The Science Behind Care Transition Management: More Than Case Managers and Discharge Calls

Jennifer DragoAmong the myths surrounding care transitions management is the belief the intervention can be effectively executed pre-discharge or by phone only, explains Jennifer Drago, executive vice president of population health for Sun Health.

In this audio interview, Ms. Drago dispels this myth, outlining requirements for a professionally designed, evidence-based transitions of care program, and why inclusion of dedicated staff and home visits will enhance clinical outcomes and possibly save lives.

During A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay, Ms. Drago shared the key features of Sun Health’s care transitions program, which achieved the lowest readmissions rates in CMS’s recently concluded Community-Based Care Transitions Program.


Length: 2:34 minutes

UT Southwestern ACO Home Health Narrow Network Reinforces Providers’ Home Care Accountability

Cathy BryanAfter UT Southwestern Accountable Care Network (UTSACN) discovered its home health spend was more than twice the national average, it applied data analytics to create a preferred home health network of 20 agencies (down from 1,200) that has saved more than $6 million in home health utilization in the first quarter of 2016 alone.

In this podcast, Cathy Bryan, director of care coordination at UTSACN, describes the provider reeducation process supporting the launch of this narrow network that has improved accountability, data sharing and communications related to home health utilization.

During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a September 2016 webinar now available for replay, Ms. Bryan shares how her organization’s care coordination model manages utilization while achieving its mission of bridging care gaps and enhancing health outcomes for approximately 250,000 covered lives.


Length: 3:21 minutes

UPMC RAVEN ECCPs ‘Driving Force’ in Reducing Long-Term Care Hospitalizations

April KaneUnder its partnership with CMS to improve quality of care in long-term care (LTC) facilities by reducing avoidable hospitalizations, the University of Pittsburgh Medical Center RAVEN project embeds clinical staff within eighteen nursing facilities. Here, April Kane, co-director of the RAVEN project, explains how the on-site presence of enhanced care and coordination providers (ECCPs) elevates the facility’s clinical capabilities, from goal development to advanced care planning.

During Hospital-Nursing Home Collaborations to Reduce Avoidable Admissions and Readmissions: A UPMC Case Study on Curbing Long-Term Care Hospitalizations, an August 2016 webinar now available for replay, April Kane shares the key details of the RAVEN program and how UPMC is preparing for Phase 2 of the program.


Length: 3:56 minutes

Connected Care Management: Do Mathematical Risk Predictors Trump Provider Intuition?

Dr. Luke HansenEven when employing sophisticated predictive analytics to zero in on population health risk, healthcare organizations shouldn’t discount providers’ intuition, advises Luke Hansen, MD, vice president and chief medical officer, population health for AMITA Health.

With a future plan to adopt a risk prediction tool, AMITA currently creates chronic illness registries to track its high-cost patients. Listen as Dr. Hansen discusses the tradeoffs of mathematically intense risk predictors versus physicians’ guts.

During an August 2016 webinar, Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care Management Strategy, now available for replay, Dr. Hansen and Susan Wickey, AMITA Health vice president, quality and care management, share the key components of AMITA Health’s care management process, how the various care management teams work together and the impact the program is having on healthcare costs and utilization.


Length: 3:04 minutes

Novant Health Pharmacist Drug Therapy Management: Ideas to Assure Accurate Medication Lists

Novant HealthAn accurate medication list is square one for clinical pharmacists working to reconcile prescriptions and reduce readmissions among Novant Health’s highest-risk patients, explains Rebecca Bean, director of population health pharmacy for Novant Health. But maintaining a valid list can be problematic when the inventory is accessed by multiple healthcare providers.

Ms. Bean describes the challenges of maintaining an accurate medication list and suggests strategies for ensuring medication list integrity in this audio interview.

During a February 2016 webinar, Medication Management: Using Clinical Pharmacists to Complete Comprehensive Drug Therapy Management Post-Discharge in High-Risk Patients, now available for replay, Rebecca Bean shares her organization’s medication management approach and why a clinical pharmacist is key to the program’s success.


Length: 3:00 minutes

Next Generation Healthcare Nurse Navigators: The Advantages That Won Over ‘Solo Cowboy’ Practitioners

Robert FortiniWhen Bon Secours adapted Geisinger’s case management model six years ago and embedded nurse navigators within physician practices, there was reluctance and even resistance from some “solo cowboy” physician practitioners, recalls Robert Fortini, PNP, chief clinical officer for Bon Secours Medical Group. Today, providers are fiercely protective of the cadre of 70 nurse navigators, who do the “heavy lifting” of chronic care management.

In this audio interview, Fortini offers some lessons learned for organizations considering the embedded case management approach, including budgetary planning, calculations, and “icing-on-the-cake” outcomes for patients and hospitals.

During a January 2016 webinar, Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning, now available for replay, Fortini offered an inside look at Bon Secours’ experience with CMS’ chronic care management reimbursement in 2015 and how they leverage this experience for CMS’s newest billable event in 2016—advance care planning.


Length: 3:24 minutes

Memorial Hermann Immerses Care Managers in ‘Micro Culture’ of Physician Practices

Mary FolladoriHaving heard from physicians and payors alike about the challenges of engaging patients, the Memorial Hermann ACO crafted its care management program with the goal of drawing patients more fully into their care, explains Mary Folladori, RN, MSN, FACM, CMAC, system director of care management at the Memorial Hermann Physician Network and ACO.

In this podcast, Ms. Folladori shares some key program design elements from the 2014 top-performing Medicare Shared Savings Program (MSSP) ACO, including immersing care managers into the ‘micro cultures’ of the physician practice, the community and the members that they serve.

During a September 2015 webinar, Care Coordination in an ACO: Managing the Population Health Continuum from Wellness to End-of-Life, now available for replay, Ms. Folladori provided the inside details on its care coordination strategy and results.


Length: 2:57 minutes

Post-Acute Bundled Payments Opportunity to Identify Gaps in Care, Staff Training

Debbie ReberBeyond reducing per-episode costs and readmissions, Brooks Rehabilitation’s experience in CMS’s Bundled Payments for Care Improvement (BPCI) initiative helped the post-acute care provider to identify gaps in care and staff training, notes Debbie Reber, vice president of clinical services for Brooks Rehabilitation.

In this audio interview, Ms. Reber identifies how Brooks Complete Care program achieved its biggest savings as well as the care and training enhancements resulting from the rehabilitation system’s participation in BPCI’s Model 3.

During a July 2015 webinar, Bundled Payments for Post-Acute Care: Four Critical Paths To Success, now available for replay, Debbie Reber shares the inside details on the four domains of Complete Care and the resulting, significant savings Brooks achieved through the BPCI program.


Length: 3:26 minutes

Yale-New Haven Embedded High-Risk Care Coordinators Monitor Geriatric Homebound

Dr. Vivian ArgentoFollowing weekly huddles with nurse practitioners, Yale New Haven Health System (YNHHS) geriatric care coordinators use a red-yellow-green system to prioritize care for its Medicare homebound patients, explains Dr. Vivian Argento, the executive director of geriatric and palliative services at Bridgeport Hospital, in this audio interview.

While the bulk of care provided by YNHHS’s geriatric care coordination model is delivered during house calls to seniors deemed homebound by Medicare criteria, the program also provides care to patients in assisted living facilities.

The YNHHS geriatric care coordination model was one of three embedded models of care presented during a June 2015 webinar, Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, now available for replay. During the program, Dr. Argento was joined by Amanda Skinner, YNHHS executive director for clinical integration and population health, who described livingwellCARES, embedded on-site care coordination for YNHHS employees; and its patient-centered medical home’s hybrid model of centralized and embedded care coordination resources.


Length: 3:11 minutes