Care Transitions: Evidence-based best practices for Case Managers
|
|
|
- Bethanie Simmons
- 8 years ago
- Views:
Transcription
1 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 of Pennsylvania School of Nursing Patrice Sminkey Chief Executive Officer Commission for Case Manager Certification 1 Proprietary to CCMC
2 Agenda Welcome and Introductions Learning Objectives Patrice Sminkey, CEO, the Commission Mary D. Naylor, PhD, FAAN, RN, Marian S. Ware Professor in Gerontology; Director, NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing Question and Answer Session 2
3 Audience Notes There is no call-in number for today s events. Audio is by streaming only. Please use your computer speakers, or you may prefer to use headphones. There is a troubleshooting guide in the links section to the left of your screen. Refresh your screen if slides don t appear to be advancing. Please use the chat feature on the lower left-hand part of your screen to ask questions throughout the presentations. Questions will be addressed as time permits after both speakers have presented. A recording of today s session will be posted within one week to the Commission s website, One continuing education credit is available for today s webinar only to those who registered in advance and are participating today. 3
4 Learning Objectives Overview After the webinar, participants will be able to: Identify individual/family and system factors associated with poor postdischarge outcomes among hospitalized older adults. Illustrate the context for transitional care in everyday practice across health care settings. Identify key findings from testing of the Transitional Care Model and describe the core components of the model. Describe the impact of the evidence supporting the Transitional Care Model on clinical practice and health care policy recommendation. 4
5 Introduction Patrice Sminkey Chief Executive Officer Commission for Case Manager Certification
6 Webinars Certification Workshops Issue Briefs Speaker s Bureau 6
7 Bridging the gap in care transitions : 2,610 hospitals assessed penalties Oct to Sept
8 Care Transitions: Evidence-based best practices for Case Managers Mary D. Naylor, PhD, FAAN, RN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing 8 Proprietary to CCMC
9 TRANSITIONAL CARE MODEL Care Transitions: Evidence-based best practices for Case Managers Mary D. Naylor, Ph.D., RN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing Webinar December 2, 2014
10 Transitional Care Range of time limited services and environments that are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple health care team members and across settings such as hospitals to homes. (Adapted from, J Am Geriatr Soc, 2003, 51(4): )
11 The Case for Transitional Care High rates of medical errors Serious unmet needs Poor care experiences High rates of preventable rehospitalizations Tremendous human and cost burden
12 Published Evidence 21 RCTs of diverse hospital to home innovations targeting primarily chronically ill adults 9/21, + impact on at least one measure of rehospitalization plus other health outcomes Effective interventions Multidimensional and span settings Use inter-professional teams with primarily nurses, as hubs (Naylor, et al., THE CARE SPAN--The Importance of Transitional Care in Achieving Health Reform. Health Affairs, 30(4): )
13 Different Goals of Evidence-Based Interventions Address gaps in care and promote effective hand-offs Address root causes of poor outcomes with focus on longer-term value
14 Transitional Care Model Screening Maintaining Relationship Engaging Older Adult & Caregivers Coordinating Care Managing Symptoms Assuring Continuity Educating/ Promoting Self- Management Collaborating
15 Unique Features (Hospital to Home) Care is delivered and coordinated by same advanced practice nurse (APN) supported by team in hospitals, SNFs, and homes seven days per week using evidence-based protocol supported by decision support tools
16 Core Components Holistic, person/family centered approach Nurse-coordinated, team model Protocol guided, streamlined care Single point person across episode of care Information/decision support systems that span settings Focus on increasing value over long term
17 Hospital to Home Findings* BETTER CARE Decreased symptoms, Improved function, Enhanced quality of life Enhanced access, Reduced errors, Enhanced care experience BETTER HEALTH (* Based on 3 NIH funded RCTs: Ann Intern Med, 1994,120: ; JAMA, 1999, 281: ; J Am Geriatr Soc, 2004, 52: )
18 (Based on 3 NIH funded RCTs: 1 Ann Intern Med, 1994,120: ; 2 JAMA, 1999, 281: ; 3 J Am Geriatr Soc, 2004, 52: )
19 TCM's Impact on Total Health Care Costs* at 52 weeks*** $7,636 $12,481 TCM Group at 26 weeks** $3,630 $6,661 Control Group Dollars (US) * Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention group total. ** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281: *** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:
20 Translating Evidence Into Practice Penn research team formed partnerships with Aetna Corporation and large health systems to test real world applications of research-based model of care among high risk elders. Funded by The Commonwealth Fund and the following foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee (NAC)
21 Tools of Translation Patient screening and recruitment Preparation of TCM nurses, teams and sites (e.g., online seminars, on-site consultations) Documentation and quality monitoring (clinical information system) Quality improvement (case conferences grounded in root cause analysis) Evaluation
22 Foundations of Transitional Care Seminar Unit 1 Unit 2 An Introduction to the Transitional Care Model Fundamentals and Implementation Unit 3 Core Principles Unit 4 Achieving Quality and Promoting Success
23 Foundations of Transitional Care Seminar Orient nurses and other health team members Identify evidence-based tools and strategies Understand the core components of the TCM Develop operational plan to guide implementation Establish benchmarks for quality control Articulate value of TCM to organization
24 Foundations of Transitional Care Seminar Ongoing access and support from experienced, clinical transitional care experts Community Learning Network Online registration process
25 Findings (Aetna) Improvements in all quality measures Increased patient and physician satisfaction Reductions in rehospitalizations through 3 months Cost savings through one year All significant at p<0.05 (Naylor et al., Journal of Evaluation in Clinical Practice. doi: /j x.)
26 Would cognitively impaired Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, ( ) hospitalized older adults and their caregivers benefit from TCM? (Naylor et al., 2014, J Comp Eff Res, 3: ; McCauley et al., Am J Nurs, 114(10):44-52.)
27 Cognitive Deficits at Baseline DX Dementia/ Delirium, 19.2% Executive Function deficits (clock task), 37.6% Orientation Recall deficits, 43.2% 24.9% also had delirium (+ Confusion Assessment Method)
28 Time to First Readmission 100% 93.4% 79.8% TCM 75% 78.6% 67.9% 50% 63.7% ASC/RNC 53.1% 25% 0% Days TCM ASC/RNC
29 Implementation of TCM Service Line within Health Systems (e.g., UPHS) Placed within health system s home care and hospice division Reimbursed by local payers (IBC and Aetna) using case rate with defined performance expectations Implemented using a learning health system framework
30 Does the TCM Funding: Gordon and Betty Moore Foundation, Rita and Alex Hillman Foundation and the Jonas Center for Nursing Excellence ( ) add Value to the Patient Centered Medical Home? (Naylor et al., J Comparative Effectiveness Research, 2(5): )
31 Study Aims In collaboration with Patient Centered Medical Homes and guided by an Advisory Committee, the Penn team is: Comparing outcomes of PCMH+TCM, a new care delivery approach, to those achieved by the PCMH only Using lessons learned and findings to advance larger scale effort
32 Local Adaptations of Funding: Robert Wood Johnson Foundation ( ) the Transitional Care Model
33 Study Aims Describe how sites in health systems and communities across the U.S. are implementing the TCM Examine the effects of adaptations to the TCM
34 Project ACHIEVE Funding: Patient-Centered Outcomes Research Institute ( ) Achieving Patient- Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
35 Study Aims Identify which transitional care services and outcomes matter most to patients and caregivers, Compare how evidence-based transitional care services are meeting these needs Develop recommendations to spread highly effective, patient-centered care transition programs.
36 The TCM Focuses on transitions of high-risk cognitively intact and impaired older adults across all settings Has been successfully translated into practice Has been recognized by the Coalition for Evidence-Based Policy as an innovation meeting top-tier evidence standards
37 Key Lessons Solving complex problems will require multidimensional solutions Evidence is necessary but not sufficient Change is needed in structures, care processes, and health professionals roles and relationships to each other and the people they support Carpe Diem!
38
39 Question and Answer Session Mary D. Naylor, PhD, FAAN, RN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing Commission for Case Manager Certification 1120 Route 73, Suite 200, Mount Laurel, NJ Proprietary to CCMC
40 Thank you! Please fill out the survey after today s session Those who signed up for Continuing Education will receive an evaluation from the Commission. A recording of today s webinar and slides will be available in one week at 40 Proprietary to CCMC
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
Karen B. Hirschman, PhD MSW Research Assistant Professor School of Nursing. Geriatric Grand Rounds Friday, December 9, 2011 TRANSITIONS
FROM THE HOSPITAL TO HOME: ENHANCING TRANSITIONS IN CARE Geriatric Grand Rounds Friday, December 9, 2011 Karen B. Hirschman, PhD MSW Research Assistant Professor School of Nursing 1 Transitional Care Transitional
Hospital to Home: Improving Quality and Savings Through Innovative Transition Care
The Philips Healthcare Reimbursement Simplified Webinar Series Presents Hospital to Home: Improving Quality and Savings Through Innovative Transition Care May 12, 2010 12:00 1:15 pm ET Mary Naylor, Director
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
Geriatric Resource Nurse (GRN) Model
NICHE Models The NICHE nursing care models can help hospitals improve their care to better meet the needs of their hospitalized older adult patients. These models have been implemented and tested at hospitals
Collaborating for care: Embedded case managers, extending care management value
Collaborating for care: Embedded case managers, extending care management value Randall Krakauer, MD, FACP, FACR Vice President, National Medical Director Medicare Strategy, AETNA Patrice Sminkey Chief
Healthy in mind, body and spirit: The case manager's role in behavioral health care integration
Healthy in mind, body and spirit: The case manager's role in behavioral health care integration Benjamin F. Miller, PsyD Director, Eugene S. Farley, Jr. Health Policy Center and Assistant Professor, Department
Observation status and ethical considerations for case managers
Observation status and ethical considerations for case managers Carrie Valiant, Esq. Member, Epstein Becker & Green Founder and President Health Care Industry Access Initiative Patrice Sminkey Chief Executive
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.
Preventing Avoidable Re-Hospitalizations: Where Do You Fit in the Quality Care Puzzle?
Speaker Disclosures Care Transitions Interventions: The Sussex County Transitional Care Program Dr. Wang has disclosed that he has no relevant financial relationship(s). George C. Wang, MD, PhD Medical
hospital readmission rate reduction: building better interfaces within the community.
hospital readmission rate reduction: building better interfaces within the community. Whitepaper By Ken Taverner, M.Sc. the issue of hospital readmission rates Leaving the hospital after being admitted
Transitions of Care: 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
Advanced Practice Nurse Strategies to Improve Outcomes and Reduce Cost in Elders with Heart Failure
DISEASE MANAGEMENT Volume 9, Number 5, 2006 Mary Ann Liebert, Inc. Advanced Practice Nurse Strategies to Improve Outcomes and Reduce Cost in Elders with Heart Failure KATHLEEN M. MCCAULEY, Ph.D., R.N.,
The Union League of Philadelphia 140 South Broad Street Philadelphia, PA 19102
Who Should Attend: The following individuals from hospitals, LTACs, other healthcare facilities and community providers are encouraged to register: Case/Care Managers Discharge Planners Nurses Social Workers
1. Executive Summary Problem/Opportunity: Evidence: Baseline Data: Intervention: Results:
A Clinical Nurse Leader led multidisciplinary Heart Failure Program: Integrating best practice across the care continuum to reduce avoidable 30 day readmissions. 1. Executive Summary Problem/Opportunity:
PARTNERSHIPS IN MANAGED CARE Improving Quality and Satisfaction with Home Health Services WHITE PAPER 99-001
PARTNERSHIPS IN MANAGED CARE Improving Quality and Satisfaction with Home Health Services WHITE PAPER 99-001 PARTNERSHIPS IN MANAGED CARE Improving Quality and Satisfaction with Home Health Services Alexis
A TIME OF CHANGE STEERING THE FUTURE OF CARE COORDINATION CARE COORDINATION THE NATIONAL QUALITY AGENDA SIX PRIORITIES OF THE NATIONAL QUALITY AGENDA
A TIME OF CHANGE STEERING THE FUTURE OF CARE COORDINATION THE NATIONAL QUALITY AGENDA SIX PRIORITIES OF THE NATIONAL QUALITY AGENDA 1. Safer Care 2. Patient Engagement 3. Effective Prevention and Treatment
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
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
GRACE Team Care Integration of Primary Care with Geriatrics and Community-Based Social Services
GRACE Team Care Integration of Primary Care with Geriatrics and Community-Based Social Services Aged, Blind and Disabled Stakeholder Presentation Indiana Family and Social Services Administration August
Motivational Interviewing: Engaging Patients Through Communication
Motivational Interviewing: Engaging Patients Through Communication Catherine M. Mullahy, RN, BS, CRRN, CCM President of Mullahy & Associates, LLC Michael G. Goldstein, MD Associate Chief Consultant for
Measuring Care Coordination: Tools for today, tools for tomorrow
Measuring Care Coordination: Tools for today, tools for tomorrow Ellen Schultz, MS Stanford University Patrice Sminkey Chief Executive Officer Commission for Case Manager Certification 1 Proprietary to
Case managers as connectors, educators, advocates in the new insurance marketplace
Case managers as connectors, educators, advocates in the new insurance marketplace Mandy Cohen, MD Senior Advisor to the administrator Centers for Medicare & Medicaid Services Patrice Sminkey Chief Executive
8/11/2015. Role of the ANP in Translating Evidence to Practice. Identification of a Gap/Issue/Need
Utilizing an Advanced Practice Nurse Led Transitional Care Model to Improve the Health Outcomes of High Risk Elders with Heart Failure Living at Home In Western New York Linda L. Steeg DNP, RN, MS, ANP-BC
Care management of patients with complex health care needs
THE SYNTHESIS PROJECT NEW INSIGHTS FROM RESEARCH RESULTS ISSN 2155-3718 POLICY BRIEF NO. 19 DECEMBER 2009 Also see companion report available at www.policysynthesis.org Care management of patients with
MULTIDISCIPLINARY COMPETENCIES IN THE CARE OF OLDER ADULTS AT THE COMPLETION OF THE ENTRY-
ENTRY- LEVEL HEALTH PROFESSIONAL DEGREE Developed by the Partnership for Health in Aging Workgroup on Multidisciplinary Competencies in Geriatrics With Support from the American Geriatrics Society (AGS)
IssueBrief. Case managers strengthen health care s weakest link: Improving care transitions
IssueBrief VOLUME 4, ISSUE 3 Case managers strengthen health care s weakest link: Improving care transitions Don t dare call them handoffs. Guiding patients to the care they need, when they need it, lies
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
ADVISORY COMMITTEE ON INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES (ACICBL) AGENDA April 22, 2015 Parklawn Building Room 18-67
8:30 8:45 AM Welcome/Introductions Designated Federal Official, A.C.I.C.B.L. Mary Ann Forciea, M.D. Chairperson, A.C.I.C.B.L. University of Pennsylvania Health 8:45 9:15 AM Jim Macrae Welcome Acting Administrator
State Project Evaluation Activities. The Role of the State s Evaluations in the ADRC Program s Success
State Project Evaluation Activities Tuesday October 5 th, 8:30-10:00 Moderator: Karen Linkins, Ph.D., Co-Director, ADRC Technical Assistance Exchange, The Lewin Group The Role of the State s Evaluations
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
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
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
Care Transitions Model
Supported by the john Care A. Hartford transitions foundation model 19 Care Transitions Model Starting when a patient is scheduled to be discharged from the hospital, the Care Transitions Model helps older
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
PRACTICE BRIEF. Preventing Medication Errors in Home Care. Home Care Patients Are Vulnerable to Medication Errors
PRACTICE BRIEF FALL 2002 Preventing Medication Errors in Home Care This practice brief highlights the results of two home health care studies on medication errors. The first study determined how often
Designing the Role of the Embedded Care Manager
Designing the Role of the Embedded By Patricia Hines, Ph.D., RN and Marge Mercury, RN, MS, CMCE The Embedded The use of an Embedded ( ECM ) to coordinate within the complex delivery system is sharply increasing.
As today s health care system focuses increasingly on quality. Center stage in the revolution:
The Pathway to Certfication is CCMC IssueBrief VOLUME 2, ISSUE 2 Center stage in the revolution: A health care reform action guide for the professional case manager As today s health care system focuses
Care Management of Patients with Complex Health Care Needs
Care Management of Patients with Complex Health Care Needs Thomas Bodenheimer, MD Rachel Berry-Millett, BA Center for Excellence in Primary Care Department of Family and Community Medicine University of
RED, BOOST, and You: Improving the Discharge Transition of Care
RED, BOOST, and You: Improving the Discharge Transition of Care Jeffrey L. Greenwald, MD, SFHM Massachusetts General Hospital - Clinician Educator Service Co-Investigator Project RED & Project BOOST The
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
The John A. Hartford Foundation: A Legacy of Leadership in Improving Care for Older Adults
Envisioning the Future: The Changing Environment For Care of Older Adults 2015 Reynolds Grantee 13th Annual Meeting The Value Proposition for Geriatrics October 14 October 16, 2015 The John A. Hartford
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
What Do We Know? Does the Current Evidence Support Business as Usual? Eric A. Coleman, MD, MPH
Listen to Your Patients They Are Telling You How to Improve the Quality of their Transitional Care Eric A. Coleman, MD, MPH, AGSF, FACP Professor of Medicine Director, Care Transitions Program University
Coordination Debate. The Transitional Care and Comprehensive Care. Advances in medical science and technology,
GENERATIONS Journal of the American Society on Aging By Patricia J. Volland, Cheryl Schraeder, Paul Shelton, and Ida Hess The Transitional Care and Comprehensive Care Coordination Debate Which approach
Arif Nazir, MD currently holds the positions of Assistant Professor of Clinical Medicine, Indiana University School of Medicine, Division of General
Arif Nazir, MD currently holds the positions of Assistant Professor of Clinical Medicine, Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics; Consultant Geriatrician,
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
Nursing in a Transformed Health Care System: New Roles, New Rules
RESEARCH BRIEF June 2015 Nursing in a Transformed Health Care System: New Roles, New Rules Key takeaway message: Although the supply of nurses is likely to meet overall demand, the nature of a nurse s
Using Epic to Improve Care of Older Patients. Elizabeth Eckstrom,M.D. Michael L. Malone,M.D. January 19,2013
Using Epic to Improve Care of Older Patients Elizabeth Eckstrom,M.D. Michael L. Malone,M.D. January 19,2013 Learning Objectives: Discuss the successes and challenges of using the EMR to document care.
William L. Holzemer, RN, PhD, FAAN Dean and Distinguished Professor College of Nursing, Rutgers, The State University of New Jersey
William L. Holzemer, RN, PhD, FAAN Dean and Distinguished Professor College of Nursing, Rutgers, The State University of New Jersey holzemer@rutgers.edu 1 2 Objectives: 1. Update on the 8 major recommendations
Geriatric Emergency Department Guidelines New Jersey Hospital Association, Princeton, NJ Sept. 29, 2014
Geriatric Emergency Department Guidelines New Jersey Hospital Association, Princeton, NJ Sept. 29, 2014 Registration and Breakfast: 7:15 a.m. 7:45 a.m. Program Time: 7:45 a.m. 4:15 p.m. Location: NJHA
Care Coordination: Case managers connect the dots in new delivery models
The Pathway to Certfication is CCMC IssueBrief VOLUME 1, ISSUE 2 Care Coordination: Case managers connect the dots in new delivery models Well before health reform was signed into law, new models for health
Clinical Nurse Specialists Practitioners Contributing to Primary Care: A Briefing Paper
Clinical Nurse Specialists Practitioners Contributing to Primary Care: A Briefing Paper As the need grows for more practitioners of primary care, it is important to recognize the Clinical Nurse Specialist
Jeanette Ives Erickson, RN, MS Senior Vice President for Patient Care and Chief Nurse Massachusetts General Hospital
Jeanette Ives Erickson, RN, MS Senior Vice President for Patient Care and Chief Nurse Professional Development: Retreat/Continuing Education Log 2006-2007 2007 September 26-30, 2007 Robert Wood Johnson
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
The American Academy of Nursing
The American Academy of Nursing The Imperative for Patient, Family, and Population Centered Interprofessional Approaches to Care Coordination and Transitional Care March 5, 2012 The American Academy of
HOW TO PREPARE FOR THE FUTURE COMPLEX CARE MANAGEMENT
HOW TO PREPARE FOR THE FUTURE COMPLEX CARE MANAGEMENT #607 Friday, October 30, 2015 MARY NEWBERRY, MSN RN, DIRECTOR, HOME BASED & TRANSITIONAL CARE DEBORAH BRADLEY, MSN RN, MANAGER HOME HEALTH CARE BETH
Partnering To Improve Hospital-Physician Office Communication through Implementing Care Transitions Best Practices
178 Partnering To Improve Hospital-Physician Office Communication through Implementing Care Transitions Best Practices Rosa Baier, MPH, Rebekah Gardner, MD, Stefan Gravenstein, MD, MPH, and Richard Besdine,
Care Coordination by Means of Community-based
Care Coordination by Means of Community-based Nurse Care Management: Impact on Health, Hospital Utilization and Cost Outcomes Presented by: Ken Coburn, MD, MPH Health Quality Partners (www.hqp.org) CEO
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
How 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
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
PRACTICAL TOOLS AND RESOURCES
PRACTICAL TOOLS AND RESOURCES Contents 1. Education and Training...1 2. Selected Evidence Based Interventions...4 3. Focusing on the Caregiver...6 Assessment...6 Respite...7 Caregiver Well-Being...7 4.
NICHE: Innovations and Nursing Practice
NICHE: Innovations and Nursing Practice nicheprogram.org Linda Bub MSN, RN, GCNS-BC Director of Education and Program Development, NICHE Objectives Describe the NICHE program and the impact on nursing
The NYU Caregiver Intervention
The NYU Caregiver Intervention Translating an Evidence-based Intervention for Spouse-Caregivers into Community Settings Mary S. Mittelman, DrPH Center of Excellence for Brain Aging and Dementia NYU Langone
The Care Transitions Intervention: Geriatric Care. During an episode of illness, older patients may receive care in multiple settings; often resulting
The Care Transitions Intervention: A Patient-Centered Approach to Ensuring Effective Transfers Between Sites of Geriatric Care Abstract During an episode of illness, older patients may receive care in
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
ABCDEF Improvement Collaborative: A project of ICU LIBERATION Campaign
ABCDEF Improvement Collaborative: A project of ICU LIBERATION Campaign Funded by Gordon and Betty Moore Foundation Collaborative Hospital Participation: Frequently Asked Questions (FAQs) What do I need
CURRICULUM VITAE. Education. Degree Institution Specialization Diploma St. Luke s Hospital Registered Nurse School Of Nursing
CURRICULUM VITAE Nina Flanagan PhD, GNP-BC, PMHCS-BC Assistant Professor of Nursing Decker School of Nursing Vestal, N.Y Office: AB 220 607-777-6180(office) 570-209-6042(cell) Education Degree Institution
Hospice Care in The Nursing Home. Perspectives of a Medical Director Carole Baraldi, M.D.
Hospice Care in The Nursing Home Perspectives of a Medical Director Carole Baraldi, M.D. Evolution of Nursing Facilities Alms houses began over 1000 years ago Historically serve older people who can no
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
Massachusetts Department of Higher Education. Nursing Education Redesign Grant Program. Final Project Implementation Report
Massachusetts Department of Higher Education Nursing Education Redesign Grant Program Final Project Implementation Report Submitted by: Berkshire Community College November 30, 2012 Executive Summary Overview
Robin E. Remsburg, PhD, GCNS, FNGNA, FGSA, FAAN George Mason University NGNA 2012
Robin E. Remsburg, PhD, GCNS, FNGNA, FGSA, FAAN George Mason University NGNA 2012 This project is/was supported by funds from the Department of Health and Human Services (DHHS), Health Resources and Services
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
Improving Transitions & Reducing Readmissions from Skilled Nursing Facilities. Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies
Improving Transitions & Reducing Readmissions from Skilled Nursing Facilities Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies Agenda Why this is so important What we know: a review of the
MANAGING CONFLICT/FINDING MEANING SUPPORTING FAMILIES AT LIFE S END
MANAGING CONFLICT/FINDING MEANING SUPPORTING FAMILIES AT LIFE S END DESCRIPTION: The 2016 program in HFA s award-winning Living with Grief series emphasizes strategies to support families as they are dealing
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
New York Presbyterian Innovations in Health Care Reform at Academic Medical Centers
New York Presbyterian Innovations in Health Care Reform at Academic Medical Centers October 28, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization, Medical Director Associate Professor,
Prevea Health. Prevea Health automates population health management and improves health outcomes. Overview
Prevea Health Prevea Health automates population health management and improves health outcomes Overview The need Prevea Health needed an infrastructure to help its physician practices automate population
Nurses at the Forefront: Care Delivery and Transformation through Health IT
Nurses at the Forefront: Care Delivery and Transformation through Health IT Ann OBrien RN MSN CPHIMS National Senior Director of Clinical Informatics Kaiser Permanente Robert Wood Johnson Executive Nurse
Preparing for the Hospital Readmission Reduction Program
Preparing for the Hospital Readmission Reduction Program Hospital readmission rates have been rising throughout the years, and the cost of healthcare with them. According to a study conducted by Vincent
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
Why Electronic Health Records are Ill-Suited for Population Health Management An InfoMC White Paper January 2016
Why Electronic Health Records are Ill-Suited for Population Health Management An InfoMC White Paper January 2016 Many studies have demonstrated that cost of care for patients with chronic illnesses is
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
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
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
Center for Medicare and Medicaid Innovation
Center for Medicare and Medicaid Innovation Summary: Establishes within the Centers for Medicare and Medicaid Services (CMS) a Center for Medicare & Medicaid Innovation (CMI). The purpose of the Center
Home The Best Place for Health Care A positioning statement from The Joint Commission on the state of the home care industry
Home The Best Place for Health Care A positioning statement from The Joint Commission on the state of the home care industry Table of Contents Home Care is the Patient-Preferred Setting.........................................
MULTI-FACTORIAL FALL RISK ASSESSMENT AND INTERVENTION FOR COMMUNITY DWELLING SENIORS: THE ROLE OF HOME HEALTH AGENCIES. Caring Choices.
MULTI-FACTORIAL FALL RISK ASSESSMENT AND INTERVENTION FOR COMMUNITY DWELLING SENIORS: THE ROLE OF HOME HEALTH AGENCIES Caring Choices April 2006 Caring Choices Page 1 Multi-Factorial Fall Risk Assessment
High Rehospitalization Rates: Evaluation and Impact
High Rehospitalization Rates: Evaluation and Impact May 29, 2009 Denise Remus, PhD, RN Chief Quality Officer, BayCare Health System BayCare Health System BayCare is the largest full-service, community-based
March 17, 2011. Re: Feedback on the NINR Draft Strategic Plan 2011
March 17, 2011 Patricia A. Grady, PhD, RN, FAAN Director National Institute of Nursing Research National Institutes of Health 31 Center Drive, Room 5B10 Bethesda, Maryland 20892-2178 Sent Via email to:
Practice Redesign for Dementia: The UCLA Alzheimer's and Dementia Care Program
Practice Redesign for Dementia: The UCLA Alzheimer's and Dementia Care Program Zaldy S. Tan, MD, MPH Medical Director, UCLA Alzheimer s and Dementia Care Program Director, California Geriatric Education
Evaluation of the Discharge Care Coordination Process for Elderly Patients
Evaluation of the Discharge Care Coordination Process for Elderly Patients The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters. Citation
from Boeing s Intensive Outpatient Care Program
Value Based Case Management: Lessons Learned from Boeing s Intensive Outpatient Care Program Theresa Helle Manager, Health Care Quality & Efficiency Initiatives, The Boeing Company Dr. Hussein Tahan, DNSc,
Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial
Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, led Trial Mary D. Naylor, PhD, w Dorothy A. Brooten, PhD, k Roberta L. Campbell, PhD, Greg Maislin, MS, MA, z Kathleen M.
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
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
The INTERACT Program: What is It and Why Does It Matter?
2 Agenda Housekeeping/Introductions An overview of INTERACT II An overview of a new CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Resources/Next training Questions/Comments
Patient Centered Research for the Complex Patient: Older adults with multiple and complex conditions. Mary Tinetti ECRI November, 2014
Patient Centered Research for the Complex Patient: Older adults with multiple and complex conditions Mary Tinetti ECRI November, 2014 Objectives Describe current care for persons with multiple and complex
Irene Fleshner, RN, MHSA, FACHE SVP, Strategic Nursing Initiatives Genesis HealthCare Principal, Reno, Davis and Associates, Inc.
Irene Fleshner, RN, MHSA, FACHE SVP, Strategic Nursing Initiatives Genesis HealthCare Principal, Reno, Davis and Associates, Inc. Independent Living Continuing Care Retirement Community Home Care Assisted