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

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

SNF Visit Gauges Readmissions Risk, Supports SNF-to-Home Transition

Danielle AmrineTo 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.


Length: 3:16 minutes

Humana Remote Monitoring Pilots Engage Member’s Circle of Care

Humana’s remote monitoring pilots go beyond traditional targets of heart failure, diabetes and COPD to observe functionally challenged members, explains Gail Miller. This novel approach uses a Personal Emergency Response System (PERS) with a built-in accelerometer to monitor members challenged by activities of daily living (ADL), says the VP of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. Another pilot, a collaboration with HealthSense, places sensors around the member’s home to study algorithms of normal movement so Humana can detect changes and intervene before a member’s crisis.

All Humana remote monitoring pilots engage the circle of care surrounding the member — be it home health, a family member, or a spouse.

Gail Miller shared more details of Humana’s telephonic care management and how remote monitoring pilots will enhance care coordination during a March 19, 2014 webinar, Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 4:26 minutes

Navigating Patients Pre-Discharge on Care Transitions

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.


Length: 12:55 minutes

Assessing Readmission Risk to Prioritize Home Visits for Complex Patients

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.


Length: 6:28 minutes