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

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

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

Transcription

1 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: Nationally heart failure (HF) continues to be a growing problem. It is the leading cause of Medicare admissions with 6.6 million Americans burdened by this disease. Thirty-day readmissions have reached striking figures with one in four patients being readmitted nationally and similar results in Pennsylvania. Costs of these readmissions have prompted Medicare to initiate penalties to hospitals with higher than expected rates. In 2011, our network readmission rates were higher than expected, highlighting an opportunity to improve our current HF Program. In response, our administration formed a multidisciplinary team to evaluate current practices, identify gaps, and develop strategies to redesign the HF program and improve outcomes. Our goal was to reach top quartile performance. This project would be important to any facility challenged by higher than expected readmission rates. Evidence: This multidisciplinary team conducted a thorough review of current literature to identify best practices. Several models were identified that demonstrated success at improving outcomes and reducing readmissions. All emphasized the importance of improving care transitions, outpatient follow up and care coordination. Next, a needs assessment was performed and revealed multiple opportunities for improvement including: knowledge gaps regarding best practices for patients with HF among physicians, nurses and post discharge facility health care providers; no consistent process for following patients after discharge; inconsistent communication between health care settings; and a need for addressing the needs of more advanced HF patients with regards to symptom management at home. Based on the findings of our literature review and needs assessment, we chose initiatives from several studies for designing a new HF program. Baseline Data: Our baseline data was reviewed for the two previous years prior to the Heart Failure Team being led by to Clinical Nurse Leaders. Baseline readmission rates at our main campus for FY 2010 and FY 2011 were 26.7% (index 1.23) and 26.6% (index 1.23) respectively. Baseline readmission rates for the Network were 24.5 (index 1.15) in FY 2010 and 23.0% (index 1.07) in FY (Figures 1, 2, 3, and 4). Intervention: A new model for the HF program was piloted using the framework of the PDCA methodology in order to integrate best practices into our care for patients with HF. The new HF program was patient centered and focused on a coordinated outpatient approach. The program was led by two dedicated Heart Failure Care Coordinators/Clinical Nurse Leaders (HFCC/CNL). Other additional resources included two midlevel providers who alternate between the inpatient and outpatient settings dedicated to the HF population throughout the care continuum. The key components that were initiated included: timely follow-up appointments with health care provider within 3-7 days after discharge from the hospital; follow-up phone calls hours post-discharge; home health care referrals, tele-health monitoring, palliative care and improved communication between health care settings including assisted living and skilled nursing facilities. Throughout the implementation we continuously reviewed readmission data, evaluated results, identified barriers and realigned our interventions. Based on the observed success at our main campus, the model was expanded network-wide. Results: From the inception of our redesigned HF program, in November of 2011 through the end of FY 2013, we have seen an overall 38.8% reduction in HF readmissions at our main campus and a 34.8% reduction for the network. Since then, we have seen sustained improvements both at the main campus and at the network level through FY 2014 to date. The Network has achieved and sustained top quartile performance as defined by the Premier, Inc. database. Our ability to sustain continued success in reducing readmissions suggests that this program can be utilized as a model for other institutions looking to decrease HF readmissions. 1

2 2. Describe the needs assessment process and/or research conducted prior to implementing the initiative and the results of that needs assessment/research, including evidence and baseline data. Nationally heart failure (HF) continues to be a growing problem. The American Heart Association s 2012 Heart and Stroke statistical update reports that approximately 6.6 million Americans have HF and 670,000 new patients are diagnosed each year. This number is expected to grow by 3 million by 2030, a 25% increase in prevalence from 2010.¹HF is also the leading diagnosis of Medicare patients readmitted to hospitals within 30 days of discharge with a nationally reported rate of almost 25%. As many as 53% of these HF readmissions are estimated to be preventable.² Similar results are reported in Pennsylvania. According to the Pennsylvania Health Care Cost Containment Council, HF had the highest 30-day readmission rate in 2010 at 24.3 % and accounted for 37.7 % of all the readmissions.³ Medicare reports readmissions cost more than 17 billion dollars annually and account for much of the wasteful spending prevalent in their system. Health Care Reform and changes in Medicare reimbursement policies has challenged hospitals and other health care facilities to improve care processes for patients discharged after an acute episode of HF to reduce these costly and often unnecessary readmissions. 4 Our organization is a non-profit, tertiary-care, academic, multi-hospital system in Pennsylvania which offers many medical specialties. A high volume of patients fall into our cardiac service line. Our network admits over 2,000 patients with cardiac diagnoses and for cardiac procedures. Admissions for HF remain the largest sector with annual encounters over Our mission is to provide compassionate, quality and cost-effective health care to residents of the communities we serve. Included in this mission is providing best practices to patients admitted with HF to improve outcomes and reduce avoidable readmissions. An analysis of our readmission rates for HF at our main campus and the network revealed that for FY 2010 and 2011 our rate was higher than expected when compared with data from the Premier, Inc. database. In response to these higher than expected readmission rates, senior administration from the cardiac service line, nursing and quality met to discuss strategies for improvement. A commitment to additional resources was also established based on predicted cost benefit analysis of penalties with reduced reimbursements from Medicare if current readmission rates were not improved. The first step was to conduct a thorough review of the literature in order to identify current best practices recommended to reduce HF readmissions. A review of the current literature identified several models demonstrating success at improving outcomes and reducing readmissions. These included, The Transitional Care Model, Project Boost, Project Red and Transforming Care at the Bedside and Hospital to Home (H2H). 5-9 All emphasized care transitions and the importance of outpatient follow up and care coordination. While no one specific model was chosen, initiatives were taken from several to trial for our new HF program. These initiatives highlight the importance of a multidisciplinary team approach that focus on care across the care continuum. The key components identified include: patient education and self-management; use of teach back in evaluating patient understanding; timely follow-up appointments with a health care provider within 3-7 days after discharge from the hospital; follow-up phone calls to be done hours post discharge; home health care referrals, tele-health monitoring, palliative care and improved communication between health care settings including assisted living and skilled nursing facilities. Recommended HF guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) were also reviewed and supported the need for a disease management program that involved a multidisciplinary team approach that followed patients beyond the hospital setting. 11 The next step was to perform a needs assessment to evaluate current practices and identify where gaps in best practices existed. This assessment revealed multiple areas for improvement including: knowledge gaps regarding best practices for patients with HF among physicians; nurses and post discharge facility health care workers; no consistent process for following patients after discharge; inconsistent communication between health care settings and a lack of process to address the needs of more advanced HF patients with regards to symptom management at home. 2

3 In light of these findings and based on current best practices identified, a plan was developed to redesign the existing HF program. This program would be managed by two Heart Failure Care Coordinators/Clinical Nurse Leaders (HFCC/CNL) with a focus on post discharge care coordination in the outpatient setting. The CNL is a new graduate nursing role with a focus on quality improvement, inter-professional communication, leadership and evidence based practice. In order to define our goals for this new HF program we analyzed data on past readmission rates from FY 2010 and FY 2011 at our main campus and for the network. Our goal was to improve our readmission rates and reach top quartile performance based on benchmarking from Premier, Inc. This new HF model would be centered on a coordinated outpatient care approach that would include two HFCC/CNLs and two mid-level providers. The HFCC/CNLs would oversee the program and the midlevel providers would alternate between the inpatient and outpatient setting providing dedicated resources to this patient population both during admission and in the outpatient setting. The overall goal of the program would be integrating best practices and care coordination for patients with HF across the care continuum to improve outcomes and reduce avoidable readmissions. 1. American Heart Association. (2011). Heart disease and stroke statistics-2012 update. Circulation, 125(), e2-e220. doi: /cir.obo13e31823ac Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalization among patients in Medicare fee-for-service program. New England Journal of Medicine, 360, Pennsylvania Health Care Cost Containment Council. (2012). Hospital Readmissions in Pennsylvania News release April 26,2012. Retrieved from 4. U.S Department of Health and Human Services. (2010). Affordable care act. Retrieved from 5. Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, control trial. Journal of the American Geriatric Society, 52, Retrieved from 6. Project Boost. (n.d.) Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E.,...Culpepper, L. (2009). A reengineered hospital discharge program to decrease hospitalizations. Annals of Internal Medicine, 150, Retrieved from 8. Nielsen, G. A., Bartley, A., Coleman, E., Resar, R., Rutherford, P., Souw, D., & Taylor, J. (2008). Transforming care at the bedside how-to guide: Creating an ideal transition home for patients with heart failure. Retrieved from 9. Hospital tohome. (n.d.) Jessup, M., Abraham, W., Casey, D., Feldman, A., Francis, G., Konstam, M.,...Yancy, C. (2009) Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults. Circulation, 119, doi: /circulationaha Identify the steps taken to initiate your effort(s) including strategies, implementation plan, and the interventions. Based on our initial goal to reduce HF readmission rates and reach top quartile performance, a new model for the HF program was piloted utilizing PDCA methodology in order to integrate best practices into our care for patients with HF. PDCA is a successive cycle consisting of Plan, Do, Check, Act steps which begins by implementing small changes and then incorporates increasing knowledge and successes to ultimately achieve later and more targeted effects. Our efforts were as follows: Plan - In order to achieve our goal of reducing avoidable HF readmissions, we initially concentrated our efforts at our main campus and focused on integrating best practices with particular attention to our post discharge processes. More specifically we developed the following: 3

4 Outpatient HF Care Coordinator /Clinical Nurse Leader (HFCC/CNL) role who are responsible for overall HF program processes and monitoring of outcomes HF midlevel provider positions- one inpatient and one outpatient who would rotate to assist in continuity of care and timely post-discharge follow up appointments Scripted post discharge telephone calls utilizing a teach-back style of questioning- one for patients/caregivers discharged to home and one for health care workers at skilled nursing/rehabilitation facilities (SNF/rehab). (Figures 5 and 6). Risk assessment tool (Figure 7). Do - Following processes gleaned in the review of best practices we initially implemented the following: Daily tracking of discharge HF patients by HFCC utilizing daily census and Horizon Enterprise Visibility (HEV) boards remotely hour follow up phone calls utilizing teach back scripting to evaluate gaps in care transitions to home as well as SNF/rehabs. Risk Stratification Tool based on follow up phone call assessment, co-morbidities, number of previous hospital utilization episodes (admit or emergency room) in past year and care transition evaluation Subsequent phone calls weekly or biweekly based on risk stratification HF Hotline or program number given to patients with HF education as a safety net for patients to call with problems or questions 3-7 day follow up appointments with midlevel provider Assistance in making timely appointment with PCP, private cardiologist, or at Clinic for indigent patients Medical staff and resident education and pocket reminder cards to promote best practices, adherence to Core Measures and consistency with documentation Promoting home health care (HHC) services for all eligible patients Tele-monitoring system implemented by our own HHC agency Community SNF/Rehab education programs and stakeholder meetings to improve care transitions Palliative Care Program for patients with HF Administration of IV diuretics in the office setting Check - Throughout our implementation process we continually collected data on readmission rates as well as compliance with best practices (i.e. 3-7 day follow up appointment, HHC services ordered, adherence to Core Measures) and HF patient responses to teach back questions. We thoroughly examined our results, identified barriers, and verified improvement. This involved: Regular audits of follow up phone calls to HF patents discharged to home and to SNF/Rehab Drill down assessment of 30 day readmissions when they occur: interviewing patient/caregiver, assessing gaps in process and providing feedback regarding areas for improvement Monthly HF Task Force meetings: bringing together HF team, representatives from medical staff (hospitalist, cardiology and emergency medicine) nursing and case management to evaluate process implementation and barriers Regular assessment of 30 day readmission rates, with data provided by Premier, Inc. Act- Based on the success we observed with implementation of our HF program at our main campus, we then chose to expand this plan on a broader scale throughout the network. This involved: Creating a HF champion role at each of these campuses who would be responsible for ensuring best practices were implemented and utilized under the direction and support of the HFCC/CNL RNs Expanded education to medical, nursing and case management staff regarding best practices Monthly campus specific HF Task Force meetings 4. Summarize the success of your initiative and provide evidence of sustained improvements. From the inception of our HFCC/CNL led HF program, we noted substantial improvements in our readmission rates at our main campus (Figures 1 and 2). Between FY 2011 and FY 2013, we reduced our readmissions from 4

5 26.6% (index 1.23) to 16.3% (index 0.77), a 38.8% decrease in readmission rates. Moving forward to FYTD 2014, readmission rates through December show a similar result with a readmission rate of 16.6%. We have observed similar results at the network level (Figures 3 and 4). Between FY 2011and FY 2013, there was a 34.8% reduction in 30 day readmissions. The readmission rate for FY 2013 decreased to 15.0% (index 0.72) from 23% (index 1.07) in FY Network readmission data for FY2014 through December show slightly higher, though overall sustained results at 15.4%. The factors that were crucial for the success of our HF program in reducing 30 day readmissions across our network were several-fold: Commitment of administration and nursing leadership to champion a HFCC/CNL nurse driven HF program A focus on the outpatient process and care coordination after discharge Real time drill downs of 30 day readmissions daily with feedback Engagement of medical and nursing staff to promote and sustain best practices 5. Describe the potential ability to replicate your initiative in other organizations that provide the same service or serve the same population. Recent changes from the Affordable Care Act have challenged hospitals to reduce 30 day readmissions for several diagnoses including HF or suffer significant penalties. Attention to care transitions and implementation of chronic disease management programs have been suggested as first step to improving outcomes. The HFCC/CNL role is well aligned to address these challenges to reduce 30 day readmissions and improve the quality of care our patients with HF receive. This CNL led HF program required an initial investment of two cardiology midlevel providers and two CNLs. The cost of these resources is estimated at $367,463 per year. Additionally $22,000 was invested in the purchase of 20 tele-health monitoring systems for use by our home health care agency. Financial data for FY2013 was analyzed for our Network and identified that one HF readmission costs an average of $9,552 including direct and indirect costs. Network data for FY 2013 revealed 57 fewer HF readmissions and a cost savings of approximately $544,464. Cost per admission for FY 2014 is estimated at $10,205. Annualized data for FY 2014 is trending towards an additional 22 fewer readmissions and a further cost saving of $224,510. The combined total savings since implementation of the new HF program is estimated at $768,974 Aside from these salaries, no other expenditures were necessary. For many hospitals and networks, penalties incurred will exceed the cost of these additional resources. Additionally, our Finance department estimated savings of approximately $400,000 in reduced penalties for FY The success of this program in reducing 30 day readmissions well below expected values, combined with increasing penalties from Medicare for those hospitals with higher than the expected readmission rates make an excellent case for initiating this program at other hospitals. Currently, a similar program, for COPD patients is being trialed and preliminary results suggest this program may work well for other chronic diseases. 5

6 Appendix Figure 1. Readmission rates, Main Campus. Achieved an overall 38.8% reduction in readmission rates by FY 2013 and maintaining results. Figure 3. Readmission rates, Network. Achieved an overall 34.8% decrease in readmission rates by FY 2013 and maintaining results. Figure 2. Readmission Index, Main Campus. Premier, Inc. top quartile Figure 4. Readmission Index, Network. Premier, Inc. top quartile

7 Figure 5.Post-discharge phone call progress note, patient at home. Figure 6.Post-discharge phone call progress note, patient at SNF or rehab facility. 7

8 Figure 7. Risk Assessment Tool. 8

Cheri Basso BSN, RN-BC,CHFN Hospital Initiatives to Improve Outcomes. FINANCIAL DISCLOSURE: No relevant financial relationship exists

Cheri 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 information

Nurse Transition Coach Model: Innovative, Evidence-based, and Cost Effective Solutions to Reduce Hospital Readmissions

Nurse Transition Coach Model: Innovative, Evidence-based, and Cost Effective Solutions to Reduce Hospital Readmissions Nurse Transition Coach Model: Innovative, Evidence-based, and Cost Effective Solutions to Reduce Hospital Readmissions Leslie Becker RN, BS Jennifer Smith RN, MSN, MBA Leslie Frain MSN, RN Jan Machanis

More information

Health Care Leader Action Guide to Reduce Avoidable Readmissions

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

More information

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

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

More information

Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION

Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION At the end of this session, you will be able to: Identify ways RT skills can be utilized for

More information

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

Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation How Does CMS Measure the Rate of Acute Care Hospitalization (ACH)? Until January 2013, CMS measured Acute Care Hospitalization (ACH) through the Outcomes Assessment and Information Set (OASIS) reporting

More information

Congestive Heart Failure Management Program

Congestive Heart Failure Management Program Congestive Heart Failure Management Program The Congestive Heart Failure Program is the third statewide disease management program developed by CCNC. The clinical directors reviewed prevalence and outcome

More information

Henry Ford Health System Care Coordination and Readmissions Update

Henry Ford Health System Care Coordination and Readmissions Update Henry Ford Health System Care Coordination and Readmissions Update September 2013 BACKGROUND Most hospital readmissions are viewed as avoidable, costly, and in some cases as a potential marker of poor

More information

Nancy L. Wilson Department of Medicine-Geriatrics Houston Center for Quality of Care& Utilization Studies Texas Consortium of Geriatric Education

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

More information

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 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

More information

Reducing Readmissions and Safe Transitions Collaborative: Implementing Re-Engineered Discharge (RED) In 19 Colorado Hospitals White Paper

Reducing Readmissions and Safe Transitions Collaborative: Implementing Re-Engineered Discharge (RED) In 19 Colorado Hospitals White Paper Reducing Readmissions and Safe Transitions Collaborative: Implementing Re-Engineered Discharge (RED) In 19 Colorado Hospitals White Paper Executive Summary Objective: To implement the 11 action steps of

More information

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

5/10/13 HEALTH CARE REFORM LONGITUDINAL CARE COORDINATION HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO WHY WHAT HOW WHEN WHO TRANSITION CARE TRANSITION CARE WHY WHAT HOW WHEN WHO HEALTH CARE REFORM HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO Cost/Quality equation Higher cost care has not/does not equate with higher

More information

From 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 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 information

Ensure Timely Post-Hospital Care Follow-Up

Ensure Timely Post-Hospital Care Follow-Up Ensure Timely Post-Hospital Care Follow-Up Peg Bradke and Eric Coleman February 3, 2011 These presenters have nothing to disclose. Session Objectives Participants will be able to: Provide an overview of

More information

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

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

More information

CARE MANAGEMENT SERIES Part 5 Preventing Readmissions

CARE MANAGEMENT SERIES Part 5 Preventing Readmissions January 2015 CARE MANAGEMENT SERIES Part 5 Preventing Readmissions CMS estimates that hospital readmissions for Medicare patients costs the American taxpayers more than $26 billion per year, more than

More information

Presented by: Char Brar, ACNP, MS(Chem.), MSN, RN Cardiology Nurse Practitioner JBVAMC, Chicago

Presented by: Char Brar, ACNP, MS(Chem.), MSN, RN Cardiology Nurse Practitioner JBVAMC, Chicago Presented by: Char Brar, ACNP, MS(Chem.), MSN, RN Cardiology Nurse Practitioner JBVAMC, Chicago 200 bed acute care facility 4 Community Based Out-patient Clinics (CBOCs) 58,000 Veterans IN FY 2008 : 768

More information

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

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

More information

Essentia Health. Heart Failure and Remote Monitoring. Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager

Essentia Health. Heart Failure and Remote Monitoring. Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager Essentia Health Heart Failure and Remote Monitoring Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager Essentia Health Oct 2014 No reproduction without permission Why Heart Failure? Prevalence

More information

HealthCare Partners of Nevada. Heart Failure

HealthCare Partners of Nevada. Heart Failure HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with

More information

Reducing Readmissions with Predictive Analytics

Reducing Readmissions with Predictive Analytics Reducing Readmissions with Predictive Analytics Conway Regional Health System uses analytics and the LACE Index from Medisolv s RAPID business intelligence software to identify patients poised for early

More information

Population Health Solutions for Employers MEDIA RESOURCES

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

More information

Readmissions as an Enterprise Priority. Presenters 4/17/2014

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 Vmaniscalco@parkmanorrehab.com Eileen

More information

Coordinating Transitions of Care: It Takes a Village

Coordinating Transitions of Care: It Takes a Village Coordinating Transitions of Care: It Takes a Village Ken Laube RN, BSN, MBA: Vice President Clinical Excellence Situation/Background Patients face significant challenges when moving from one health care

More information

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 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)

More information

Continuum of Care. Bridging the Gap between the Hospital and Nursing Home. Scott Wells, RN MSN Tiffany Noller, RN MSN

Continuum of Care. Bridging the Gap between the Hospital and Nursing Home. Scott Wells, RN MSN Tiffany Noller, RN MSN 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

RT AS PROJECT MANAGER:

RT AS PROJECT MANAGER: RT AS PROJECT MANAGER: IMPROVING CARE TRANSITIONS DECREASES UNPLANNED READMISSIONS TAMMY JARNAGIN, BHS, RRT DIRECTOR CARDIOPULMONARY SERVICES, NEURODIAGNOSTICS, HOME MEDICAL EQUIPMENT Objectives Recognize

More information

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 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 information

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 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 information

10/24/2014. 9 th Annual Nursing Research Conference Presented By: Heather Powell & Jeanmarie Okoniewski

10/24/2014. 9 th Annual Nursing Research Conference Presented By: Heather Powell & Jeanmarie Okoniewski 9 th Annual Nursing Research Conference Presented By: Heather Powell & Jeanmarie Okoniewski Heather J. Powell, MSN, RN, RN-BC Kimberly D. Williams, MPH Jeanmarie Okoniewski, MSN, RN, RN-BC Melinda Acevedo,

More information

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

Plenary Session 1. Health Dimensions Group. 2010 Health Dimensions Group Plenary Session 1 Kathleen M. Griffin, PhD Health Dimensions Group March 31, 2011 Hospital, Post Acute and Long-Term Care Collaboration in Health Care Reform: Critical Success Factors National Summit:

More information

Care Coordination and Transitions in Behavioral Health

Care Coordination and Transitions in Behavioral Health Care Coordination and Transitions in Behavioral Health Pam Pietruszewski Integrated Health Consultant The National Council for Behavioral Health This product is supported by the Florida Department of Children

More information

AVOID READMISSIONS through COLLABORATION March 23, 2011 ARC Webinar

AVOID READMISSIONS through COLLABORATION March 23, 2011 ARC Webinar Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing AVOID READMISSIONS through COLLABORATION

More information

Reducing Hospital Readmissions & The Affordable Care Act

Reducing Hospital Readmissions & The Affordable Care Act 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

More information

Statement on the Redirection of Nursing Education Medicare Funds to Graduate Nurse Education

Statement on the Redirection of Nursing Education Medicare Funds to Graduate Nurse Education Statement on the Redirection of Nursing Education Medicare Funds to Graduate Nurse Education To the National Bipartisan Commission on the Future of Medicare Graduate Medical Education Study Group (January

More information

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) 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,

More information

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 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

More information

Advanced Practice Nurse-managed Heart Failure Clinic Benefits Patient s Quality of Life and Limits Readmissions

Advanced Practice Nurse-managed Heart Failure Clinic Benefits Patient s Quality of Life and Limits Readmissions Nursing and Health 1(3): 47-51, 2013 DOI: 10.13189/nh.2013.010301 http://www.hrpub.org Advanced Practice Nurse-managed Heart Failure Clinic Benefits Patient s Quality of Life and Limits Readmissions Christina

More information

BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM?

BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM? BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM? Uniform Data System for Medical Rehabilitation Annual Conference August 10, 2012 Presented by: Donna Cameron Rich Bajner

More information

How Health Reform Will Affect Health Care Quality and the Delivery of Services

How Health Reform Will Affect Health Care Quality and the Delivery of Services Fact Sheet AARP Public Policy Institute How Health Reform Will Affect Health Care Quality and the Delivery of Services The recently enacted Affordable Care Act contains provisions to improve health care

More information

Implementing an Evidence Based Hospital Discharge Process

Implementing an Evidence Based Hospital Discharge Process Implementing an Evidence Based Hospital Discharge Process Learning from the experience of Project Re-Engineered Discharge (RED) Webinar January 14, 2013 Chris Manasseh, MD Director, Boston HealthNet Inpatient

More information

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: 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 information

Post Discharge Pharmacy Phone Calls. Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist

Post Discharge Pharmacy Phone Calls. Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist Post Discharge Pharmacy Phone Calls Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist St. Mary s Medical Center Member of Ascension Health Number of Available Beds: 509 Admissions:

More information

Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment

Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Donna Zazworsky, RN, MS, CCM, FAAN Vice President: Community Health and Continuum Care Carondelet Health

More information

Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care

Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care Charley P. Starnes, RRT, RCP Clinical Respiratory Specialist- COPD Education Important Milestones July 2011-

More information

PCMH and Care Management: Where do we start?

PCMH and Care Management: Where do we start? PCMH and Care Management: Where do we start? Patricia Bohs, RN, BSN Quality Assurance Manager Kelly McCloughan QA Data Manager Wayne Memorial Community Health Centers Honesdale, PA Wayne Memorial Community

More information

Barriers to Care Coordination. Pitfalls. Ineffective Transitions Lead to Poor Outcomes

Barriers to Care Coordination. Pitfalls. Ineffective Transitions Lead to Poor Outcomes Eliminating the Pitfalls and Barriers to Reducing Rehospitalizations Evelyn Thompson RN,CMC Director of Care Transitions Genesis Healthcare October 2013 Barriers to Care Coordination System level barriers

More information

SPECIALTY CASE MANAGEMENT

SPECIALTY CASE MANAGEMENT SPECIALTY CASE MANAGEMENT Our Specialty Case Management programs boost ROI and empower members to make informed decisions and work with their physicians to better manage their health. KEPRO is Effectively

More information

Readmissions Change PaCkage improving Care Transitions and Reducing Readmissions

Readmissions Change PaCkage improving Care Transitions and Reducing Readmissions Readmissions Change PaCkage improving Care Transitions and Reducing Readmissions 2014 UPDATE Table of Contents what s new in This edition?...................................... 1 Background..........................................................

More information

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 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

More information

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

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

More information

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 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

More information

Managing Patients with Multiple Chronic Conditions

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

More information

Transitions of Care: The need for a more effective approach to continuing patient care

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

More information

WHITE PAPER. How a multi-tiered strategy can reduce readmission rates and significantly enhance patient experience

WHITE PAPER. How a multi-tiered strategy can reduce readmission rates and significantly enhance patient experience WHITE PAPER How a multi-tiered strategy can reduce readmission rates and significantly enhance patient experience Vocera Communications, Inc. June, 2014 SUMMARY Hospitals that reduce readmission rates

More information

3/11/15. COPD Disease Management Tackling the Transition. Objectives. Describe the multidisciplinary approach to inpatient care for COPD patients

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

More information

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

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

More information

Michigan Engagement Center

Michigan Engagement Center Michigan Engagement Center Quality Improvement Activities Provider Key Updates The ValueOptions Michigan Engagement Center is committed to being a center for excellence in developing and coordinating quality

More information

Engaging Effective Post Acute Partners in New Models of Care. A Transitional Care Model

Engaging Effective Post Acute Partners in New Models of Care. A Transitional Care Model Engaging Effective Post Acute Partners in New Models of Care A Transitional Care Model Please note that the views expressed by the conference speakers do not necessarily reflect the views of the American

More information

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

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

More information

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

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

More information

Implementation Guide to Reduce Avoidable Readmissions. HRET Contact (312)

Implementation Guide to Reduce Avoidable Readmissions. HRET Contact (312) Implementation Guide to Reduce Avoidable Readmissions HRET Contact hen@aha.org (312) 834-7056 www.hret-hen.org Implementation Guide to Reduce Avoidable Readmissions 2 Table of Contents PREVENTING AVOIDABLE

More information

Modern care management

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

More information

Care Transitions: Evidence-based best practices for Case Managers

Care Transitions: Evidence-based best practices for Case Managers Care Transitions: Evidence-based best practices for Case Managers Mary D. Naylor, PhD, FAAN, RN Marian S. Ware Professor in Gerontology Director, NewCourtlandCenter for Transitions & Health University

More information

Empowering Case Managers In The Emergency Department A STRATEGIC ROLE BENEFITS PATIENTS, CARE TEAMS, AND PROVIDERS

Empowering Case Managers In The Emergency Department A STRATEGIC ROLE BENEFITS PATIENTS, CARE TEAMS, AND PROVIDERS Empowering Case Managers In The Emergency Department A STRATEGIC ROLE BENEFITS PATIENTS, CARE TEAMS, AND PROVIDERS Empowering Case Managers In The Emergency Department A STRATEGIC ROLE BENEFITS PATIENTS,

More information

DATA DRIVEN HEALTH CARE TRANSFORMATION

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

More information

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

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

More information

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

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

More information

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions Support for the Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions

More information

Assessing Risk of Readmission. NoCVA Preventing Avoidable Readmission Collaborative Laura Maynard, MDiv, NCQC Amanda Hobbs, NCQC July 31, 2013

Assessing Risk of Readmission. NoCVA Preventing Avoidable Readmission Collaborative Laura Maynard, MDiv, NCQC Amanda Hobbs, NCQC July 31, 2013 Assessing Risk of Readmission NoCVA Preventing Avoidable Readmission Collaborative Laura Maynard, MDiv, NCQC Amanda Hobbs, NCQC July 31, 2013 Collaborative Goals Reduce readmission rates by 20% Increase

More information

Emerging g Trends in Home Care

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

More information

Preventing Readmissions

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

More information

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

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

More information

Breathe With Ease. Asthma Disease Management Program

Breathe With Ease. Asthma Disease Management Program Breathe With Ease Asthma Disease Management Program MOLINA Breathe With Ease Pediatric and Adult Asthma Disease Management Program Background According to the National Asthma Education and Prevention Program

More information

Utilizing information technology to improve transition of care from hospital to home

Utilizing information technology to improve transition of care from hospital to home ORIGINAL RESEARCH Utilizing information technology to improve transition of care from hospital to home Dorothy G. Andrew, Susan E. Puls, Kerrie S. Guerrero Houston Methodist Hospital, Houston, United States

More information

Alameda County s Health Care Coverage Initiative Network Structure: Interim Findings

Alameda County s Health Care Coverage Initiative Network Structure: Interim Findings Alameda County s Health Care Coverage Initiative Network Structure: Interim Findings Introduction The Health Care Coverage Initiative (HCCI) Program in Alameda County is called Alameda County Excellence

More information

Patient Centered Medical Home: An Approach for the Health Plan

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

More information

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs)

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Senate Bill 832 directed the Oregon Health Authority (OHA) to develop standards for achieving integration of behavioral health

More information

A Comprehensive Case Management Program to Improve Access to Palliative Care. Aetna s Compassionate Care SM

A Comprehensive Case Management Program to Improve Access to Palliative Care. Aetna s Compassionate Care SM A Comprehensive Case Management Program to Improve Access to Palliative Care Aetna s Compassionate Care SM Our chief want in life is somebody who shall make us do what we can. Ralph Waldo Emerson Marcia

More information

Atrius Health Pioneer ACO: First Year Accomplishments, Results and Insights

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 Emily_Brower@AtriusHealth.org November 2013 1 Contents Overview of

More information

Population Health Management For Behavioral Health. MHA s 2015 Annual Conference June 3, 2015

Population Health Management For Behavioral Health. MHA s 2015 Annual Conference June 3, 2015 Population Health Management For Behavioral Health MHA s 2015 Annual Conference June 3, 2015 Goals of the Affordable Care Act Improve the health of populations Lower per capita costs Improve the patient

More information

Increasing Profitability via Care Transitions. Is providing health care transition services a strategic fit for your organization?

Increasing Profitability via Care Transitions. Is providing health care transition services a strategic fit for your organization? Increasing Profitability via Care Transitions Is providing health care transition services a strategic fit for your organization? Executive Summary: While effectively managing health care transitions has

More information

Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program

Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program Cristina Boccuti and Giselle Casillas For Medicare patients, hospitalizations can be stressful; even more so when

More information

4/22/2013. Transitions Handoffs Vulnerable exchange points Adverse clinical events Unmet needs Poor patient satisfaction

4/22/2013. Transitions Handoffs Vulnerable exchange points Adverse clinical events Unmet needs Poor patient satisfaction Objectives Transitions of Care and the Pharmacy Practice Model Initiative Emily Bennett, PharmD Melody Hartzler, PharmD, AE-C Describe the Affordable Care Act and it s implications on current healthcare

More information

How to Prepare for Your Post Acute Partnership: A Fresh Look at Reducing Avoidable Re Hospitalization

How to Prepare for Your Post Acute Partnership: A Fresh Look at Reducing Avoidable Re Hospitalization How to Prepare for Your Post Acute Partnership: A Fresh Look at Reducing Avoidable Re Hospitalization Presented by: Sandy Bennis, RN, BSN, MBA AVP, Executive Director, Virtua Home Care Diane Flynn, BSN,

More information

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

Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services Objectives Understand the new consequences to hospitals for discharged clients being re-admitted within selected time

More information

Cheryl Schraeder, RN, PhD, FAAN. The demographic landscape of America is changing at an accelerated pace

Cheryl Schraeder, RN, PhD, FAAN. The demographic landscape of America is changing at an accelerated pace Stepping up to the challenge: Changing the way we deliver care Cheryl Schraeder, RN, PhD, FAAN 1 Goals of Presentation To Identify: The key challenges in delivering evidence-based & cost-effective care

More information

Care 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 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 information

The Cost-Effectiveness of Homecare

The Cost-Effectiveness of Homecare The Cost-Effectiveness of Homecare Homecare Reduces Costs by 37 Percent for Heart Failure Patients The May 2004 Journal of the American Geriatrics Society reports a study conducted at six Philadelphia

More information

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 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 information

Care Transitions: Chasms, Bridges

Care Transitions: Chasms, Bridges Care Transitions: Chasms, Bridges NH-VT ACP Chapter Meeting October 2013 Julius Yang, MD, PhD Medical Director of Health Care Quality Beth Israel Deaconess Medical Center Boston, MA Care Transitions: Definition

More information

Senate Special Committee on Aging

Senate Special Committee on Aging Senate Special Committee on Aging Field Hearing July 31, 2015 Five Star Senior Center, St. Louis, Missouri Testimony Delivered by Sandra Van Trease Group President, BJC HealthCare Introduction Members

More information

Post-Acute Care Transitions: An Essential Component of Accountable Care

Post-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 information

Dual RFI Response Summary

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

More information

Running head: COMMUNITY PROJECT 1. Community Project: Nurse Educator for Heart Failure Patients

Running head: COMMUNITY PROJECT 1. Community Project: Nurse Educator for Heart Failure Patients Running head: COMMUNITY PROJECT 1 Community Project: Nurse Educator for Heart Failure Patients Isaac Agbettor, Anise Camacho, Nicole Hassna, Yesenia Hurtado, and Matthew Vega October 11, 2013 NURS 4410:

More information

Rehabilitation s Role in Decreasing Returns to Acute Care

Rehabilitation s Role in Decreasing Returns to Acute Care Rehabilitation s Role in Decreasing Returns to Acute Care Glenda Mack, PT, MSPT, MBA, CLT, CWS Division Vice President Clinical Operations, RehabCare Objectives Participants will verbalize three primary

More information

HOW TO UNDERSTAND YOUR QUALITY AND RESOURCE USE REPORT

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

More information

Taking Aim at Reducing Hospital Readmission Rates

Taking Aim at Reducing Hospital Readmission Rates Taking Aim at Reducing Hospital Readmission Rates It has been three years since the Centers for Medicare & Medicaid Services (CMS) implemented progressive penalties to hospitals that have higher 30-day

More information

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

Transitions of Care: The need for collaboration across entire care continuum H O T T O P I C S I N H E A L T H C A R E, I S S U E # 2 Transitions of Care: The need for collaboration across entire care continuum Safe, quality Transitions Effective C o l l a b o r a t i v e S u c

More information

Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management

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

More information