Working to bridge the gap between hospital discharge and permanent supportive housing for homeless patients, the California-based Chronic Care Plus program found that 40 percent of client needs are related to social determinants, explains Paul Leon, CEO of the Illumination Foundation, a Chronic Care Plus joint venture partner. In this audio interview, Leon explains the need to not only house patients but also to connect them to a plethora of social services, including mental health appointments.
During Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients, a December 2016 webinar now available for replay, Mr. Leon shares the inside details of this recuperative care program that offers community-based stabilization for medically vulnerable chronically homeless patients, including program results and savings achieved.
Community Care of North Carolina’s Transitional Care program was awarded the Hearst Health Prize this month not only for demonstrating how effective transitional care is for its 1.5 million Medicaid beneficiaries, but also for continually evaluating and modifying the intervention based on its findings.
In this broadcast, Carlos Jackson, CCNC’s director of program evaluation, shares one of CCNC’s more interesting findings, identifying the priority population for the intervention, and explains why the care transition management mindset must expand beyond reducing hospital readmissions.
During a March 2016 webinar, Measuring and Evaluating the Impact of Home Visits for Clinically Complex Patients, now available for replay, Carlos Jackson shares the details behind CCNC’s home visits program, a key aspect of the care transitions program, from how individuals are identified for the intervention to the impact it has on key performance metrics.
When 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.
As groundwork for participation in CMS’s Bundled Payments for Care Improvement initiative, St. Vincent’s Health Partners (SVHP) formed a cross-functional cross-boundary Transitions Leadership Group to map what happens to patients moving along their care journeys, explains Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration.
In this audio interview, Ms. Swedberg describes the structure and goals of the Transitions Leadership Group and some tools and protocols it developed to set standards for any post-acute provider wishing to join the SVHP network.
During a September 2015 webinar, Post-Acute Care Trends: Aligning Clinical Standards and Provider Demands in the Changing Landscape, now available for replay, Ms. Swedberg and Julia Portale, vice president of community services, Jewish Senior Services, share their organizations’ collaborative approaches to the evolving post-acute care market.
Following 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.
To help patients transition from a skilled nursing facility (SNF) to independent living, the Council on Aging of Southwestern Ohio visits high-risk patients at SNFs within 10 calendar days of admittance, explained Danielle Amrine, the council’s transitional care business manager. During an April 21, 2015 webinar, Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, Ms. Amrine described seven key questions to ask patients during the SNF visit, how field coaches assess the SNF patient’s risk for readmission to the hospital, and the council’s novel arrangement for completing the SNF visits.
The SNF visits are one component of the council’s multi-faceted home visits intervention, a participant in CMS’s Community-Based Care Transitions Program (CCTP).
During the 45-minute webinar, now available as an on-demand replay, Ms. Amrine shared the key features of the council’s home visits program, including visit scheduling, patient assessment, post-visit touch points and program evolution.
To 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.
The 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.
With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital’s Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF’s and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over.
Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers, a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.
Modifying a popular hospital admissions risk assessment tool for its own use helps Stanford Coordinated Care to prioritize home visits for its roster of high-risk patients, all of whom have complex chronic conditions, explains Samantha Valcourt, MS, RN, CNS, Stanford’s clinical nurse specialist. Stanford’s HARMS-11, based on Iowa Healthcare Collaborative’s HARMS-8 hospital risk screening tool, looks at individuals’ utilization, social support and medication issues, among other factors, to measure a patient’s risk of readmission.
The resulting home visits, a critical component of Stanford’s care transitions management program, help to uncover health challenges the complex chronic patient may still face, including four common medication adherence barriers Ms. Valcourt describes in this interview.
Samantha Valcourt shared how Stanford’s Coordinated Care uses a home visit assessment to improve care transitions post-discharge during a December 19, 2013 webinar, Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions.