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.
Among other data, detail tables in a physician practice’s Quality Use and Resource Reports (QRURs) pinpoint specialist referral networks for Medicare beneficiaries, explains William Holding, consultant, PDA, Inc., which can help physician practices determine their highest value referral pathways.
In this audio interview, Holding explains the benefits of tapping CMS-generated QRUR reports to enhance performance under Merit-Based Incentive Payment Systems (MIPS), one of two payment paths for physician reimbursement under MACRA.
During Physician MACRA Preparation: Using QRUR and Other CMS Data To Maximize Your Performance, a January 2017 webinar now available for replay, Holding and colleague Nancy Lane, president of PDA, Inc., share the critical steps physician practices should take when analyzing their QRUR data, along with details on other CMS data points that can help practices improve MIPS performance.
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.
The engagement of patients, particularly those with multiple chronic conditions, continues to challenge healthcare providers.
However, as Steven Valentine, vice president of advisory consulting services for Premier Inc., explains in this podcast, clinicians actually have a host of tools at their fingertips to engage patients—tools they must employ in order to succeed in value-based healthcare.
During Trends Shaping the Healthcare Industry in 2017: A Strategic Planning Session, a November 2016 webinar now available for replay, Steven Valentine provides a roadmap to the key issues, challenges and opportunities for healthcare organizations in 2017.
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.
The patient experience begins before an individual even thinks about going to the doctor or hospital, notes Laura Jacobs, executive vice president for GE Healthcare Camden Group, and patient satisfaction has moved beyond what is measured on surveys. As such, healthcare organizations should thoughtfully craft communications and care delivery strategies to meet rising consumer expectations and boost quality metrics. In this audio interview, Ms. Jacobs suggests how to better manage the consumer experience across the care spectrum and respond to the proliferation of consumer-generated healthcare data via apps and social media.
During a November 2015 webinar, Trends Shaping the Healthcare Industry in 2016: A Strategic Planning Session, now available for replay, Ms. Jacobs and Paul Keckley, managing director of Navigant, provided a roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2016.
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 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.
Despite the migration of some Pioneer ACOs to CMS’s Medicare Shared Savings Program (MSSP), expect the surge in commercial accountable care organizations to continue in 2014, predicts Steven Valentine, president, The Camden Group. In this audio interview, Valentine suggests improvements to patient handoffs, an area in which ACOs have disappointed, in Valentine’s view, as well as expectations for the other much-modeled care delivery platform, the patient-centered medical home (PCMH).
In both the ACO and the PCMH, Valentine anticipates specialists will be critical parts of the solution, especially when it comes to emerging payment models, quality and performance.
Steven Valentine and Catherine Sreckovich, managing director, healthcare, Navigant, provided a roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2014 during an October 30, 2013 webinar, Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.
To rise to the challenge of non-compliant patients, providers should ask how they can work together to empower patients toward self-management rather than why patients are non-adherent in the first place, suggests Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC). CFMC coordinates the work of state-based Quality Improvement Organizations (QIOs), who have been working with hospitals and community providers to improve care transitions and reduce readmissions.
In this interview, Ms. Goroski describes some of the interventions focused on patients, providers or both groups that have not only lowered key Medicare readmission rates but also reduced participants’ overall admission stats.
Ms. Goroski shared lessons learned from the 14 communities that participated in the CMS care transition demonstration project and details on program rollout to over 12 million Medicare beneficiaries in 400 communities during a May 22, 2013 webinar, now available for replay Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions.