SFHN Care Transitions Task Force: Standards Are Starting Point for Quality Improvement

Dr. Michelle SchneidermannTo narrow its focus while creating transitional care standards, the San Francisco Health Network (SFHN) Care Transitions Task Force divided into three subgroups: inpatient, outpatient and pharmacy. During a February 26, 2015 webinar, Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, task force leader Dr. Michelle Schneidermann, associate clinical professor of medicine for the division of hospital medicine at University of California San Francisco/SFGH, outlined the work of each subgroup.

During the 45-minute webinar, now available as on on-demand replay, Dr. Schneidermann, who is also medical director of the San Francisco Department of Public Health Medical Respite and Sobering Center, shared the key achievements of the Care Transitions Task Force and its impact on readmission rates.


Length: 4:01 minutes

CHRISTUS Remote Monitoring for Chronic Condition Management: Coaching Patients to Wellness at Home

Shannon CliftonThe daily monitoring phase of CHRISTUS Health’s remote care management workflow involves the patient, a care transition nurse coach, and the patient’s primary care physician if needed. During a February 24, 2015 webinar, Remote Patient Monitoring for Chronic Condition Management, Shannon Clifton, director of connected care for CHRISTUS Health, described this critical stage of the 60-day program that strives to keep high-risk patients within wellness parameters.

During the 45-minute webinar, now available as on on-demand replay, Ms. Clifton and Dr. Luke Webster, chief medical information officer, CHRISTUS Health, shared the key features of the remote monitoring effort, including program design and impact, ROI, and how the program fits into Christus’ long-term strategy as a risk-bearing organization.


Length: 3:46 minutes

Billable Chronic Care Management Services: What Counts as Care Coordination, and What Doesn’t?

Paul RudolfWhat constitutes care coordination under the new Chronic Care Management (CCM) codes?

While CMS has identified a long list of CCM activities that can be counted toward the 20-minutes-per-month requirement, physician practices must also keep in mind certain services that cannot be billed when CCM is billed.

During a February 12, 2015 webinar, Chronic Care Management Reimbursement Compliance: Overcoming Obstacles and Meeting Requirements, Paul Rudolf, MD, a partner with Arnold & Porter LLC, outlined exceptions to and examples of billable CCM tasks.

During the 45-minute program, now available as on on-demand replay, Dr. Rudolfe and Nicole Liffrig Molife, counsel, Arnold & Porter, delve into CMS requirements and discuss approaches and challenges to meeting the CCM requirements. The program was sponsored by the Healthcare Intelligence Network.


Length: 3:43 minutes