Welcome to the New England QIN-QIO Care Transitions Webinar!
|
|
- Scot Bridges
- 5 years ago
- Views:
Transcription
1 Welcome to the New England QIN-QIO Care Transitions Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: Passcode: Slides are available for 1
2 Lessons Learned from a Southwestern Vermont Transitional Care Program Speakers: Gail Colgan, RN, BSN ~ Vermont Care Transitions Lead, New England QIN-QIO Barbara Richardson MS, RN-BC, CCRN ~ Clinical Nurse Specialist / Transitional Care Nurse, Southwestern Vermont Medical Center Stephanie Baker, MHA ~ Massachusetts Care Transitions Program Coordinator, New England QIN-QIO March 23, :00am 12:00pm This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy CMSQINC
3 Chat in Introduce yourself please type in your name, role, organization and state 3
4 Today s Speakers Gail Colgan, RN, BSN Vermont Care Transitions Lead New England QIN-QIO Barbara Richardson MS, RN-BC, CCRN Clinical Nurse Specialist Transitional Care Nurse Southwestern Vermont Medical Center Stephanie Baker, MHA Massachusetts Care Transitions Program Coordinator New England QIN-QIO 4
5 SVMCs Transitional Care Program Nurses as Architects of Integrated Healthcare Delivery Barbara Richardson MS, RN-BC, CCRN Clinical Nurse Specialist Transitional Care Nurse 5
6 SVHC is a Health System part of the Vermont Care Organization (a statewide ACO) 99 bed, rural hospital 150 bed, long term care/rehab Medicare dependent High Medicaid population Vermont = 2nd oldest state Medical Home 90% NCQA certified Health Service Area Bennington population 35,000 Total Service Area 75, Patient Centered Medical Homes Independent and Employed Practices 6
7 Healthcare Reform 7
8 Silos of Care 8
9 Future of Healthcare 9
10 Transitional Care Model Range of time limited services that compliment primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and cross settings. 10
11 Clinical Nurse Specialist (CNS) Role Redesign Acute Care Based Population Based Focused on Inpatient Care Delivery Focus on the Continuum of Care High Degree of Control Person Centric 11
12 VNA / Home Health & Hospice Case Management Sub Acute and Rehab Nursing Home Primary Care Office 12
13 Who really Controls Outcomes? The majority of health care occurs at the low-acuity end of the scale, where outcomes are controlled not by physicians or the system but by the everyday choices of individuals and families. The largest opportunity clinical staff have to influence health outcomes is to influence choices by partnering over time. 100 Patient/Family Control 0 Low Acuity The System High Ref: Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management. January
14 Challenges Turf issues Duplication of services Why a masters prepared nurse? 14
15 Patient is introduced to the TCN during a scheduled visit. TCN introduces the role of the TCN as an extension of the PCP office to assist with communication, education and support Patient Transitions to Subacute Care Primary Care Provider (PCP) Patient Transitions to Hospital TCN visits patient in subacute care within hours of notification TCN coordinates with the facility to prevent duplication of efforts and ensure a smooth transition. TCN visits patient as needed Patient Transitions Home TCN visit patient in hospital within hours of notification. TCN partners with hospital care team to provide additional information that may assist with care. TCN visits patient regularly. For patients discharged with home health support, TCN coordinates with the home health agency to prevent duplication of efforts and ensure a smooth transition. TCN visits patient within hours of notification to review discharge plan, assist with medication reconciliation, plan referral appointments, and provide additional teaching to supplement patient teaching down in institutional setting. 15
16 Village Primary Care 1 st partnership with primary care Focus on complex chronically ill, high risk patients Follow across continuum Disease self-management education Medication review and selfmanagement Evaluate social needs and connect with resources 16
17 IDR Redeployment of Hospital Resources Diabetes Educator 17
18 Lack of insurance/coverage Inability to pay for basic necessities (ex. medications) Homeless/safe housing Psychosocial support (connect with community resources) Substance abuse or mental illness Advance Directives Integrated Social Work 18
19 Clinical Pharmacists 19
20 Community Care Team 20
21 Hemoglobin A1C Level Diabetic Educators: Hemoglobin A1C Reduction Program Wide: Pre & Post Intervention % Reduction in average Hemoglobin A1C post intervention 257 total patients seen by educators 3 practice sites engaged Program Totals 7.16 Average Initial A1C Average Follow-Up A1C 194 patients with pre & post intervention Hemoglobin A1C s for comparison. N = 194 patients 21
22 Pulmonary Rehabilitation Goal: Improve quality of life, ability to manage illness & health status, and restore patient to highest functional ability 71% of participants completed the program Individuals who stayed in the Maintenance Program had a 0% readmission rate for the 3 months after graduation. January 2015 December 2016 N = 77 participants 22
23 Measuring Improvements 63.6% Improvement with dyspnea 67.3% 65.5% 67.3% Improved quality of life Improvement in functional ability to walk 10 meters Improvement in functional ability to walk for 6 minutes 23
24 INTERACT: Reducing LTC Readmissions COLST (Clinician Orders of Life Sustaining Treatment) Auditing & Completion Scheduled procedures & imaging Transfusions, x-rays, labs Hospice or palliative care intervention when appropriate The project described was supported by Funding Opportunity Number CMS-1G from the U.S. Department of 24 Health & Human Services, Centers for Medicare & Medicaid Services.
25 Interdisciplinary Rounds Transitional Care Nurses(TCN) Dieticians VNA Case Management Social Worker Respiratory Therapy Physical Therapy/Occupational Therapy Clinical Nurse Hospitalist Clinical Coordinator 48% of TCN Referrals 25
26 Program Totals: ED Visit Reduction N = 789 patients (August 2013 January 2017) 26
27 TCN Intervention: Reducing Inpatient & Observation Admissions 27
28 Program Totals: Inpatient & Observation Visit Reduction N = 789 patients (August 2013 January 2017) 28
29 Fresh Eyes can see clearly.. Standardized patient education Community Care Team ED Care Plan Medication Reconciliation Community Social Worker Integrated Diabetes Education 29
30 20% Clinical Care 80% Health Behaviors Physical Environment Social & Economic Factors 30
31 Food Insecurity Grateful Heart Project Healthcare Shares Meals on Wheels voucher Leftovers to Food Pantry Summer Meal Program VT Food Bank drop site Campus Garden (food donated to Transitional Care Program) 31
32 32
33 The Keys to Success Culture Communication Creativity 33
34 Partnering Magic Be Patient Educate Embrace Leverage Take Risks Nurse Driven Major Obstacles Housing Food Transportation Health literacy Polypharmacy Engage patients in decisions 34
35 Thank You Barbara Richardson (802)
36 Key Takeaways Evaluate the true needs in your community If you are only focused on clinical aspects of transitions you are missing the full picture Identify gaps Partners can make all the difference Track progress and share findings 36
37 We Want to Hear from You We will open the phone lines so you can pose your questions and share own experiences Review questions, comments, observations from chat 37
38 Interested in Learning More & Connecting with Others - Contact your QIO Care Transitions State Lead Connecticut Shelia Eckenrode seckenrode@qualidigm.org Maine Maureen Leary mleary@healthcentricadvisors.org Massachusetts Dawn Hobill dhobill@healthcentricadvisors.org New Hampshire Tim Boyd tboyd@qualidigm.org Rhode Island Kathy Calandra kcalandra@healthcentricadvisors.org Vermont Gail Colgan gcolgan@qualidigm.org 38
39 Antibiotic Stewardship Upcoming Learning Events Community-Based Approach March 28 th : Lessons Learned - One Provider's Community-Based Antibiotic Stewardship Experience Focus in Long-Term Care February 28 th : Introduction to Antimicrobial Stewardship in Long Term Care: What is Antimicrobial Stewardship and Why is it Important? March 28 th : Antimicrobial Stewardship: Strategies for Implementation April 25 th : Approach to the Patient with Suspected UTI June 1 st : Antibiotic Selection, De-Escalation, and Duration June 27 th : How to Get an A on Your Report Card: Prevention and Management of C. difficile and Other Healthcare Associated Infections July 25 th : Measure Your Success: Monitoring and Tracking Data Learn more, view archived events or register for upcoming session on our event page
40 Connect with the New England QIN-QIO on Social Media! 40
INTERACT Webinar Series
INTERACT Webinar Series Session 4: Communication Tools (Part 1) Stop & Watch & SBAR Quality Improvement: PDSA Cycle May 27, 2015 with presenters: Florence Johnson, MSN, MHA Sheila Eckenrode, BSN, MA, CPHQ
More informationAccountable Community of Health. Billie Lynn Allard MS, RN Administrative Director of Nursing for Community Health & Putnam Medical Group
Accountable Community of Health Billie Lynn Allard MS, RN Administrative Director of Nursing for Community Health & Putnam Medical Group Sout hwester n Vermont Healthcare ME NY VT NH MA SVMC FAST FACTS
More informationWelcome to the New England QIN-QIO Webinar!
Welcome to the New England QIN-QIO Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: 888-895-6448 Passcode: 519-6001 Slides
More informationJourney to a Successful Antibiotic Stewardship Program in a Small Rural Healthcare Facility
Journey to a Successful Antibiotic Stewardship Program in a Small Rural Healthcare Facility Please make sure to dial into the phone line: 888-895-6448 Passcode: 519-6001 This material was prepared by the
More informationCDI Preventing and Managing Clostridium Difficile - A Provider's Perspective
Thank You for Joining! CDI Preventing and Managing Clostridium Difficile - A Provider's Perspective New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888)
More informationWEBINAR: Making the Numbers Count-Using Your Pharmacy Data to Support Antibiotic Stewardship and Infection Control
WEBINAR: Making the Numbers Count-Using Your Pharmacy Data to Support Antibiotic Stewardship and Infection Control New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In
More informationWelcome to the New England QIN-QIO Medication Safety Webinar!
Welcome to the New England QIN-QIO Medication Safety Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: 888-895-6448 Passcode:
More informationCDI Initiative: Accessing your Data Reports from NHSN
Thank You for Joining! CDI Initiative: Accessing your Data Reports from NHSN New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888) 895-6448 Access Code:
More informationNew England Home Health Collaborative
New England Home Health Collaborative The Use of Aspirin in Heart Disease Kathryn D. Roby, M.Ed., M.S., CHCE, CHAP QIN-QIO Home Health Consultant April 8, 2015 The New England Quality Innovation Network
More informationModule 6: End-of-Life Care in the Skilled Nursing Center
Module 6: End-of-Life Care in the Skilled Nursing Center Lesson 2 NE QIN-QIO & Good Shepherd Community Care This material was prepared by the New England Quality Innovation Network-Quality Improvement
More informationThank You for Joining!
Thank You for Joining! C. difficile Event Reporting for NHSN Webinar Will Begin Shortly. Call-In Number: (888) 895-6448 Access Code: 1272870 C. difficile Event Reporting for NHSN March 29, 2017 Janet Robinson
More informationCare Management in the Patient Centered Medical Home. Self Study Module
Care Management in the Patient Centered Medical Home Self Study Module Objectives Describe the goals of care management Identify elements of successful care management Recognize the 5 step Care Management
More informationThe Price is Right and the Choice is Wise: Antibiotic Stewardship
The Price is Right and the Choice is Wise: Antibiotic Stewardship Amanda Gagnon, RN, BSN New England QIN-QIO Kellie Slate Vitcavage, MS Maine Quality Counts September 29, 2017 Your Presenters Amanda Gagnon,
More informationInstitutional Handbook of Operating Procedures Policy
Section: Clinical Policies Institutional Handbook of Operating Procedures Policy 09.01.13 Responsible Vice President: EVP and CEO Health System Subject: Admission, Discharge, and Transfer Responsible Entity:
More informationCollaborative Approach to Improving Care and Reducing Readmissions
Collaborative Approach to Improving Care and Reducing Readmissions Edna Clifton, MBA, BSN, RN Associate Director, Care Coordination Health Services Advisory Group (HSAG) March 14, 2017 Presentation Objectives
More informationCollaborative Approach to Improving Care and Reducing Readmissions
Collaborative Approach to Improving Care and Reducing Readmissions Edna Clifton, MBA, BSN, RN Associate Director, Care Coordination Health Services Advisory Group (HSAG) March 14, 2017 Presentation Objectives
More informationNew England Home Health Collaborative
New England Home Health Collaborative Clinical Collaboration: Partnering with Physicians Kathryn D. Roby, M.Ed., M.S., CHCE, CHAP QIN-QIO Home Health Consultant May 13, 2015 The New England Quality Innovation
More informationCoordinated Outreach Achieving Community Health (COACH) for Heart Failure Learning Objectives
Coordinated Outreach Achieving Community Health (COACH) for Heart Failure Session C917 October 9, 2015 Colleen Cameron, DNP, FNP-BC Rochelle Eggleton, MBA, BS, RN Susan Spink, BSN, RN-BC Linda Griffin,
More informationBundled Payments to Align Providers and Increase Value to Patients
Bundled Payments to Align Providers and Increase Value to Patients Stephanie Calcasola, MSN, RN-BC Director of Quality and Medical Management Baystate Health Baystate Medical Center Baystate Health Is
More informationPartner 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 informationSafe Transitions Best Practice Measures for
Safe Transitions Best Practice Measures for Nursing Homes Setting-specific process measures focused on cross-setting communication and patient activation, supporting safe patient care across the continuum
More informationRehospitalizations: How Do You Measure Up?
Rehospitalizations: How Do You Measure Up? National Nursing Home Quality Care Collaborative (NNHQCC) Health Services Advisory Group (HSAG) Today s Objectives Recognize the role skilled nursing facilities
More informationWhen Medications Hurt: Preventing Adverse Drug Events. Plan for today.
When Medications Hurt: Preventing Adverse Drug Events Rachel Crowe, MPH, BSN, RN Danielle Watford, CMQ OE, MS Patient Safety Academy September 8, 2016 This material was prepared by Healthcentric Advisors,
More informationThank You for Joining!
Thank You for Joining! Learning Series 2: Improving Dementia Care New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888) 895-6448 Access Code: 5196001 2/10/2016
More informationUpcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know
Upcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know Aimee Ford, QI Consultant, Qualis Health June 8, 2016 Qualis Health A leading national population health management
More informationStroke Patients: Transition From Hospital to Home
Stroke Patients: Transition From Hospital to Home Lauren Pond RN CCM Administrative Director, Case Management Jennifer Thiesen RNP CCRN Director, Care Transitions Presenter Disclosure Information Lauren
More informationTRANSITIONS of CARE. Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine
TRANSITIONS of CARE Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine 5-15-15 Objectives At the conclusion of the presentation, the participant will be able to: 1. Improve
More informationMonarch HealthCare, a Medical Group, Inc.
Monarch HealthCare, a Medical Group, Inc. Accountable Care in the Independent Practice Model June 7, 2010 Jay J. Cohen, MD, MBA President/Chairman Monarch HealthCare Monarch HealthCare, a Medical Group,
More informationPalliative Care in the Skilled Nursing Facility Setting: Opportunities Abound
Palliative Care in the Skilled Nursing Facility Setting: Opportunities Abound Date: February 1, 2017 Jennifer Judson, Project Lead: Palliative Care Jennifer Hodge, HIIN Quality Specialist 1/18/2017 2 Objectives
More informationTest bank PowerPoint slides for each chapter Instructor guides for each chapter (with answers for discussion questions and case studies)
This is a sample of the instructor materials for Dimensions of Long-Term Care Management: An Introduction, second edition, edited by Mary Helen McSweeney-Feld, Carol Molinari, and Reid Oetjen. The complete
More informationLet s All Pull Together:
Let s All Pull Together: Effective Partnering Across Quality Networks at the Community Level Sven Berg, MD Chief Medical Officer, West Virginia Medical Institute Keith T. Kanel, MD Chief Medical Officer,
More informationMedical Home as a Platform for Population Health
Medical Home as a Platform for Population Health Population Health Colloquium March 8, 2016 Emily Brower Vice President, Population Health Atrius Health Emily_Brower@atriushealth.org 2016 Atrius Health,
More informationCMS Hospital Discharge Planning Standards 101. Friday, March 21st, 2014
CMS Hospital Discharge Planning Standards 101 Friday, March 21st, 2014 Speaker Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Consulting Board Member
More informationHealthcare Leadership Council: John Perticone Golden Living 3/9/2016
Healthcare Leadership Council: Care Transitions in Post Acute Care John Perticone Golden Living 3/9/2016 Golden Living Profile Golden Living Centers and Communities 296 skilled nursing facilities 15 assisted
More informationWelcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans
Welcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans The presentation will begin momentarily. Please dial in to hear audio: 1-888-670-3525
More informationHOME IS THE HUB. An Initiative to Accelerate Progress to Reduce Readmissions in Virginia Deep Dive: Post-Acute Care Strategies May 17, 2017
HOME IS THE HUB An Initiative to Accelerate Progress to Reduce Readmissions in Virginia Deep Dive: Post-Acute Care Strategies May 17, 2017 HOUSEKEEPING Slides were sent this morning Webinar is being recorded
More informationDisclaimer This webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws.
Disclaimer This webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws. This should not be used as legal advice. Itentive recognizes that
More informationPresenter Disclosure Information
The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 3/1/2013 2010, American Heart Association 1 1 2
More informationSWAN Alerts and Best Practices for Improved Care Coordination
SWAN Alerts and Best Practices for Improved Care Coordination IHIN and SWAN Course Overview Our Goal: To educate healthcare providers in how to manage SWAN alerts for meaningful impact at the point of
More informationPlanning a Course to Population Health Management
Planning a Course to Population Health Management A Complimentary Webinar From healthsystemcio.com Your Line Will Be Silent Until Our Event Begins at 12:00 ET Thank You! Slide Deck: http://goo.gl/1w119j
More informationVNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides
VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE Training Slides 061015 Why Take Action to Prevent Readmissions? Better patient care and patient experience Home
More informationHome Health Infection Prevention Toolkit
Home Health Infection Prevention Toolkit Paula Sitzman, RN, BSN Great Plains Quality Innovation Network Judy Riggert, RN, MS Visiting Nurse Association of the Midlands Map Great Plains Quality Innovation
More informationCore Elements for Antibiotic Stewardship in Nursing Homes
Core Elements for Antibiotic Stewardship in Nursing Homes 1 http://www.cdc.gov/longtermcare/pdfs/coreelements-antibiotic-stewardship.pdf 2 Antibiotic Stewardship A set of commitments and activities designed
More informationEnhancing Specialty and Primary Care Communication May 2016
Enhancing Specialty and Primary Care Communication May 2016 ACO Announcements Reminders: ACO Notifications PECOS-Maintain active enrollment 2016 Patient Prospective Lists Upcoming provider meetings: Annual
More informationCross-Systems Collaboration: Working Together to Identify and Support Children and Youth with Special Health Care Needs
Cross-Systems Collaboration: Working Together to Identify and Support Children and Youth with Special Health Care Needs Tuesday, March 3, 2015 3:30 4:30 pm ET For audio, please listen through your speakers
More informationThank you for joining us!
Thank you for joining us! We will start at 1:00 p.m. CT. You will hear silence until the session begins. Audio Options: Recommended: Audio broadcast using your computer speakers (automatically join the
More informationChronic Disease Management Resources & Services
Chronic Disease Management Resources & Services Michelle Nelson, RN, BSN Director of Ambulatory Services & Chronic Disease Management Gidgett Bates, RN, BSN Manager of Palliative Care, Diabetes Education,
More informationLearning Session 3: CDI Tracer and Assessment Tool
National Nursing Home Quality Care Collaborative (NNHQCC) II and the Clostridium difficile Infection (CDI) Initiative Learning Session 3: CDI Tracer and Assessment Tool Health Services Advisory Group (HSAG)
More informationGenerations Advantage Focus DC (HMO SNP) Diabetes Care Special Needs Plan GENERAL MODEL OF CARE (MOC) TRAINING
Generations Advantage Focus DC (HMO SNP) Diabetes Care Special Needs Plan GENERAL MODEL OF CARE (MOC) TRAINING Through this training you will learn: What is a SNP? What is Martin s Point Generations Advantage
More informationWHEN THINGS ARE CHANGING FAST
The Home Health Challenge PLAN, POSITION, PARTNER Presented by: Tim Ashe MSN, MBA Partner Fazzi Associates, Inc. tashe@fazzi.com WHEN THINGS ARE CHANGING FAST Not Paying Attention to the Changes and Not
More informationGetting Ready for the Maryland Primary Care Program
Getting Ready for the Maryland Primary Care Program Presentation to Maryland Academy of Nutrition and Dietetics March 19, 2018 Maryland Department of Health All-Payer Model: Performance to Date Performance
More informationFlorida Health Care Association 2013 Annual Conference
Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #53 Assess and Educate to Prevent Rehospitalizations Thursday, August 8 10:00 to 11:30 a.m. Regency 1 Upon
More informationKalispell Regional Healthcare Kalispell, Montana Managing the Needs of Medically and Socially Complex Patients or Superutilizers
Kalispell Regional Healthcare Kalispell, Montana Managing the Needs of Medically and Socially Complex Patients or Superutilizers A small number of individuals drive much of the cost in the American health
More informationOMC Strategic Plan Final Draft. Dear Community, Working together to provide excellence in health care.
Dear Community, Working together to provide excellence in health care. This mission statement, established nearly two decades ago, continues to be fulfilled by our employees and medical staff. This mission
More informationPain: 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 informationDecoding the QPP Year 2 Quality Measure Benchmarks and Deciles to Maximize Performance
Decoding the QPP Year 2 Quality Measure Benchmarks and s to Maximize Performance Leila Volinsky, MHA, MSN, RN, PCMH CCE, CPHQ Senior Program Administrator New England Regional Lead Quality Payment Program
More informationPatient Navigator Program
Using Patient Navigators and Education to Improve Post-Acute Transitions Emerging innovators in post-acute care delivery models are finding ways to provide patient-centered, quality care to integrate today
More informationHOME IS THE HUB. An Initiative to Accelerate Progress to Reduce Readmissions in Virginia. Webinar #3 Post-Acute Care Readmissions September 8, 2016
HOME IS THE HUB An Initiative to Accelerate Progress to Reduce Readmissions in Virginia Webinar #3 Post-Acute Care Readmissions September 8, 2016 HOUSEKEEPING Slides were sent this morning Webinar is being
More information2 nd Annual PPS Quality and Patient Safety Conference
2 nd Annual PPS Quality and Patient Safety Conference Jointly Sponsored by MHA and Stratis Health Welcome and Introduction Jennifer Lundblad, PhD, MBA, President & CEO, Stratis Health Healthcare-Centric
More informationReadmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ. A Catholic healthcare ministry serving Ohio and Kentucky
Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ A Catholic healthcare ministry serving Ohio and Kentucky 1 Mission, Values and Promise Our Mission We extend the healing ministry of Jesus by improving
More informationFOR LEADINGAGE POST-ACUTE AND LONG TERM SERVICES AND SUPPORTS
December 2016 MODEL SCORE CARD ELEMENTS FOR LEADINGAGE POST-ACUTE AND LONG TERM SERVICES AND SUPPORTS BACKGROUND The purpose of this scorecard is threefold: 1. To help organize quality measures into internal
More informationMichigan Primary Care Transformation Project. HEDIS, Quality and the Care Manager s Role in Closing Gaps in Care
Michigan Primary Care Transformation Project HEDIS, Quality and the Care Manager s Role in Closing Gaps in Care 7.22.15 Topics for Today s Webinar Healthcare Effectiveness Data and Information Set (HEDIS)
More informationAntimicrobial Stewardship Program in the Nursing Home
Antimicrobial Stewardship Program in the Nursing Home CAHF San Bernardino/Riverside Chapter May 19 th, 2016 Presented by Robert Jackson, Pharm.D. Pharmaceutical Consultant II, Specialist CDPH Licensing
More informationThank you for spending your valuable time with us today. This webinar will be recorded for your convenience.
Kick Off 4/6/2017 Thank you for spending your valuable time with us today. This webinar will be recorded for your convenience. A copy of today s presentation and the webinar recording will be available
More informationACOs: California Style
ACOs: California Style ACO Congress John E. Jenrette, M.D. Chief Executive Officer Sharp Community Medical Group November 2, 2011 California Style California Style A CO California Style California Style
More informationWebinar Instructions. Thank you for joining today, please wait while others sign in.
Webinar Instructions Thank you for joining today, please wait while others sign in. Phone Dial-in: 1-866-740-1260 Access Code: 4796665# Due to the large number of participants, all lines will be muted
More informationPPS Performance and Outcome Measures: Additional Resources
PPS Performance and Outcome Measures: PPS Performance and Outcome Measures: This document includes supplemental resources to the content on PPS Performance and Outcome Measures presented at the December
More informationFebruary 27, Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models
1 February 27, 2014 Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models 2 Having Audio Issues? If you experience any disruptions or other issues
More informationPRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management
PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication
More informationCMS REVISED RULES OF PARTICIPATION
CMS REVISED RULES OF PARTICIPATION Webinar #3 December 1, 2016 Rebecca J. Bartle, RN, MSN, HFA Hoosier Owners and Providers for the Elderly Ref: S&C 17-07-NH (11/9/16) Centers for Medicare and Medicaid
More informationYes, for all plans, see or call for a list of network providers.
Important Questions (Massachusetts ) (New England ) (National ) What is the overall $0.00 Are there other s for specific? Is there an out of pocket limit on my expenses? What is not included in the out
More informationNGA and Center for Health Care Strategies Summit: High Utilizers
Medicaid Chronic Care Initiative: Strategies for High Utilizers NGA and Center for Health Care Strategies Summit: High Utilizers February 12, 2013 Eileen Girling, MPH, RN, CAMS Director, VCCI Department
More informationAn Initiative to Improve Patient Discharge Satisfaction
An Initiative to Improve Patient Discharge Satisfaction Speaker Disclosure Statement Sally Strong, RN, APN-CNS, CNRN, CRRN Clinical Nurse Specialist Marianjoy Rehabilitation Hospital Adjunct Faculty Elmhurst
More informationPost Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator
Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator Janet Tomcavage, RN, MSN VP Health Services, Geisinger Health Plan Danville, PA February 3, 2012 Patient-centered primary care
More informationThe Michigan Primary Care Transformation (MiPCT) Project: An Overview. Medicaid Health Plan- MiPCT Coordination Meeting
The Michigan Primary Care Transformation (MiPCT) Project: An Overview Medicaid Health Plan- MiPCT Coordination Meeting April 14, 2016 2 Welcome and Goals for the Day 3 Welcome! Our Goals for the Day Create
More informationPutting PCMH into Practice: A Transformation Series Care Coordination & Care Transitions (CC) September 12, 2018
Putting PCMH into Practice: A Transformation Series Care Coordination & Care Transitions (CC) September 12, 2018 WEBINAR FACILITATOR Hannah Stanfield NCQA PCMH CCE Practice Transformation Coordinator WACMHC
More informationBenefits Why AmeriHealth Caritas VIP Care Plus Was Created
Benefits Benefits Why AmeriHealth Caritas VIP Care Plus Was Created The Medicare Medicaid Plan, AmeriHealth Caritas VIP Care Plus, was created to coordinate Medicare and Medicaid services, simplify the
More informationHome 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 informationQAPI & Infection Prevention: Putting the Pieces Together
QAPI & Infection Prevention: Putting the Pieces Together Tammy Baumann, RN, LSSGB Quality Improvement Advisor Great Plains Quality Innovation Network Objectives Identify how QAPI intersects with infection
More informationSession 74X Leveraging Your Hospital's Hidden Assets to Drive Meaningful Change
Prepared for the Foundation of the American College of Healthcare Executives Session 74X Leveraging Your Hospital's Hidden Assets to Drive Meaningful Change Presented by: James Vieira, PharmD EIleen Dohmann
More informationFIDA. Care Management for ALL
Care Management for ALL In 2011, Governor Andrew M. Cuomo established a Medicaid Redesign Team (MRT), which initiated significant reforms to the state s Medicaid program. This included a critical initiative
More informationHMO BLUE. VALUE HMO HMO Blue New England - $500 deductible (New England Network) PPO 90 Blue Care Elect Preferred 90 Copay (National Network)
Important Questions (Massachusetts ) (New England ) (National ) What is the overall $0.00 Are there other s for specific? Is there an out of pocket limit on my expenses? What is not included in the out
More informationImproving Systems of Care for Children and Youth with Special Health Care Needs
Improving Systems of Care for Children and Youth with Special Health Care Needs L E A R N I N G C O L L A B O R A T I V E O N I M P R O V I N G Q U A L I T Y A N D A C C E S S T O C A R E I N M A T E R
More informationCoordination of Care Initiative Mora Area Community
Coordination of Care Initiative Mora Area Community Community Meeting October 9, 2018 FirstLight Health System Download meeting agenda and slide handout: Agenda Presentation handout 2 1 Welcome Introductions
More informationHealth Home State Plan Amendment
Health Home State Plan Amendment OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Transmittal Number: OK-14-0011 Supersedes Transmittal Number: Proposed Effective Date: Jan 1, 2015 Approval Date:
More informationHow Does This Fit into the Provisions of the Affordable Care Act? The goals are aligned
Background April 2012 The Federal Centers for Medicare and Medicaid Services (CMS) approved 3 NJ Accountable Care Organizations (ACOs) to participate in the Medicare Shared Savings Program Accountable
More informationImproving Patient Safety Across Michigan and Illinois
Improving Patient Safety Across Michigan and Illinois Readmissions Collaborative Kickoff January 20, 2016 1 Agenda Readmissions Collaborative Structure and Overview Business case for readmissions Using
More informationModel of Care Training
Medicare Advantage Special Needs Plan Chronic Care Program Model of Care Training 2012-2013 Course Overview This course will describe: PHP s Model of Care Chronic Care Program Health Homes Interdisciplinary
More informationTHE BEST OF TIMES: PHARMACY IN AN ERA OF
OBJECTIVES THE BEST OF TIMES: PHARMACY IN AN ERA OF ACCOUNTABLE CARE Toni Fera, BS, PharmD October 17, 2014 1. Describe the role of pharmacists in accountable care organizations (ACO). 2. List four key
More informationThe Playbook: Better Care for People with Complex Needs
The Playbook: Better Care for People with Complex Needs Catherine Arnold Mather, MA Director Institute for Healthcare Improvement October 26, 2017 The Better Care Playbook is supported by a funders collaborative
More informationSession Objectives 10/27/2014. How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider? Kim Barrows RN BSN
How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider? Kim Barrows RN BSN Session Objectives At the end of the session the learner will be able to: 1. Discuss the history
More informationCourse Module Objectives
Course Module Objectives CM100-18: Scope of Services, Practice, and Education CM200-18: The Professional Case Manager Case Management History, Regulations and Practice Settings Case Management Scope of
More informationImproving Care Transitions for Rhode Island Patients
Improving Care Transitions for Rhode Island Patients Nelia Odom, RN, BSN, MBA, MHA Senior Program Coordinator, Quality Partners of Rhode Island Deborah Correia Morales, MSW Senior Program Coordinator,
More informationNavigating the Hospital Readmission Reduction Program
Navigating the Hospital Readmission Reduction Program Since the Affordable Care Act passed in 2010, a hospital s 30-day readmission rate has become synonymous with quality of care. Beginning in 2012, the
More informationSkilled 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 informationHOUSEKEEPING. Slides were sent this morning Webinar is being recorded Please use the telephone option
HOME IS THE HUB An Initiative to Accelerate Progress to Reduce Readmissions in Virginia Webinar #6 Deep Dive Series: ED-based Strategies January 25, 2017 HOUSEKEEPING Slides were sent this morning Webinar
More informationCentral Ohio Primary Care (COPC) Spotlight on Innovation
Central Ohio Primary Care (COPC) Spotlight on Innovation BY BETTER MEDICARE ALLIANCE MARCH 2017 Central Ohio Primary Care Spotlight on Innovation 1 Central Ohio Primary Care (COPC) Spotlight on Innovation
More informationReducing Readmission Case Stories Discussion of Successes
Reducing Readmission Case Stories Discussion of Successes University of California, San Francisco Maureen Carroll RN, CHFN Transitional Care Manager Heart Failure Program Coordinator UnityPoint Cedar Rapids
More informationTechnology Driven Strategies for Enhancing Patient Engagement Within an ACO Model. ACO Congress November 5, 2013 Charles Kennedy
Technology Driven Strategies for Enhancing Patient Engagement Within an ACO Model ACO Congress November 5, 2013 Charles Kennedy Aetna s values drive ACS strategy apple 2 Changing the emphasis from volume
More informationHospital Inpatient Quality Reporting (IQR) Program
Improving the Patient Experience of Care Questions and Answers Speakers Rita J. Bowling, RN, MSN, MBA, CPHQ Project Director KEPRO BFCC-QIO Allison Fields, RN, BSN Clinical Educator Jennings American Legion
More information