr Jeffery Liles, MD FHM. Providence Health Care
Outcomes and Applications of a Hospital Based Transitions of Care Program. Dr Jeffery Liles, MD FHM Medical Director Care Management Providence Health Care -Importance of D/C planning and transitions of
More informationHeart Failure Best Practice Strategies: Featuring Target: HF Honor Roll Hospitals
Heart Failure Best Practice Strategies: Featuring Target: HF Honor Roll Hospitals 12/18/2013 12/18/13 2013, American Heart Association 1 Thank you for Joining the Webinar Today. The Presentation will Begin
More informationKaiser 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 informationPCMH 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 informationFrom the Ground Up: The implementation of a Transition Care Program (TOC) and its impact in COPD 30-day readmissions
From the Ground Up: The implementation of a Transition Care Program (TOC) and its impact in COPD 30-day readmissions Cristiane L. Fukuda RN, MSN, ANP-BC Email: cristiane.fukuda@northside.com Office: 404-851-6914
More informationHealth Care System. Troyen Brennan, M.D., M.P.H. Executive Vice President & Chief Medical Officer
Creating a More Connected Health Care System Troyen Brennan, M.D., M.P.H. Executive Vice President & Chief Medical Officer Agenda Our Role in the Changing Health Care System CVS/minuteclinic: Growth and
More informationMedication Reconciliation
Medication Reconciliation Jackie Rice, RN EMR Team Supervisor Frederick Memorial Hospital Frederick, Maryland Scope of the Project Implement an automated medication reconciliation tool Meet the 2006 JCAHO
More informationCommunity Care of North Carolina
Community Care of North Carolina CCNC Transitional Care Management Jennifer Cockerham, RN, BSN, CDE Director, Chronic Care Programs & Quality Management 1 Chronic Care Population Within the NC Medicaid
More informationMANITOWOC 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
More informationCedars Sinai Medical Center (CSMC) Learning Objectives. Why Medication Reconciliation?
Management Case Study: Transitions Trifecta Calibrating the Severity of Drug Related Problems, dherence, and Literacy in a High Risk Population Tuesday, December 10, 2013 2:00 p.m. 2:30 p.m. Management
More informationSuccessful Heart Failure Management Nurse/NP Run Clinics
Dagmar Knot RN BScN CCCN Transplant Coordination Team Leader Organ Transplant Center KFSHRC Riyadh, KSA Heart Failure Nurses Role, responsibilities & education Successful Heart Failure Management Nurse/NP
More informationJoan 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
More informationDisclosure. Meaningful use 2009. Objectives. Meaningful use. Fundamentals of Transitions of Care (TOC)
47 th Annual Meeting August 2-4, 2013 Orlando, FL Fundamentals of Transitions of Care (TOC) Rebecca R. Prevost, B.S., Pharm.D., PSO Medication Safety Officer Florida Hospital Disclosure I do not have a
More informationMedicare 2015 QI Program Evaluation
Color Code: Red does not meet 5 star threshold, or target. Green meets or exceeds 5 star threshold/target. Improving or Maintaining Physical Health (HOS) Improving or Maintaining Mental Health (HOS) Diabetes
More informationTransitional Care at Mount Sinai The PACT Program
Transitional Care at Mount Sinai The PACT Program Maria Basso Lipani, LCSW Program Director, PACT Mount Sinai Hospital Mount Sinai Medical Center Founded in 1852 1,171-bed tertiary-care teaching and research
More informationFollow-Up Visits after Heart Failure Hospitalizations: Impact of a Medication Reconciliation Clinic
Follow-Up Visits after Heart Failure Hospitalizations: Impact of a Medication Reconciliation Clinic Sherry K. Milfred-LaForest, PharmD, BCPS Clinical Pharmacy Specialist, Cardiology and Organ Transplantation
More informationPassport 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
More informationMedical Necessity & Charting Guidelines
Medical Necessity & Charting Guidelines 1 In most cases we are told the rules up front - or will be told if we ask Like most games, the one who knows the rules the best WINS 4 2 Nationally Recognized Industry
More informationReconciling the Differences. Karen Lippett B.Sc.Phm Humber River Regional Hospital Renal Dialysis Unit
Reconciling the Differences Karen Lippett B.Sc.Phm Humber River Regional Hospital Renal Dialysis Unit Objectives 1. Review the medication discharge counselling process in the renal dialysis program 2.
More informationAvoiding 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 informationReadmissions as an Enterprise Priority. Presenters 4/17/2014
Readmissions as an Enterprise Priority April 24, 2014 Presenters Vincent A. Maniscalco, MPA, LNHA Administrator Middletown Park Rehabilitation and Health Care Center Vmaniscalco@parkmanorrehab.com Eileen
More informationExpanding the team to the health care community. One practice s experience Holly Cleney, MD
Expanding the team to the health care community One practice s experience Holly Cleney, MD Objectives Develop a strategy for coordinating care effectively for patients across hospital stays and through
More informationMedication Safety Committee Guidelines. Emergency Department Medication Management Safety Tool
ication Safety Committee Guidelines Department ication Management Safety Tool TABLE OF CONTENTS REVISION LOG... 2 INTRODUCTION... 3 COMMITTEE REPRESENTATION... 3 EMERGENCY DEPARTMENT MEDICATION MANAGEMENT
More informationRemote Access Technologies/Telehealth Services Medicare Effective January 1, 2016
Remote Access Technologies/Telehealth Services Medicare Effective January 1, 2016 Prior Authorization Requirement Yes No Not Applicable * Not covered by Medicare but is covered by HealthPartners Freedom
More informationGet With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15
Get With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15 Date and time first seen by ED MD: The time entered should be the earliest
More informationMedication Reconciliation Training Packet. Legacy Health System
Medication Reconciliation Training Packet Legacy Health System 1 Objectives To identify the key elements of the medication reconciliation process To describe the role of the nurse in the medication reconciliation
More informationKaiser 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 informationMain Section of the Proposal
Main Section of the Proposal 1. Overall Aim and Objectives: The primary aim of this proposed project is to increase the number of tobacco- using patients admitted to two University of Washington (UW) hospitals
More informationFIRST HOME VISIT. What barriers do you feel you may have in following these instructions?
FIRST HOME VISIT Clinical Assessment Perform initial comprehensive assessment including. BP: take in both arms. Arm should be supported and not dependent. Determine which arm has higher reading. This is
More informationPhysician Practice Connections Patient Centered Medical Home
Physician Practice Connections Patient Centered Medical Home Getting Started Any practice assessing its ability to achieve NCQA Physician Recognition in PPC- PCMH is taking a bold step toward aligning
More informationDEPARTMENT 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
More informationManaging 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 informationPOPULATION 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
More informationHypertension Best Practices Symposium
essentia health: east region 1 Hypertension Best Practices Symposium RN Hypertension Management Pilot Essentia Health: East Region Duluth, MN ORGANIZATION PROFILE Essentia Health is an integrated health
More informationNurse 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 informationUtilizing Pharmacy Technicians for Medication Reconciliation. Kristy Malacos, MS, CPhT Magruder Hospital Port Clinton, OH Pharmacy Systems, Inc.
Utilizing Pharmacy Technicians for Medication Reconciliation Kristy Malacos, MS, CPhT Magruder Hospital Port Clinton, OH Pharmacy Systems, Inc. Magruder Hospital Located on the shores of Lake Erie in Port
More informationCheri Basso BSN, RN-BC,CHFN Hospital Initiatives to Improve Outcomes. FINANCIAL DISCLOSURE: No relevant financial relationship exists
Cheri Basso BSN, RN-BC, CHFN Mary Washington Healthcare Fredericksburg, VA Cheri Basso BSN, RN-BC,CHFN Hospital Initiatives to Improve Outcomes FINANCIAL DISCLOSURE: No relevant financial relationship
More informationCommunity Health Program Outpatient Care Management Program
Community Health Program Outpatient Care Management Program Beverly Dowling Assistant Vice President Community Health Network Office of Health Policy and Legislative Affairs The University of Texas Medical
More informationProvidence Health Plans
Providence Health Plans v Providence Enrollment Service Area Providence Medicare Advantage Plans Special Attributes Established network of doctors and hospitals Over 11,000 in network providers and growing
More informationAnnual Notice of Changes for 2016
Healthy Advantage Plus HMO offered by Molina Healthcare of Utah Annual Notice of Changes for 2016 You are currently enrolled as a member of Healthy Advantage Plus HMO. Next year, there will be some changes
More information1. TITLE: Colin A. Banas MD, MSHA Chief Medical Information Officer Secondary Point of Contact: 804-827- 4196, cbanas@mcvh-vcu.edu
1. TITLE: Using Health Information Technology - CPOE to Advance Performance Improvement in Heart Failure Patients at Virginia Commonwealth University Health System 2. ORGANIZATION: Virginia Commonwealth
More informationWHITE 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 informationUCare provides case management for all UCare members not affiliated with one of the above listed care systems. 2011 UCare for Seniors
Case Requirements Updated 3/16/2011 According to the Case Society of America (CMSA), Case Model Act of 2009, Case management is a collaborative process of assessment, planning, facilitation, care coordination,
More informationHome 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
More informationGROUP MEDICARE SUPPLEMENT PLANS. S5753_081213_GB03_MN Internal Approval 08/13/2013
2014 GROUP MEDICARE SUPPLEMENT PLANS S5753_081213_GB03_MN Internal Approval 08/13/2013 CREATE A HEALTHIER ORGANIZATION. Your employees are your organization s most valuable asset. As they retire, you want
More informationRole of the Pharmacy Technician in the Emergency. Pat Miller Pharmacy Technician Victoria General Hospital
Role of the Pharmacy Technician in the Emergency Pat Miller Pharmacy Technician Victoria General Hospital Back Ground Graduate of the South WPG Pharmacy Technician course. Pharmacy Technicain for 25 years.
More informationMaryland Cancer Plan Pain Management Committee
Maryland Cancer Plan Pain Management Committee IDEAL MODEL FOR CANCER CONTROL PROBLEM or ISSUE Lack of provider awareness regarding appropriate pain assessment and management and relevant policy Definition:
More informationCHAPTER 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 informationPediatric Physician. and Advanced Providers Handbook. for Inpatient Cerner Use
Pediatric Physician and Advanced Providers Handbook for Inpatient Cerner Use Section Last updated Page(s) Background Jan-13 2 Admission Process Nov-12 11 Codes Nov-12 17 Discharge Process Nov-12 13 Downtime
More informationUse of Social Workers Post Discharge
Institute For Intergenerational Studies Southern Tier Center on Aging Use of Social Workers Post Discharge Laura Bronstein, PhD, LCSWR, ACSW Interim Dean, College of Community and Public Affairs; Director,
More information5/10/13 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 informationPrior Authorization, Pharmacy and Health Case Management Information. Prior Authorization. Pharmacy Information. Health Case Management
Prior Authorization, Pharmacy and Health Case Management Information The purpose of this information sheet is to provide you with details on how Great-West Life will be assessing and managing your claim
More informationKeeping patients safe when they transfer between care providers getting the medicines right
PART 1 Keeping patients safe when they transfer between care providers getting the medicines right Good practice guidance for healthcare professions July 2011 Endorsed by: Foreword Taking a medicine is
More informationWhat 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
More informationTransition Post Hospital Discharge
Transition Post Hospital Discharge Transition Post Hospital Discharge Independent Clinic Experience Privately owned Who is Multicare Primary Care Focused Fridley, Blaine, Roseville 13 FP, 3 Peds, 4 OB,
More informationMember name, address, phone number, DOB, MC400 Member ID, MA Recipient Number
CONNECTED CARE DATA TEMPLATE Member Tier Display SMI Tier 1, 2, or 3 (plus historical activity to show changes in tier) Member Demographics Member name, address, phone number, DOB, MC400 Member ID, MA
More informationNancy 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
More informationAnalytic-Driven Quality Keys Success in Risk-Based Contracts. Ross Gustafson, Vice President Allina Performance Resources, Health Catalyst
Analytic-Driven Quality Keys Success in Risk-Based Contracts March 2 nd, 2016 Ross Gustafson, Vice President Allina Performance Resources, Health Catalyst Brian Rice, Vice President Network/ACO Integration,
More informationHow Can We Get the Best Medication History?
How Can We Get the Best Medication History? Stephen Shalansky, Pharm.D., FCSHP Pharmacy Department, St. Paul s Hospital Faculty of Pharmaceutical Sciences, UBC How Are We Doing Now? Completeness of Medication
More informationReducing Resident Readmissions: The Pierce County Medicaid Nursing Home Collaborative
Reducing Resident Readmissions: The Pierce County Medicaid Nursing Home Collaborative April 2015 Overview The Washington State Department of Social & Health Services (DSHS) and Qualis Health engaged 14
More informationUsing 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 informationImproving EMR Adoption, Utilization and Analytics: Working Towards Obtaining HIMSS Stage 7
Improving EMR Adoption, Utilization and Analytics: Working Towards Obtaining HIMSS Stage 7 About Ontario Shores-Our Vision Recovering Best Health Nurturing Hope Inspiring Discovery Our vision is bold and
More informationEssentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare
Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 24 (HMO-POS). Next year, there will
More informationEssentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare
Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 25 (HMO-POS). Next year, there will
More informationCarolina s Journey: Turning Big Data Into Better Care. Michael Dulin, MD, PhD
Carolina s Journey: Turning Big Data Into Better Care Michael Dulin, MD, PhD Current State: Massive investments in EMR systems Rapidly Increase Amount of Data (Velocity, Volume, Veracity) The Data has
More informationOut of Sight, Out of Mind? Post Acute Strategies for Stroke Care Disclosures
Out of Sight, Out of Mind? Post Acute Strategies for Stroke Care Kathy Morrison, MSN, RN, CNRN, SCRN Alicia Richardson, MSN, RN, ACCNS-AG Kari Moore, MSN, AGACNP-BC Disclosures Kathy Morrison Kari Moore
More informationGo With The Flow- From Charge Nurse to Patient Flow Coordinator. Donna Ojanen Thomas, RN, MSN Cynthia J. Royall, RN, BSN
Go With The Flow- From Charge Nurse to Patient Flow Coordinator Donna Ojanen Thomas, RN, MSN Cynthia J. Royall, RN, BSN Primary Children s Medical Center About PCMC Not for profit hospital, part of Intermountain
More informationHeart Failure & Cardiac Rehabilitation
Heart Failure & Cardiac Rehabilitation Karen Lui, RN, MS, MAACVPR SCACVPR Greenville May 3, 2014 1 I have no disclosures. 2 Outline New Professional Certification New AACVPR CR Guidelines New Heart Failure
More informationAT&T Global Network Client for Windows Product Support Matrix January 29, 2015
AT&T Global Network Client for Windows Product Support Matrix January 29, 2015 Product Support Matrix Following is the Product Support Matrix for the AT&T Global Network Client. See the AT&T Global Network
More informationREWRITING PAYER/PROVIDER COLLABORATION July 24, 2015. MIKE FAY Vice President, Health Networks
REWRITING PAYER/PROVIDER COLLABORATION July 24, 2015 MIKE FAY Vice President, Health Networks AGENDA ACO Overview ACO Financial Performance ACO Quality Performance Observations 2 AGENDA ACO OVERVIEW ACO
More information