A Solution to Sustain Independent Living for People with Complex Care Needs. Senscio Systems, Inc.

Size: px
Start display at page:

Download "A Solution to Sustain Independent Living for People with Complex Care Needs. Senscio Systems, Inc."

Transcription

1 A Solution to Sustain Independent Living for People with Complex Care Needs Senscio Systems, Inc.

2 For 95 million people in the US with complex health, Senscio provides an infrastructure of technology and services for real-time health intervention, resulting in fewer health complications The solution, called Ibis, allows individuals to live and be cared for in the least restrictive setting, balancing quality of life, health and cost of care Reduced ER and hospital days Delayed transitions to institutional care More efficient healthcare experience What do we do? 95 million with multiple chronic conditions (MCC) Delayed Development (10 million) Multiple Chronic Conditions (75 million) Mental Illness (10 million) # with MCC (in million) % of population 49% in age group 80% 18% 7% Age 0-17 Age Age Age 65+ 2

3 Ibis Person reported data Passively collected data Ibis Interpreting health and behavioral data Clinician reported data Case Management Rapid and timely interventions (delivered through partners) Meal skippers with poor glycemic control CHF patients with poor diuretic adherence with fluid retention issues Insights for Care Management Good COPD care with stabilized pulmonary function All Individuals Poor medication adherence, possibly due to side effects Healthy eaters with good exercise habits and good glycemic control

4 Our Value Proposition Ibis fills an operational gap Today s Chronic Care Gap filled by Ibis Episodic Care (when exacerbations happen) Routine Care (weekly, monthly, quarterly) Daily interventions, as needed Daily reminders and assessments Ibis fills a functional gap Disease Management + Case + Real-Time = Management Analytics More Time in Less Costly Settings Our Partners Ibis

5 Ibis Components CareStation The Ibis CareStation empowers people to input symptoms and vital signs, take medications, and report care plan-related activities. Warbler The Warbler wearable activity tracker detects and records daily activity, including movement, sleep, and adverse events such as falls. Devices Collect physiologic and environmental data Scio Scio is an artificial intelligence program that contextualizes data on health status and daily behavior and reports insights to the patient s care team. CarePortal With real-time data and insights incorporated into understanding a person s condition, providers and payers can improve outcomes and reduce costs.

6 Ibis CareStation Deep activation and engagement drives accountability and adherence 6

7 Ibis CareStation CareStation tracks meals, medication, mood and activities Addresses most common challenges with health conditions and activities of daily living 7

8 Ibis CareStation CareStation reports on and provides pathway for management of adverse events 8

9 Passive Activity Monitoring A wearable sensor and distributed receivers track movement within the house Movement data are processed to learn patterns corresponding to routine activities: cooking, eating, resting, bathroom use Anomalies in routines are detected and notified

10 Ibis CarePortal Data and Analytics enable Early, Targeted Intervention Health BLOOD PRESSURE READINGS Text messages activate care team Adherence CarePortal provides details about person s health and behavior

11 Population Health Management Ibis automatically clusters into groups based on behavioral patterns Trends in behavior and health impact can be identified as they happen allowing effective prioritization of care support programs 11

12 Structure and Support Care Team member creates care plan Care Team Ibis Care Station structures the daily care per care plan Ibis Care Team coaches Client and adjusts care plan as needed Care Team Person uses Care Station to self-manage daily Person Ibis notifies Care Team when client needs attention Ibis Ibis assesses health and self care constantly Ibis

13 Achieving Desired Outcomes 70-year-old female with COPD Medications Missed Starting to feel progressively worse Hospitalized Early intervention for COPD is reducing emergency care O2 Sat holding steady Labored breathing Worsening cough 13

14 Expected Outcomes 10% fewer ER visits 10% fewer inpatient days 20% fewer hospital readmissions within 60 days 20% labor productivity gain 75% of individuals have clinical indicators that are stable in the target range, or are trending towards that range(blood pressure, A1C, oxygen saturation) 80% average medication adherence for at least 80% of individuals who self administer medications Keep care in community setting and toward less restrictive independent living environments 14

15 Questions?

CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT PATHWAY

CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT PATHWAY CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATHWAY PROCESS OUTCOMES ADMISSION This will help you understand what will happen to you during your stay at the hospital. If you do not understand, please feel free

More information

Improving Patient Care through Remote Patient Monitoring

Improving Patient Care through Remote Patient Monitoring Improving Patient Care through Remote Patient Monitoring A Collaborative Approach Between Olmsted Medical Center Rochester, MN and The Evangelical Lutheran Good Samaritan Society LivingWell@Home Sioux

More information

2015 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members

2015 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members 2015 Congestive Heart Failure Program Evaluation Our mission is to improve the health and quality of life of our members 2015 Congestive Heart Failure Program Evaluation Program Title: Congestive Heart

More information

2017 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members

2017 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members 2017 Congestive Heart Failure Program Evaluation Our mission is to improve the health and quality of life of our members 2017 Congestive Heart Failure Program Evaluation Program Title: Congestive Heart

More information

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

CHRONIC OBSTRUCTIVE PULMONARY DISEASE GREY BRUCE HEALTH NETWORK EVIDENCE-BASED CARE PROGRAM CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATHWAY Updated June 2009 Review June 2011 2006-2010 Grey Bruce Health Network ADMISSION This will help you understand

More information

Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease This booklet has been written to answer questions that many patients and family members ask about their care during their hospital stay. It will explain the experiences

More information

A Bridge Back Home: Care Transition Coaching for the Post-Acute Heart Failure Patient. February 8, 2018

A Bridge Back Home: Care Transition Coaching for the Post-Acute Heart Failure Patient. February 8, 2018 A Bridge Back Home: Care Transition Coaching for the Post-Acute Heart Failure Patient February 8, 2018 3 Partners in Care (Partners) A Mission-Driven Organization Our Mission Partners shapes the evolving

More information

CONNECTED SM. Blue Care Connection SIMPLY AN ACTIVE APPROACH TO INTEGRATED HEALTH MANAGEMENT

CONNECTED SM. Blue Care Connection SIMPLY AN ACTIVE APPROACH TO INTEGRATED HEALTH MANAGEMENT SIMPLY CONNECTED SM Blue Care Connection AN ACTIVE APPROACH TO INTEGRATED HEALTH MANAGEMENT Jeanine Patterson, MS, RN, HSMI Clinical Account Consultant July 23, 2013 Blue Cross and Blue Shield of Illinois,

More information

National Institutes of Health, National Heart, Lung and Blood Institute (NHLBI)

National Institutes of Health, National Heart, Lung and Blood Institute (NHLBI) October 27, 2016 To: Subject: National Institutes of Health, National Heart, Lung and Blood Institute (NHLBI) COPD National Action Plan As the national professional organization with a membership of over

More information

Value model in the new healthcare paradigm: Producing value at a single specialty center.

Value model in the new healthcare paradigm: Producing value at a single specialty center. Value model in the new healthcare paradigm: Producing value at a single specialty center. State of Spine Surgery Think Tank June 17, 2017 Catherine MacLean, MD, PhD Chief Value Medical Officer Center for

More information

How 2018 Will Be The Year You Embrace Continuous Connectivity. NERSI NAZARI, PHD Chief Executive Officer

How 2018 Will Be The Year You Embrace Continuous Connectivity. NERSI NAZARI, PHD Chief Executive Officer How 2018 Will Be The Year You Embrace Continuous Connectivity NERSI NAZARI, PHD Chief Executive Officer WE ARE CONTINUOUSLY CONNECTED Socially Friends and community Financially Balances and bills Parenting

More information

MEDICATION THERAPY MANAGEMENT. MemberChoice FORMULARY MANAGEMENT MEDICATION THERAPY MANAGEMENT (MTM) SPECIALTY DRUG MANAGEMENT

MEDICATION THERAPY MANAGEMENT. MemberChoice FORMULARY MANAGEMENT MEDICATION THERAPY MANAGEMENT (MTM) SPECIALTY DRUG MANAGEMENT MemberChoice FORMULARY MANAGEMENT MEDICATION THERAPY MANAGEMENT (MTM) SPECIALTY DRUG MANAGEMENT MEDICATION THERAPY MANAGEMENT Medication Therapy Management 1 $ 290 Billion Wasted in avoidable costs due

More information

EVOLENT HEALTH, LLC. Heart Failure Program Description 2017

EVOLENT HEALTH, LLC. Heart Failure Program Description 2017 EVOLENT HEALTH, LLC Heart Failure Program Description 2017 1 Evolent Health Heart Failure Program Description 2017 Table of Contents Section Page Number I. Introduction. 3 II. Program Scope. 3 III. Program

More information

Improving Healthcare and Patient Outcomes Through Connected Devices

Improving Healthcare and Patient Outcomes Through Connected Devices Improving Healthcare and Patient Outcomes Through Connected Devices A whitepaper by Scalable Health TABLE OF CONTENTS EXECUTIVE SUMMARY 3 DIVERSE APPLICATIONS OF IoT 5 HOW IoT WILL REVOLUTIONIZE THE HEALTHCARE

More information

Rapid Response Nursing Program: Supporting Chronic Disease Management through Transitions in Care

Rapid Response Nursing Program: Supporting Chronic Disease Management through Transitions in Care Rapid Response Nursing Program: Supporting Chronic Disease Management through Transitions in Care Geriatric Day Hospitals Institute Sunnybrook Health Science Centre November 25, 2013 Liana Sikharulidze,

More information

Care Coordination (CC) assists members and their families with complex needs

Care Coordination (CC) assists members and their families with complex needs Care Coordination (CC) assists members and their families with complex needs Care is member-centered, family-focused, and culturally competent. CC assists in locating services to meet the health and social

More information

Telemedicine: Solving the Root Causes for Preventable 30-day Readmissions in SNF Settings

Telemedicine: Solving the Root Causes for Preventable 30-day Readmissions in SNF Settings For Immediate Release: 05/11/18 Written By: Scott Whitaker Telemedicine: Solving the Root Causes for Preventable 30-day Readmissions in SNF Settings Outlining the Problem: Reducing preventable 30-day hospital

More information

Needs-based population segmentation

Needs-based population segmentation Needs-based population segmentation David Matchar, MD, FACP, FAMS Duke Medicine (General Internal Medicine) Duke-NUS Medical School (Health Services and Systems Research) Service mismatch: Many beds filled

More information

POST-ACUTE CARE Savings for Medicare Advantage Plans

POST-ACUTE CARE Savings for Medicare Advantage Plans POST-ACUTE CARE Savings for Medicare Advantage Plans TABLE OF CONTENTS Homing In: The Roles of Care Management and Network Management...3 Care Management Opportunities...3 Identify the Most Efficient Care

More information

EVOLENT HEALTH, LLC Diabetes Program Description 2018

EVOLENT HEALTH, LLC Diabetes Program Description 2018 EVOLENT HEALTH, LLC Diabetes Program Description 2018 1 Evolent Health Diabetes Program Description 2018 Table of Contents Section Page Number I. Introduction... 3 II. Program Scope... 3 III. Program Goals...

More information

Defining and Driving Value: Provider and Payer Perspectives

Defining and Driving Value: Provider and Payer Perspectives Defining and Driving Value: Provider and Payer Perspectives NAHC Financial Managers Meeting June 2013 Serving the Midcoast of Maine in Knox Waldo Lincoln Counties 1 Who we are... Medicare Certified & State

More information

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred 1

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred   1 POPULATION HEALTH PLAYBOOK Mark Wendling, MD Executive Director LVPHO/Valley Preferred www.populytics.com 1 Today s Agenda Outline LVHN, LVPHO and Populytics Overview Population Health Approach Population

More information

Using Facets of Midas+ Hospital Case Management to Support Transitions of Care. Barbara Craig, Midas+ SaaS Advisor

Using Facets of Midas+ Hospital Case Management to Support Transitions of Care. Barbara Craig, Midas+ SaaS Advisor Using Facets of Midas+ Hospital Case Management to Support Transitions of Care Barbara Craig, Midas+ SaaS Advisor What does Transitional Care Include? Transitional Care is the smooth conversion of a patient

More information

Big Data NLP for improved healthcare outcomes

Big Data NLP for improved healthcare outcomes Big Data NLP for improved healthcare outcomes A white paper Big Data NLP for improved healthcare outcomes Executive summary Shifting payment models based on quality and value are fueling the demand for

More information

Results from the Iowa Medicaid Congestive Heart Failure Population Disease Management

Results from the Iowa Medicaid Congestive Heart Failure Population Disease Management EXECUTIVE SUMMARY Study Validates Use of Technology-Based Remote Monitoring Platform to Reduce Healthcare Utilization and Cost Results from the Iowa Medicaid Congestive Heart Failure Population Disease

More information

Population Health Management. Shaping the future of healthcare. How health systems can move beyond sick care to proactively keep populations healthy

Population Health Management. Shaping the future of healthcare. How health systems can move beyond sick care to proactively keep populations healthy Population Health Management Shaping the future of healthcare How health systems can move beyond sick care to proactively keep populations healthy Introduction: We see the transition from fee-for-service

More information

The Role of the RT in Homecare and Pulmonary Rehab: What the Future May Hold

The Role of the RT in Homecare and Pulmonary Rehab: What the Future May Hold The Role of the RT in Homecare and Pulmonary Rehab: What the Future May Hold Presented by Kenneth A. Wyka, MS, RRT, AE-C, FAARC Director Clinical Education and Associate Dean Independence University, Salt

More information

Population Health Management In The Medical Home

Population Health Management In The Medical Home Population Health Management In The Medical Home Karen Handmaker, MPP (Moderator), Population Health Strategies Patrick Dunn, PhD, American Heart Association Sherrie Peterson, The Evangelical Lutheran

More information

Programs and Procedures for Chronic and High Cost Conditions Related to the Early Retiree Reinsurance Program

Programs and Procedures for Chronic and High Cost Conditions Related to the Early Retiree Reinsurance Program s and Procedures for Chronic and High Cost Conditions Related to the Early Retiree Reinsurance HealthPartners Disease and Case Management programs are targeted to those who have been identified with a

More information

Return to independent living Self manage breathing techniques, secretion clearance Recognize early symptoms of COPD exacerbation

Return to independent living Self manage breathing techniques, secretion clearance Recognize early symptoms of COPD exacerbation CLINICAL PATHWAY Chronic Obstructive Pulmonary Disease Exacerbation (COPD-E) Civic General Clinical Frailty Scale (At baseline, at least 2 weeks before hospitalization) Init. Diagram Frailty Scale Description

More information

Provider Information Guide Complex Care and Condition Care Overview

Provider Information Guide Complex Care and Condition Care Overview Complex and Overview Introduction Complex and are essential components of Passport Health Plan s (Passport) Coordination services, which are used to support the practitioner-patient relationship and plan

More information

Quality Standards. Patient Reference Guide. Chronic Obstructive Pulmonary Disease Care in the Community for Adults. November 2017

Quality Standards. Patient Reference Guide. Chronic Obstructive Pulmonary Disease Care in the Community for Adults. November 2017 Quality Standards Patient Reference Guide Chronic Obstructive Pulmonary Disease Care in the Community for Adults November 2017 Quality standards outline what high-quality care looks like. They focus on

More information

Redefining Care for Seniors and the Chronically Ill. Gary German President & CEO. New York, NY

Redefining Care for Seniors and the Chronically Ill. Gary German President & CEO. New York, NY Redefining Care for Seniors and the Chronically Ill Gary German President & CEO New York, NY www.nonnatech.com @nonnatech garygerman@nonnatech.com Demographic Trends The world s senior population will

More information

ALZIRA RIBERA SALUD. How the Alzira model for integrated care achieves the best outcomes for it s citizens

ALZIRA RIBERA SALUD. How the Alzira model for integrated care achieves the best outcomes for it s citizens ALZIRA RIBERA SALUD How the Alzira model for integrated care achieves the best outcomes for it s citizens What is the Alzira Model? A model of Integrated Care that started its life in 1993 when a new form

More information

EarlySense InSight. Integrating Acute and Community Care

EarlySense InSight. Integrating Acute and Community Care EarlySense InSight Integrating Acute and Community Care Helps Comply with CQC Standards Timely Discharge from Hospital Reduces Bed Blocking Reduces Agency Staffing Costs Provides Early Warnings of Deterioration

More information

Partner with Health Services Advisory Group

Partner with Health Services Advisory Group Partner with Health Services Advisory Group Bonnie Hollopeter, LPN, CPHQ, CPEHR Health Services Advisory Group (HSAG) Quality Improvement Lead Rosalie McGinnis, MS, RN HSAG Quality Improvement Lead November

More information

Pain: Facility Assessment Checklists

Pain: Facility Assessment Checklists Pain: Facility Assessment Checklists This is a series of self-assessment checklists for nursing home staff to use to assess processes related to pain management in the facility, in order to identify areas

More information

Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs)

Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs) Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs) Referral Review referrals to determine if care needs can be met in your facility by: Triaging

More information

Maternity Management. The best part? These are available to you at no additional cost. Intro

Maternity Management. The best part? These are available to you at no additional cost. Intro Telligen provides the following services for Connecticut Carpenters members to help you better manage your health and enjoy a good quality of life. The programs include both Maternity Management and Condition

More information

CLINICAL PROTOCOL National Early Warning Score (NEWS) Observation Chart

CLINICAL PROTOCOL National Early Warning Score (NEWS) Observation Chart CLINICAL PROTOCOL National Early Warning Score (NEWS) Observation Chart November 2014 1 Document Profile Type i.e. Strategy, Policy, Procedure, Guideline, Protocol Title Category i.e. organisational, clinical,

More information

EVOLENT HEALTH, LLC. Asthma Program Description 2018

EVOLENT HEALTH, LLC. Asthma Program Description 2018 EVOLENT HEALTH, LLC Asthma Program Description 2018 1 Evolent Health Asthma Program Description 2018 Table of Contents Section Page Number I. Introduction... 3 II. Program Scope... 3 III. Program Goals...

More information

Improving patient outcomes & health economics through connected health innovation

Improving patient outcomes & health economics through connected health innovation Improving patient outcomes & health economics through connected health innovation Session 103, February 21, 2017 Jeroen Tas, Chief Innovation & Strategy Officer, Philips Dr. Kevin Dellsperger, MD, PhD,

More information

Emergency Department Visits After Inpatient Discharge in Massachusetts: Applying Insights from Data to Inform Improvement.

Emergency Department Visits After Inpatient Discharge in Massachusetts: Applying Insights from Data to Inform Improvement. Emergency Department Visits After Inpatient Discharge in Massachusetts: Applying Insights from Data to Inform Improvement November 15, 2017 Today Introductory Remarks Patricia M. Noga, PhD, RN, FAAN, Vice

More information

The impact of technology: innovation to help patients Patient experience as innovation driver in healthcare technologies

The impact of technology: innovation to help patients Patient experience as innovation driver in healthcare technologies The impact of technology: innovation to help patients Patient experience as innovation driver in healthcare technologies Felip MIRALLES Manager Unit ehealth 21/09/2016 innovation for the industry 2 Eurecat

More information

Smarter Healthcare: An Industry Perspective. Mary Singer Director, Healthcare Strategic Services

Smarter Healthcare: An Industry Perspective. Mary Singer Director, Healthcare Strategic Services Smarter Healthcare: An Industry Perspective Mary Singer Director, Healthcare Strategic Services 1 The healthcare industry is facing challenges and opportunities Empowered consumers expect better value,

More information

COPD Management in the community

COPD Management in the community COPD Management in the community Anne Jones Independent Respiratory Nurse Consultant RN,BSc(Hons),PGDip(RespMed)/MA Content of session Will consider the impact of COPD COPD Strategy recommendations and

More information

Transitional Care Clinic and post-discharge calls boost patient-centered care effectiveness and cost savings.

Transitional Care Clinic and post-discharge calls boost patient-centered care effectiveness and cost savings. CASE STUDY Transitional Care Clinic and post-discharge calls boost patient-centered care effectiveness and cost savings. OUR WORK WITH Via Christi Health nrchealth.com CASE STUDY Overview With its long-standing

More information

Congestive Heart Failure

Congestive Heart Failure TM Nightingale Congestive Heart Failure Do you or someone you know have any of the following symptoms? 1. Shortness of breath (dyspnea) when you exert yourself or when you lie down 2. Swelling in your

More information

NAVIGATING COPD CARE INSIDE THIS ISSUE WHAT IS COPD? SUMMER 2017

NAVIGATING COPD CARE INSIDE THIS ISSUE WHAT IS COPD? SUMMER 2017 SUMMER 2017 Respiratory Health Association s newsletter for people living with Chronic Obstructive Pulmonary Disease (COPD), their families, and caregivers INSIDE THIS ISSUE 1 Navigating COPD Care 2 RHA

More information

Tunstall telehealth solutions

Tunstall telehealth solutions solutions sheet Tunstall telehealth solutions The combination of Tunstall RTX3370 and RTX3371 telehealth monitors and CSO/Telehealth TM software provides an extremely well designed and flexible solution

More information

Digitizing healthcare Digital Innovation Forum Henk van Houten Chief Technology Officer, Philips

Digitizing healthcare Digital Innovation Forum Henk van Houten Chief Technology Officer, Philips Digitizing healthcare Digital Innovation Forum 2017 Henk van Houten Chief Technology Officer, Philips Digitization is transforming every industry The digital revolution: how photography evolved Mechanization

More information

Improving Patient Surveillance: Instituting a Respiratory Risk Screening Tool

Improving Patient Surveillance: Instituting a Respiratory Risk Screening Tool Improving Patient Surveillance: Instituting a Respiratory Risk Screening Tool Sandra Maddux, RN, MSN, CNS-BC, Michelle Giffin, RN, BSN, & Patti Leglar, RN-C, BSN Purpose To share an evidence-based protocol

More information

For fully insured groups of 100 or more eligible employees. HealthyOutcomes. A fully-integrated health management solution that works for you

For fully insured groups of 100 or more eligible employees. HealthyOutcomes. A fully-integrated health management solution that works for you For fully insured groups of 100 or more eligible employees HealthyOutcomes wellness case management condition care maternity A fully-integrated health management solution that works for you HealthyOutcomes

More information

Stage 2 GP longitudinal placement learning outcomes

Stage 2 GP longitudinal placement learning outcomes Faculty of Life Sciences and Medicine Department of Primary Care & Public Health Sciences Stage 2 GP longitudinal placement learning outcomes Description This block focuses on how people and their health

More information

Hot Spotter Report User Guide

Hot Spotter Report User Guide PATIENT-CENTERED CARE Hot Spotter Report User Guide Overview The Hot Spotter Report is designed to give providers and care team members a heads up when their attributed patients appear to be at risk for

More information

The Promise of Care Coordination: Models That Decrease Hospitalizations and Improve Outcomes for Beneficiaries with Chronic Illnesses

The Promise of Care Coordination: Models That Decrease Hospitalizations and Improve Outcomes for Beneficiaries with Chronic Illnesses The Promise of Care Coordination: Models That Decrease Hospitalizations and Improve Outcomes for Beneficiaries with Chronic Illnesses August 5, 2009 Center for Health Care Strategies Webinar Randall Brown,

More information

Care Transitions. Objectives. An Overview of Care Transitions Efforts in Arkansas

Care Transitions. Objectives. An Overview of Care Transitions Efforts in Arkansas An Overview of Care Transitions Efforts in Arkansas June 6, 2013 Christi Quarles Smith, PharmD Manager, Quality Programs Care Transitions Project Lead Arkansas Foundation for Medical Care THIS MATERIAL

More information

Policy & Providers. for Managing Chronic Care Patients. Mary Alexander Strategic Alliances Director - Home Instead, Inc. Kelly Funk.

Policy & Providers. for Managing Chronic Care Patients. Mary Alexander Strategic Alliances Director - Home Instead, Inc. Kelly Funk. Policy & Providers Lessons From The Health Care Arena for Managing Chronic Care Patients Producer: Bob Bua President - CareScout Panel: Peter Sosnow VP Corporate Development - Humana / SeniorBridge Mary

More information

Alberta Breathes: Proposed Standards for Respiratory Health of Albertans

Alberta Breathes: Proposed Standards for Respiratory Health of Albertans Alberta Breathes: Proposed Standards for Respiratory Health of Albertans The concept of Alberta Breathes and these standards was developed in consultation with over 150 health professionals and stakeholders

More information

Home Health. Improving Patient Outcomes & Reducing Readmissions. Home Health: Improving Outcomes & Reducing Readmissions

Home Health. Improving Patient Outcomes & Reducing Readmissions. Home Health: Improving Outcomes & Reducing Readmissions Home Health Improving Patient Outcomes & Reducing Readmissions Home Health: Improving Outcomes & Reducing Readmissions Benefits of Home Health Care Scientific evidence proves people heal more quickly,

More information

Jumpstarting population health management

Jumpstarting population health management Jumpstarting population health management Issue Brief April 2016 kpmg.com Table of contents Taking small, tangible steps towards PHM for scalable achievements 2 The power of PHM: Five steps 3 Case study

More information

Powys Teaching Health Board. Respiratory Delivery Plan

Powys Teaching Health Board. Respiratory Delivery Plan Powys Teaching Health Board Respiratory Delivery Plan 2016-17 CONTENTS 1. BACKGROUD AND CONTEXT 1.1 The Vision 1.2 The Drivers 1.3 What do we want to achieve? 2. ORGANISATIONAL PROFILE 2.1 Overview 3.

More information

The Future of Home Health is Here

The Future of Home Health is Here The Future of Home Health is Here How Home Health Agencies Can Bridge the Care Gap for ACOs and Hospital Networks The Future of Home Health is Here How Home Health Agencies Can Bridge the Care Gap for

More information

Breathing Easy: A Case Study on Asthma Prevention

Breathing Easy: A Case Study on Asthma Prevention Breathing Easy: A Case Study on Asthma Prevention Bob Morrow, MD, MBA Market President, Houston & Southeast Texas Blue Cross and Blue Shield of Texas @DrBobMorrow A Division of Health Care Service Corporation,

More information

Care Management Framework:

Care Management Framework: WHITE PAPER Care Management Framework: The Critical Path to Implementing a Care Management Strategy An Encore Point of View Randy Thomas, FHIMSS, Barbara Doyle, MSN, RN, January 2017 Tina Burbine, MBA,

More information

Effective Care Transitions to Reduce Hospital Readmissions

Effective Care Transitions to Reduce Hospital Readmissions Effective Care Transitions to Reduce Hospital Readmissions November 8, 2017 Anchorage, Alaska The vicious cycle of readmissions What is Care Transitions? The movement of patients across settings, referred

More information

Mental Health Engagement Network (MHEN): Facilitating Mobile Patient Centric Care

Mental Health Engagement Network (MHEN): Facilitating Mobile Patient Centric Care Mental Health Engagement Network (MHEN): Facilitating Mobile Patient Centric Care Presentation Outline MHEN Project Context MHEN Project Results and Findings Lessons Learned and Implications Sandbox Mental

More information

TEXAS CHILDREN S EMPLOYEE MEDICAL CLINIC

TEXAS CHILDREN S EMPLOYEE MEDICAL CLINIC DEPARTMENT NAME TEXAS CHILDREN S EMPLOYEE MEDICAL CLINIC THE NEW VALUE IN EMPLOYER HEALTH CENTERS & SERVICES Julie Griffith, Manager, Employee Medical Clinic and Wellness Houston Business Coalition on

More information

WebEx Quick Reference

WebEx Quick Reference IHI Expedition: Effective Implementation of Heart Failure Core Processes Peg Bradke, RN, MA, Faculty Christine McMullan, MPA, Director December 15, 2011 These presenters have nothing to disclose WebEx

More information

Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP)

Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP) Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP) Medicare Drug and Health Plan Contract Administration Group Donna Williamson & Brandy Alston December 6, 2016

More information

COPD National Action Plan. COPD.nih.gov

COPD National Action Plan. COPD.nih.gov COPD National Action Plan COPD.nih.gov Kyle Mahan, MSM, RRT Vice President of KSRC DCE for Jefferson Community and Technical College RCP 14-ish Years AZ native. I am not from Kentucky, but I got here as

More information

Independent investigation into the death of Mr Norman Saunders a prisoner at HMP Rye Hill on 5 January 2017

Independent investigation into the death of Mr Norman Saunders a prisoner at HMP Rye Hill on 5 January 2017 Independent investigation into the death of Mr Norman Saunders a prisoner at HMP Rye Hill on 5 January 2017 Crown copyright 2015 This publication is licensed under the terms of the Open Government Licence

More information

Promoting Interoperability Measures

Promoting Interoperability Measures Promoting Interoperability Measures Previously known as Advancing Care Information for 2017 and Meaningful Use from 2011-2016 Participants: In 2018, promoting interoperability measure reporting (PI) is

More information

WPS Integrated Care Management Improving health, one member at a time

WPS Integrated Care Management Improving health, one member at a time WPS Integrated Care Management Improving health, one member at a time Integrated Care Management supports and promotes member health Looking for more from your group health insurance for your employees?

More information

7/18/2017. Malinda Peeples MS, RN, CDE VP Clinical Advocacy WellDoc Columbia, MD. Disclosure to Participants

7/18/2017. Malinda Peeples MS, RN, CDE VP Clinical Advocacy WellDoc Columbia, MD. Disclosure to Participants Malinda Peeples MS, RN, CDE VP Clinical Advocacy WellDoc Columbia, MD Janice MacLeod MA, RDN, LDN, CDE Director Clinical Innovation WellDoc Columbia, MD Disclosure to Participants Notice of Requirements

More information

THE ALPHABET SOUP OF MEDICAL PAYMENTS: WHAT IS MACRA, VBP AND MORE! Lisa Scheppers MD FACP Margo Ferguson MT MSOM

THE ALPHABET SOUP OF MEDICAL PAYMENTS: WHAT IS MACRA, VBP AND MORE! Lisa Scheppers MD FACP Margo Ferguson MT MSOM THE ALPHABET SOUP OF MEDICAL PAYMENTS: WHAT IS MACRA, VBP AND MORE! Lisa Scheppers MD FACP Margo Ferguson MT MSOM THE REASON FOR CHANGE VOLUME TO VALUE Fee-for-service PAYMENT Bundled, Shared Patient FOCUS

More information

Community Counseling Centers, Inc. & North Country Health Care

Community Counseling Centers, Inc. & North Country Health Care Community Counseling Centers, Inc. & North Country Health Care Holbrook & Show Low Navajo County Communities 9/28/11 The CCC multi-faceted approach to an integrated health program with North Country Health

More information

*Your Name *Nursing Facility. radiation therapy. SECTION 2: Acute Change in Condition and Factors that Contributed to the Transfer

*Your Name *Nursing Facility. radiation therapy. SECTION 2: Acute Change in Condition and Factors that Contributed to the Transfer Gaining information about resident transfers is an important goal of the OPTIMISTC project. CMS also requires us to report these data. This form is where data relating to long stay transfers are to be

More information

Using EHRs and Case Management to Improve Patient Care and Population Health

Using EHRs and Case Management to Improve Patient Care and Population Health Using EHRs and Case Management to Improve Patient Care and Population Health Session #211, February 22, 2017 Thomas Schiller, MD and Jennifer Kuroda, SwedishAmerican Health System A Division of UW 1 Speaker

More information

Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery

Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Betty Shephard Lead VP, Care Management HealthCare Partners National Health Policy Forum October 19, 2012 HCP

More information

Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015

Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015 Nevada County Health and Human Services FY14 Rural Health Care Services Outreach Grant Project Evaluation Report June 30, 2015 I. Executive Summary The vision of Nevada County Behavioral Health (NCBH)

More information

Effective Care Coordination

Effective Care Coordination Effective Care Coordination Coordinating Care for Adults with Multiple Chronic Illnesses: Searching for the Holy Grail National Health Policy Forum March 27, 2009 Randall Brown, Ph.D. Goals of Presentation

More information

Scaling Remote Patient Monitoring to over 60,000 Patients, Where One Device Does Not Fit All

Scaling Remote Patient Monitoring to over 60,000 Patients, Where One Device Does Not Fit All Scaling Remote Patient Monitoring to over 60,000 Patients, Where One Device Does Not Fit All Don t Move The Patient, Move The Data Presented by: RALPH HAMZO SAVVY PATIENTS: Technology means independence

More information

Consumer ehealth Affinity Group

Consumer ehealth Affinity Group Consumer ehealth Affinity Group Embracing Barriers in the Delivery of IVR Technology for Older, Chronically ll Patients Jeremy Rich HealthCare Partners Institute and HealthCare Partners Medical Group Janelle

More information

Remote Telemonitoring for Chronic Respiratory Illness Gains Ground in Portugal

Remote Telemonitoring for Chronic Respiratory Illness Gains Ground in Portugal Remote Telemonitoring for Chronic Respiratory Illness Gains Ground in Portugal The innovation and creativity of the service providers, the enthusiasm of the clinicians, and the openness of patients to

More information

A Model of Urgent and Emergency Mental Health Care

A Model of Urgent and Emergency Mental Health Care A Model of Urgent and Emergency Mental Health Care Transforming Urgent Access to Mental Health Services across 7 days & Interfacing with the wider system Kate Chartres, Nurse Consultant, Psychiatric Liaison,

More information

Recognising a Deteriorating Patient. Study guide

Recognising a Deteriorating Patient. Study guide Recognising a Deteriorating Patient Study guide Recognising a deteriorating patient Recognising and responding to clinical deterioration Background Clinical deterioration can occur at any time in a patient

More information

Using Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity

Using Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity 1 The Documentation Faces of Medical Necessity ç3 Setting the Stage

More information

Kidney Health Australia

Kidney Health Australia Victoria 125 Cecil Street South Melbourne VIC 3205 GPO Box 9993 Melbourne VIC 3001 www.kidney.org.au vic@kidney.org.au Telephone 03 9674 4300 Facsimile 03 9686 7289 Submission to the Primary Health Care

More information

The TeleHealth Model THE TELEHEALTH SOLUTION

The TeleHealth Model THE TELEHEALTH SOLUTION The Model 1 CareCycle Solutions The Solution Calendar Year 2011 Data Company Overview CareCycle Solutions (CCS) specializes in managing the needs of chronically ill patients through the use of Interventional

More information

INTEGRATED CARE SERVICE AND OUTCOMES

INTEGRATED CARE SERVICE AND OUTCOMES DR. HADAS LEWY INTEGRATED CARE SERVICE AND OUTCOMES 10/8/2014 1 Maccabi Healthcare Services Second largest and fastest growing HMO in Israel ( 25% of Market) Non-profit mutual Recognized health fund -

More information

Improving Care Transitions

Improving Care Transitions Care Transitions Collaborative Improving Care Transitions Laura Cole, RN South Carolina Partnership for Health SPECIFIC QUESTIONS WE WILL EXPLORE TODAY: Why the focus on care transitions? What strategies

More information

Saint Agnes Hospital. Pharmacist utilization of the LACE tool to prevent hospital readmissions. Program/Project Description, including Goals:

Saint Agnes Hospital. Pharmacist utilization of the LACE tool to prevent hospital readmissions. Program/Project Description, including Goals: Saint Agnes Hospital Pharmacist utilization of the LACE tool to prevent hospital readmissions Program/Project Description, including Goals: Safe transitions of care have always been a frontline patient

More information

Harnessing Disruptive Technology in Healthcare

Harnessing Disruptive Technology in Healthcare Harnessing Disruptive Technology in Healthcare Case study in home healthcare point-of-care testing Dr. Malcolm Luker, VP & General Manager, Philips Home Clinical Monitoring The King s Fund Seminar April

More information

Using Data for Proactive Patient Population Management

Using Data for Proactive Patient Population Management Using Data for Proactive Patient Population Management Kate Lichtenberg, DO, MPH, FAAFP October 16, 2013 Topics Review population based care Understand the use of registries Harnessing the power of EHRs

More information

The STAAR Initiative

The STAAR Initiative The STAAR Initiative Getting Started Kit for the STAAR Collaborative September 2010 Institute for Healthcare Improvement, 2010 Page 1 Table of Contents STAAR Collaborative Charter... 3 Statement of Need...

More information

Hendrick Medical Center. Community Health Needs Assessment Implementation Plan

Hendrick Medical Center. Community Health Needs Assessment Implementation Plan Hendrick Medical Center Community Health Needs Assessment Implementation Plan - 2014-2016 Hendrick Medical Center Community Health Needs Assessment Implementation Plan - 2014-2016 Overview: Hendrick Medical

More information

G: Surgical. College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 67

G: Surgical. College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 67 G: Surgical College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 67 Major Competency Area: G Surgical Competency: G-1 Surgical Nursing Date: June 1, 2015 G-1-1 G-1-2 G-1-3

More information

Improvement Activities for ACI Bonus Measures

Improvement Activities for ACI Bonus Measures Improvement Activity Performance Category Subcategory Expanded Practice Activity Name Activity Improvement Activity Performance Category Weight Provide 24/7 access to eligible clinicians or groups, who

More information

UPMC Health Plan. Value Based Insurance Design (VBID) Spark Your Health

UPMC Health Plan. Value Based Insurance Design (VBID) Spark Your Health UPMC Health Plan Value Based Insurance Design (VBID) Spark Your Health Value Based Insurance Design (VBID) Spark Your Health Medicare Advantage Summit April 6, 2017 Helene Weinraub 1 The statements contained

More information