Care Transitions: Care Across the Continuum

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1 Arkansas Hospital Association Hospital Engagement Network And Arkansas Foundation for Medical Care, subcontractor with TMF Quality Innovation Network Quality Improvement Organization Presents Care Transitions: Care Across the Continuum Community Engagement (across all care settings) Consumer Engagement (patient and family) Countenance (support from leadership) Commitment (to quality care transitions) September 15, 2016 Hilton Garden Inn West Little Rock

2 AGENDA 8:30 a.m. - 9:00 a.m. Registration 9:00 a.m. - 9:30 a.m. Welcome and Overview: Collaboration for Improvement Pam Brown, BSN, RN, CPHQ, CPPS, VP of Quality and Patient Safety, Arkansas Hospital Association Jo Nycum, MPH, RN, Outreach Specialist/Quality Division, Arkansas Foundation for Medical Care 9:30 a.m.-11:00 a.m. Memphis Model: Familiar Faces Joy Sharp, Program Manager-Community Health, Memphis, TN 11:00 a.m.-11:45 a.m. Identifying and Transitioning Patients to Hospice Care: Options to Avoid Readmissions Pollyanna Burt Elton, Community Education Specialist, Hospice Home Care 11:45 a.m.-1:00 p.m. Lunch on Your Own 1:00 p.m.-1:30 p.m. Population Health through the Eyes of Centralized Care Coordination Amy Stephenson, BSN, RN, CCM, Supervisor Care Coordination/Program Lead, Arkansas Health Group 1:30 p.m.-2:00 p.m. Health Literacy/Teach-back Kristi Hadden, PhD, Executive Director, UAMS Center for Health Literacy 2:00 p.m.-2:45 p.m. Care Transitions in an Acute Care Setting Karen Byers, MSN, RN, Nurse Leader of Care Transitions, Conway Regional Health Systems Amanda Kelley, BSN, RN, Care Transitions Nurse, Conway Regional Health Systems 2:45 p.m.-3:15 p.m. Wrap up and Next Steps Objectives: At the conclusion of this program, participants will be able to: Acknowledge the importance of improving care transitions and reducing readmissions across multiple organizations and stakeholders. Describe the path that Methodist Le Bonheur Healthcare took to address healthcare disparities in their underserved community through their Familiar Faces program as well as the outcomes of the program. Identify hospice appropriate patients and offer care options to families. Identify the components of managing patients with chronic care needs to prevent rehospitalization and improve care transitions. Define health literacy, recognize risk factors for low health literacy and explain teach-back, its purpose and practical approaches. Describe project RED and identify improvement strategies that decrease 30-day readmissions, decrease emergency room visits and has a positive impact on patient safety outcomes and patient satisfaction

3 Disclosure of Financial Relationships The speakers listed above for this continuing education activity have no financial relationships with commercial interests to disclose. Continuing Education Certificates of attendance with clock hours will be issued to all registrants attending the conference. 5.0 Nursing contact hours will be provided to nurses who sign-in and attend the entire program. Nursing certificates will be mailed following the conference. The Arkansas Hospital Association is an approved provider of continuing nursing education by the Midwest Multistate Division, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Faculty Karen Byers MSN, RN, in education obtained from UCA. Nurse Leader of Care Transition Program at Conway Regional Health System. Nurse for 30 years, Member of ANA and ArOne, Background in Psych, Cardiac, Med/Surg, Home Care Nursing, School Nursing, Utilization Review, Magnet coordinator, and Clinical Management Amanda Kelley BSN, RN, graduated from UCA in Care Transition Nurse. Nurse for 14 years at Conway Regional Health System, Background in Med/Surg, Pediatrics, and Cardiac Nursing Pollyanna Burt Elton, a native of Ashley County, with 15 years in marketing and advertising, Elton spent 3 years as marketing and admissions coordinator for two skilled nursing facilities in Southeast Arkansas. She then transitioned to Hospice Home Care as community educator and admission coordinator for the past 3 years. Joy Sharp has been in the heart of the South Memphis community for many years. For over 30 years, has been more than a zip code in the Memphis community; it has been her home. Peers in the field would often express Joy as infectious in her passion to help others, and it is transparent in her presentations and administration techniques. Sharp formally began her work in 2001 at Christ Community Health Services, Tennessee s largest Federally Qualified Health Center, where she served in many capacities beginning as an Outreach Programs Coordinator and rapidly advancing to be the Program Manager of Outreach Services. While in those roles, she coordinated and implemented various programs to enhance the residents of the city such as Memphis Healthy Churches, Heart of a Woman, Shelby Alliance of Faith Based Efforts against Sexual Assault and CHOICES Abstinence Education Program; using project management and community development to enhance quality of life in the needed community. In 2013, Sharp began working at Methodist Healthcare as a navigator helping to coordinate and manage population health initiatives for the health system in the zip code. She now serves of the Program Manager of Community Health. Sharp is a growth-oriented and highly talented lifestyle coach with a strong background in all aspects of chronic disease management, care management, community project facilitation, curriculum development, wellness/health education, grant writing and grant funding budgeting processes. She has many years experience in chronic disease management /wellness coaching as well as excellent communication and leadership skills. Dr. Kristie Hadden graduated from Radford University in Radford, VA with a BS in Communication Disorders. She then obtained a Master s Degree in Speech Language Pathology from the University of Arkansas for Medical Sciences. She practiced as a speech-language pathologist and worked in public health as the State Director of

4 Programs at the March of Dimes before completing her PhD in Health Promotion and Prevention Research at UAMS. She is currently the Executive Director of the UAMS Center for Health Literacy where she conducts health literacy research, consults, oversees outreach programs, and participates in policy initiatives to improve health literacy locally, statewide and nationally. Dr. Hadden also holds the Carl L. Nelson Chair of Orthopaedic Creativity at UAMS. Dr. Hadden s primary faculty appointment is in the College of Medicine in Medical Humanities, and she holds secondary appointments in the Colleges of Nursing, Pharmacy, Public Health, Health Professions, as well as the UAMS Graduate School. Pam Brown, RN, BSN, CPHQ, CPPS is the VP of Quality and Patient Safety for the Arkansas Hospital Association (AHA) leading the development and implementation of the AHA s Quality and Patient Safety Program. For the past 4 years at AHA she has overseen the work of the AHA Hospital Engagement Network as well as supporting member hospitals in other projects such as Stop CAUTI and Surgical Unit-based Safety Programs. Prior to joining AHA, Pam served as the AVP of Quality Programs at Arkansas Foundation for Medical Care (AFMC), the state s Quality Improvement Organization for the Centers for Medicare and Medicaid Services. During her 11 years at AFMC she provided oversight for quality initiatives to Arkansas providers, which included providing education, technical assistance, research references and collaborative support for a variety of clinical topics, health information technology, patient safety as well as quality specific to the rural community. She is a Certified Professional in Healthcare Quality and Patient Safety and a Certified Professional in Patient Safety. She completed the Patient Safety Improvement Corp IV and AHRQ/VA TeamSTEPPS Facilitator training for Patient Safety in Her professional career has included more than 22 years experience in quality improvement and 34 years in nursing in a variety of settings, which include acute care, long-term acute care, and home health. Amy Stephenson, BSN, RN, CCM has been a registered nurse with 13 years of experience in the areas of adult critical care / cardiovascular intensive care, medical intensive care, surgery, neonatal intensive care, and care coordination. The past 6 years have been spent in the area of care coordination where she has led programs such as HEDIS Gaps in Care, PCMH, and CPCi. Amy currently supervises 20 ambulatory care coordinators, 4 centralized care coordinators, and 7 transitional care coordinators which are housed within the Baptist Health hospitals. With the announcement of the new program, CPC Plus, to begin in 2017, Amy will be expanding her care coordination program to include an additional 6 care coordinators for a grand total of 37 that are charged with managing complex patients in an ambulatory setting. Jo Nycum MPH, RN, is a registered nurse who holds a BA in psychology and a Master Degree in Public Health from UAMS. She has 20 years of clinical experience including, ambulatory cardiology services, inpatient CCU, ICU, OR, Vascular Interventional Radiology and High-Risk OB-GYN. Post clinical experience includes 5 years with ABCBS as a Medicare Carrier data analyst after which she moved into a quality role with AFMC. Jo has been with AFMC for 15 years and quality projects have included - quality reporting, practice transformation, prevention and population health. She served as a Quality Advisor for the ADH Chronic Illness Collaborative, AR Diabetes Advisory Council and currently serves on the UAMS Caregiver Advisory Council. About TMF QIN-QIO Led by TMF Health Quality Institute in Texas and Oklahoma, in partnership with the Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Research Organization, Inc. in Puerto Rico, the TMF QIN-QIO is a collaborative effort to accomplish better care and better health for people and communities as well as more affordable care through quality improvement.

5 Care Transitions: Care Across the Continuum Community Engagement (across all care settings) Consumer Engagement (patient and family) Countenance (support from leadership) Commitment (to quality care transitions) Registration Form September 15, 2016 Hilton Garden Inn West Little Rock Name Title Organization Address City State Zip Telephone FAX There is no fee for registration, but all team members must register in advance in order to attend. 2 Ways to Register: FAX: Mail: Cindy Harris, Arkansas Hospital Association 419 Natural Resources Drive Little Rock, AR Phone:

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