To hold the line on hospital readmissions, a tri-county, skilled nursing facility (SNF) collaborative in Michigan evaluates 130 participating SNFs by a host of quality metrics the SNFs enter into a common data portal.
In this podcast, Susan Craft of the Henry Ford Health System (HFHS), one of four collaborative founders, outlines a few SNF participation and reporting mandates that run the gamut from meeting attendance to LACE readmission risk scores.
During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvement, a May 2017 webinar now available for replay, Ms. Craft, director, care coordination, family caregiver program, HFHS Office of Clinical Quality & Safety, shared the key details behind this SNF collaborative, the program’s impact on readmission rates, and new readmission reduction targets derived from the program’s data analysis.
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.
Caldwell UNC Health Care case managers embedded in primary care practices take patient follow-up seriously, calling 90 percent of individuals who visit the ED and almost all discharged from a hospital stay, explains Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care. In particular, connecting with the recently discharged has helped her organization to reduce 30-day rehospitalizations from 19.16 percent in 2012 to 9.69 percent in 2013. If that crucial transition of care is well managed, all other goals for the patient should fall in line, she notes.
In this audio interview, Ms. Fox describes the 12-point checklist for the recently discharged and offers advice on engaging providers and staff before the case manager even settles in at physician practice.
Melanie Fox will describe how Caldwell UNC Health Care’s managers embedded in primary care practices and work sites are improving the quality of care and reducing healthcare costs during a September 25, 2014 webinar, Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols, a 45-minute program sponsored by The Healthcare Intelligence Network.