Among 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.
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.
Under 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.
An 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.
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.
Beyond 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.
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.
Although initally challenging, the engagement of specialists in Blue Cross Blue Shield of Michigan’s medical home program generated several outstanding primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend related to difficult-to-manage patients, notes Donna Saxton, field team manager for BCBSM’s value partnerships program.
A pioneer since 2005 in the development of outcomes-based measures to evaluate patient care, BCBSM based its standards on the Chronic Care Model. Today, the payor acts as a resource for other medical home recognition and accreditation efforts.
Donna Saxton share details from its PCMH designation requirements and the system of rewards and incentives that has produced results for the plan, the PCMH practices and its members during an April 30, 2014 webinar, Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures, a 45-minute program sponsored by The Healthcare Intelligence Network, now available for replay.
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.