10/12/2011. Hospital Admissions. Length of stay. Patient and caregiver knowledge Patient empowerment
|
|
- Antonia Melton
- 5 years ago
- Views:
Transcription
1 How the Transition Coach Model is employed at United Memorial Medical Center Amy Snyder RN Since our program started at United Memorial Medical Center Home Visits Home Visits Home Visit thus far Our Goals of the Program Minimize Hospital Admissions Acuity of patient at the time of admission Length of stay Increase Patient and caregiver knowledge Patient empowerment 1
2 Process begins with Identifying potential patients for program Admissions register Referrals Case Manager MD Nursing Home discharging patients from rehab Disqualifiers Discharge to Nursing Home Discharge to Hospice Transfer to a higher level of care Co morbidities case by case evaluation Process begins with Identifying potential patients for program I meet with patients during their inpatient stay. I will call the patient or caregiver at home after discharge. if the discharge plan is potentially to a rehab situation if the patient is admitted and discharged prior to my meeting with them. Process begins with Identifying potential patients for program I present this to the patient and or caregiver as a care package or tools to help them manage the symptoms of Congestive Heart Failure. I tell them this is a free service that the hospital is providing to help keep them healthy. 2
3 During the Home Visit the goal is to cover the 4 Pillars D Daily Weight Monitor Sodium intake Monitor Daily symptoms Tk Take Mdi Medications i as directed dand dkeep up to date medication list. Encourage patient and caregiver to own their medical formation and be prepared to show updates and changes to other providers that may be involved in their care. Determine if a follow up appointment has been made since Hospitalization Care Package The Care Package or Tools is given to patients at the time of the Home Visit. 3
4 Items included in the Care Package A digital scales Calendar with cartoon captions Red Flags List A Li Living i with ihh Heart Failure C Calendar Companion Pill Box Notebook with attached pen Blank Medication List Leave Patients and or caregivers with a business card. Post Home Visit Letter to MD telling him/her that his/her patient has received these supplies. 3 follow up phone calls 1 month 3 months 6 months Phone call to MD and or caregiver if the home visit produced a concern for safety. Less is more in relation to educational materials The home visit needs to be tailored to the needs and education level of the patient. 4
5 Some patients are enlightened about sodium values in their food. They are often shocked on how quickly it adds up. One hot dog with condiments Hot dog itself mg Hot dog roll 200mg Ketchup 1 tbsp 160mg Mustard 1 tsp 60mg Relish 1 tbsp 100mg 1 hot dog totals 920 to 1120 mg sodium Some visits are spent with the emphasis on reconciling medications. One visit exposed several expired medications in a bag mixed with current medications. Another visit 30 medication bottles all over his kitchen table and freezer filled with hot dogs. Two other visits found scripts for Digoxin and Lasix that never made it to the patients home 5
6 Other visits especially those of compromised intellectual ability reinforcing the importance of daily weights when to call the doctor becomes the focus We have reached out to local Nursing Homes. I am actively taking referrals for discharged patients from rehab with the diagnosis of Congestive Heart Failure. If a patient who received a home visit is readmitted I try to stop in and see the patient in the hospital. 6
7 Life still needs to go on despite a CHF diagnosis. We have learned that not all patients are coachable and the program is best employed earlier than later in the disease process. Connections to further improve Patient Transitions Referrals are now being made to Disease Management Programs of the patient s Insurance Plan MVP Independent Health Community Blue/Blue Cross of WNY (Buffalo) Excellus/Blue Choice of Rochester Connections to further improve Patient Transitions Working with Genesee County Office of Aging Service Directory for Seniors, persons with disabilities i and their caregivers. Falls Prevention Program Referrals. Living Healthy Workshops. Interest to expand Transition Coaching to other chronic conditions such as COPD and DM 7
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 information10/27/10. Michelle Mourad MD Arpana Vidyarthi Ellen Kynoch. pulmonary edema. sodium intake & daily weights
Michelle Mourad MD Arpana Vidyarthi Ellen Kynoch pulmonary edema sodium intake & daily weights 1 What makes her at risk for readmission? Why didn t she listen to her doctors about her salt intake? Did
More informationSO YOU WANT TO IMPROVE THE DISCHARGE PROCESS?
Who are we? Why are we here? SO YOU WANT TO IMPROVE THE DISCHARGE PROCESS? Michelle Mourad MD Arpana Vidyarthi Ellen Kynoch Oh Betty Why Betty? pulmonary edema sodium intake & daily weights What makes
More informationABBEVILLE COUNTY EMERGENCY SERVICES COMMUNITY PARAMEDIC PROGRAM
ABBEVILLE COUNTY EMERGENCY SERVICES COMMUNITY PARAMEDIC PROGRAM Objectives Understand the needs/goals that the Community Paramedic program was designed to address Understand how Abbeville County implemented
More information2015 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 information2017 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 informationHeart Failure Education Consider Health Literacy
Heart Failure Education Consider Health Literacy Sandy Hall RN BSN Heart Failure Case Manager Mercy Medical Center Des Moines, IA August 2012 What does this mean to you? Cardiac diet 1 Is it this? Low
More informationTRANSITIONS OF CARE: INCREASING PATIENT ENGAGEMENT AND COMMUNICATION ACROSS HEALTH CARE SETTINGS
TRANSITIONS OF CARE: INCREASING PATIENT ENGAGEMENT AND COMMUNICATION ACROSS HEALTH CARE SETTINGS Leslie Lentz, BA Care Transitions Project Coordinator Health Care Excel, the Indiana Medicare Quality Improvement
More informationPatient Interview/Readmission Chart Review. Hospital Review:
Appendix: Readmission Review Form Patient Interview/Readmission Chart Review Patient Name: Previous Hospital Admission Date Account Number Previous Hospital D/C Date: D/C MD: Previous Hospital Discharge
More informationSENTARA HEALTHCARE. Norfolk, VA
SENTARA HEALTHCARE Norfolk, VA 1 Sentara Healthcare Overview 11 Acute Care Hospitals in Virginia with a total of 2572 licensed beds 1E Extended dstay hospital 9 Ambulatory Care Campuses; 5 with freestanding
More informationEmergency 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 informationImproving Patient Safety Across Michigan and Illinois
Improving Patient Safety Across Michigan and Illinois Grand Rounds April 6, 2016 1 Agenda Grand Rounds Overview and Questions Care Transitions Vignette Fairfield Memorial s Care Check Program Grand Rounds
More informationMHS Care Management Program 1017.PR.P.PP.1 10/17
MHS Care Management Program 1017.PR.P.PP.1 10/17 Sample Integrated Transitional Care Model Inpatient Admission Process Admission thru discharge and beyond Goals: Ensure safe and timely transitions of care
More informationCare Transitions: From Hospital to Home
Care Transitions: From Hospital to Home Michael Halling & Care Transitions Team TRANSITION PROGAM PURPOSE Assist patients/clients as they transition from the acute care setting back to their homes Improve
More informationEXECUTIVE SUMMARY: briefopinion: Hospital Readmissions Survey. Purpose & Methods. Results
briefopinion: Hospital Readmissions Survey EXECUTIVE SUMMARY: Purpose & Methods The purpose of this survey was to collect information about hospital readmission rates and practices. The survey was available
More informationMaternity 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 informationCKHA Quality Improvement Plan (QIP) Scorecard
CKHA Quality Improvement Plan () Scorecard 217-18 Quality dimension Performance Indicator 217-18 Performance Goals results where available Current Value Page Safety Medication Reconciliation completed
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 information2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions
2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions Project Objective: To provide a 30-day supported transition period after a hospitalization to ensure
More informationCare Transitions: Don t Lose Your Patients
Care Transitions: Don t Lose Your Patients Sabrina Edgington, MSSW Program and Policy Specialist National Health Care for the Homeless Council March 14, 2013 CARE TRANSITIONS Definition The movement of
More informationImproving Patient Outcomes through Quality Transitions
Improving Patient Outcomes through Quality Transitions Founded in 1892, Union Hospital began as a 20 bed facility and has grown into a 380 bed not-for-profit hospital Union Hospital is a Regional Referral
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 informationImproving Patient Safety Across Michigan and Illinois
Improving Patient Safety Across Michigan and Illinois Designing Your Readmission Reduction Approach February 17, 2016 Agenda Peer to Peer Learning Network/Improvement Poster (Illinois) Designing your Readmissions
More information3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information
Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking Jennifer Moore, RN Content Developer Objectives Describe two reasons why returns to the hospital are not desirable
More informationCare Transitions Partnerships that Work for Patients
Care Transitions Partnerships that Work for Patients Alyce Brophy, President/CEO, Community Visiting Nurse Association Alyssa Kizun, Director, Care Management, Somerset Medical Center Stacey Wilbur, Administrator,
More informationHeart Failure Order Sets. Standardizing Care for the Heart Failure Patient 2012
Heart Failure Order Sets Standardizing Care for the Heart Failure Patient 2012 Objectives: Standardize care for all heart failure patients in Legacy Base Practice on American Heart Association Guidelines
More informationBreaking 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 informationChristi McCarren, SVP, Retail Health & Community Based Care Lynnell Hornbeck, Manager, Home Health
Christi McCarren, SVP, Retail Health & Community Based Care Lynnell Hornbeck, Manager, Home Health Webinar: Northwest Regional Telehealth Resource Center October 27, 2016 1 MultiCare Health System MultiCare
More informationProvider 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 informationUniversity Cincinnati Medical Center
University Cincinnati Medical Center Best Practice: The Journey to an Advanced Heart Failure Program Dr. Stephanie H. Dunlap, DO Medical Director of the Advanced Heart Failure program and the Advanced
More informationRe-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready. Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting
Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting OBJECTIVES Define Rehospitalization and discuss current statistics
More informationCOPD & Pneumonia Readmission Reduction Program. October 25, 2017
COPD & Pneumonia Readmission Reduction Program October 25, 2017 Susan J. Bowers, MBA, BSN, RN Chief Quality Officer Mercy Health - Lorain 2 Locations Mercy Health Lorain Hospital Lorain, Ohio 250 bed community
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 informationMEDS TO BEDS AND CARE MANAGEMENT MEDICATION ASSESSMENT TOOLKIT: FOR HOSPITAL TEAM AND PHARMACISTS
MEDS TO BEDS AND CARE MANAGEMENT MEDICATION ASSESSMENT TOOLKIT: FOR HOSPITAL TEAM AND PHARMACISTS Implementation Toolkit Last Updated: 02/2018 OneCity Health Services 199 Water Street, 31st Floor, New
More informationReadmission Prevention: A Community Collaborative Approach
Readmission Prevention: A Community Collaborative Approach Kim Fuller, Administrative Director, Case Management, Shawnee Mission Medical Center Catherine Lauridsen RN, BSN, Care Transition Coach, Shawnee
More informationCareTrek : Nebraska s Journey to Safe Care Transitions
CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement
More informationDischarge checklist and follow-up phone calls: the foundation to an effective discharge process
Discharge checklist and follow-up phone calls: the foundation to an effective discharge process Shari Aman, BSN, RN, MBA, CPHQ Denise Andrews, MBA Stephanie Storie, BSN, RN, CMSRN Deb Nation, RN, CMSRN
More informationOptimizing Care for Complex Patients with COPD
Optimizing Care for Complex Patients with COPD Janice Gasaway, RN, MN, Director Quality & Safety Elvin Perkins, MBA, Chronic Disease Project Manager 1 Cone Health System: Who We Are Regional Health System
More informationQuality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/15/2016
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/15/2016 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop
More informationFederal Employee Program Service Benefit Plan An independent licensee of the Blue Cross and Blue Shield Association
Federal Employee Program Service Benefit Plan 2009 An independent licensee of the Blue Cross and Blue Shield Association Federal Employee Program Two PPO Products Basic Option with (in-network benefits
More informationReducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN
Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN Session Objectives At the end of the session the learner will be able to: 1. Discuss the history of hospital readmission
More informationREADMISSION ROOT CAUSE ANALYSIS REPORT
USE RESTRICTED TO ABC Hospital READMISSION ROOT CAUSE ANALYSIS REPORT State: Community Name: YZ Cohort: Hospital: A ABC Hospital Reviewer: Jane Doe Abstraction Period: 1/1/2014 6/30/2014 Charts Abstracted:
More informationComplex Care Management Protocols and Procedures
Complex Care Management Protocols and Procedures December 2014 Version 3.0 1 Table of Contents I. Complex Care Management Program Staff Roles and Responsibilities... 4 II. Complex Care Management Program
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 informationMedicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings
Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings May 11, 2009 Avalere Health LLC Avalere Health LLC The intersection
More informationCareTrek : Nebraska s Journey to Safe Care Transitions
CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement
More informationCMS Oncology Care Model s Standards for Patient Navigation
CMS Oncology Care Model s Standards for Patient Navigation Nikolas Buescher Executive Director of Cancer Services Penn Medicine, Lancaster November 13, 2017 Ann B Barshinger Health Cancer Institute scale
More informationCare Transition Coach
Lehigh Valley Health Network LVHN Scholarly Works Patient Care Services / Nursing Care Transition Coach Marlene Seidel Butz Lehigh Valley Health Network, Marlene.Butz@lvhn.org Follow this and additional
More informationMolina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)
Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience
More informationPreventing Heart Failure Readmissions by Using a Risk Stratification Tool
Preventing Heart Failure Readmissions by Using a Risk Stratification Tool Anna Dermenchyan, MSN, RN, CCRN-K Senior Clinical Quality Specialist Department of Medicine, UCLA Health PhD Student, UCLA School
More informationUsing 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 informationA Care Transitions Project
Hospital to Home: A Care Transitions Project Ann Roemen, MBA, CMPE Readmissions 1 in 5 elderly patients Resultsin23million 2.3 re-hospitalizations Annual cost to Medicare - $17 billion + Jencks SF,Williams
More informationFREQUENTLY ASKED QUESTIONS Iowa PASRR Onsite Provider Training 10/18/ /21/2016
Below you will find the frequently asked questions for the multi location Onsite Provider Training conducted. Answers to these questions were based on knowledge and policy as of 10/18/2016. Due to policy
More informationREDUCING READMISSIONS through TRANSITIONS IN CARE
REDUCING READMISSIONS through TRANSITIONS IN CARE Christina R. Whitehouse, PhD, CRNP, CDE Postdoctoral Research Fellow NewCourtland Center for Transitions and Health University of Pennsylvania School of
More informationExacerbation of Condition. VNAA Best Practice for Home Health
Exacerbation of Condition VNAA Best Practice for Home Health Learning Objectives The participant will be able to: Discuss two reasons why it is important to help a patient identify changes in their condition
More informationBeyond the Hospital Walls: Impact of a SNFist Practice Model
Beyond the Hospital Walls: Impact of a SNFist Practice Model Aaron Snyder, MD Vice President, US Acute Care Solutions Kim Repac Chief Financial Officer, WMHS Aging Population 50 Million Distribution
More informationWPS 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 informationCHF Readmission Initiative. Mary Fischer MSN, CCRN, PCCN, CHFN Cardiology Clinical Nurse Specialist St. Vincent Hospital Indianapolis, Indiana
CHF Readmission Initiative Mary Fischer MSN, CCRN, PCCN, CHFN Cardiology Clinical Nurse Specialist St. Vincent Hospital Indianapolis, Indiana St. Vincent 86 th Street Campus Heart Failure Program History
More informationMedicare Advantage in Practice: Enhanced Care Models for High Need Patients
Medicare Advantage in Practice: Enhanced Care Models for High Need Patients Rebekah Dube, Pharm.D. VP, Health Plan Clinical Programs & Interim VP, Health Plan Products Who is Martin s Point Health Care?
More informationReferral and Admission Models Explanation of Key Decision Points
JUNE 2018 Referral and Admission Models Explanation of Key Decision Points This tool is designed to assist a hospice program in evaluating their referral and admission process for efficiency in operation
More informationNew SNF Quality Measures
New SNF Quality Measures Strategies to Boost your Facility Performance Dr. Kathleen Weissberg, OTD, OTR/L Education Director Select Rehabilitation kweissberg@selectrehab.com Objectives Understand the measure
More informationWisconsin Homecare Organization
Wisconsin Homecare Organization Competitive Strategies: Key Elements for Thriving in a High-Stakes Outcomes Market Lynda Laff Strategic Healthcare Programs, LLC Thursday, May 15, 2008 2:00 p.m. 3:30 p.m.
More informationReadmission Program. Objectives. Todays Inspiration 9/17/2018. Kristi Sidel MHA, BSN, RN Director of Quality Initiatives
The In s and Out s of the CMS Readmission Program Kristi Sidel MHA, BSN, RN Director of Quality Initiatives Objectives General overview of the Hospital Readmission Reductions Program Description of measures
More informationReducing Readmissions One-caseat-a-time Using Midas+ Community Case Management
Reducing Readmissions One-caseat-a-time Using Midas+ Community Case Management John Playford, Senior Midas+ Solutions Advisor Barb Craig, Midas+ SaaS Advisor The Problem Historically, up to 25% of patients
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 informationNURSING FACILITIES: FRIENDS OR FOES? Marie C. Berliner Joy & Young, LLP Austin, Texas (512)
NURSING FACILITIES: FRIENDS OR FOES? Marie C. Berliner Joy & Young, LLP Austin, Texas (512) 330-0228 Program Overview Status of Hospice Nursing Facility Relationships Multiple contact points and transactions
More informationSnohomish County Case Management Nursing Services
Snohomish County Case Management Nursing Services Carolyn Hundley, RN /Supervisor Denice Ulowetz, RN Kirstie Clinko, RN Sue Lee, RN Joy Maine, RN Amy Robertson, RN Overview New Changes in Nursing Services
More informationGeneral Pathways Education Workshop (click t o to g o go t o to t he the desired section)
General Pathways Education Workshop (click to go to the desired section) Introduction to Workshop/Instructions Why Care Pathways? Components of the Care Pathway Care Pathway Simulation Implementing Care
More informationTransitions of Care. ACOI Clinical Challenges in Inpatient Care. March 31, 2016 John B. Bulger, DO, MBA
Transitions of Care ACOI Clinical Challenges in Inpatient Care March 31, 2016 John B. Bulger, DO, MBA Disclosure I have not accepted any honoraria, additional payments of reimbursements related to the
More informationPredicting 30-day Readmissions is THRILing
2016 CLINICAL INFORMATICS SYMPOSIUM - CONNECTING CARE THROUGH TECHNOLOGY - Predicting 30-day Readmissions is THRILing OUT OF AN OLD MODEL COMES A NEW Texas Health Resources 25 hospitals in North Texas
More informationInnovating Predictive Analytics Strengthening Data and Transfer Information at Point of Care to Improve Care Coordination
Innovating Predictive Analytics Strengthening Data and Transfer Information at Point of Care to Improve Care Coordination November 15, 2017 RRHA Healthcare Innovations Conference Agenda Arnot Health Overview
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 informationPrograms 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 informationCHF Education March Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN
CHF Education March 2015 Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN Objectives To improve patient outcomes Decrease CHF readmissions Improve patient and family compliance
More informationRenee Coughlin PT, DPT, MHS Steven Pamer PT, MPA, CGS
Improving Chronic Care Renee Coughlin PT, DPT, MHS Steven Pamer PT, MPA, CGS The Financial Imperative United States Economy - Cost $1 trillion annually and could reach $6 trillion by 2050 Failure to contain
More informationL8: Care Management for Complex Patients: Strategies, Tools and Outcomes
The Triple Aim 16 th Annual Summit: Institutes for Healthcare Improvement - Improving Patient Care in the Office Practice and the Community March 16, 2015 Dallas, Texas L8: Care Management for Complex
More informationThe impact of the heart failure health enhancement program: A retrospective pilot study
ORIGINAL ARTICLE The impact of the heart failure health enhancement program: A retrospective pilot study Cynthia J. Hadenfeldt, Marilee Aufdenkamp, Caprice A. Lueth, Jane M. Parks Creighton University
More informationCare Initiation: Crisis Management
VNAA Blueprint for Excellence Pathway to Best Practices Care Initiation: Crisis Management VNAA Best Practice for Hospice and Palliative Care: End of Life This presentation addresses crisis management
More informationReadmissions Moving beyond blame to fill the patient needs. Jackie Conrad RN, MBA, RCC Cynosure Health
Readmissions Moving beyond blame to fill the patient needs Jackie Conrad RN, MBA, RCC Cynosure Health jconrad@cynosurehealth.org 1 51 year old male with 3 acute care admissions and 2 ED visits in the past
More informationImproving Transitions to Home & Community- Based Care Settings
This presenter has nothing to disclose. Improving Transitions to Home & Community- Based Care Settings Eric Coleman September 29, 2015 Session Objectives Participants will be able to: Describe the role
More informationCongestive Heart Failure (CHF) Improvement
Congestive Heart Failure (CHF) Improvement December 3, 2015 Beth Averbeck, MD Senior Medical Director, HPMG Primary Care HealthPartners Health Plan 1.5 million members Medical Clinics 1,700 physicians
More informationImplementation Guide: Critical Interventions in the First/Second Visit. VNAA Best Practice for Home Health
Implementation Guide: Critical Interventions in the First/Second Visit VNAA Best Practice for Home Health Learning Objectives The participant will be able to: Identify three interventions that should take
More informationThe Stepping Stones Project Care Transitions and the Coaching Model
The Stepping Stones Project Care Transitions and the Coaching Model Selena Bolotin, MSW Care Transitions Project Manager Quality & Safety Initiatives Qualis Health Seattle, Washington About Qualis Health...
More informationNevada 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 informationSafe & Sound: How to Prevent Medication Mishaps. A Family Caregiver Healthcare Education Program. A Who What Where Why When Tool Kit
Safe & Sound: How to Prevent Medication Mishaps A Family Caregiver Healthcare Education Program A Who What Where Why When Tool Kit National Family Caregivers Association www.thefamilycaregiver.org 800/896-3650
More informationSolution Title: Population Health: A Paradigm Shift in how we care for Behavioral Health Patients
Solution Title: Population Health: A Paradigm Shift in how we care for Behavioral Health Patients Overview of Project A drive to Population Health and changes in reimbursement have prompted the need to
More informationH2H Mind Your Meds "Challenge. Webinar #3- Lessons Learned Wednesday, April 18, :00 pm 3:00 pm ET. Welcome
H2H Mind Your Meds "Challenge Webinar #3- Lessons Learned Wednesday, April 18, 2012 2:00 pm 3:00 pm ET 1 Welcome Take Home Messages Understand how to implement the Mind Your Meds strategies and tools in
More informationPACT AS A READMISSION REDUCTION STRATEGY KAISER PERMANENTE - COLORADO REGION
PACT AS A READMISSION REDUCTION STRATEGY KAISER PERMANENTE - COLORADO REGION Jodi Smith, MSN, CCMC, ANP-BC, ND Director of Hospital Operations, Specialty Services and Care Coordination Kaiser Permanente,
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 informationPharmacy s Role in Decreasing Hospital Readmissions
Pharmacy s Role in Decreasing Hospital Readmissions ACPE UAN 107-000-11-004-L04-P & 107-000-11-004-L04-T Activity Type: Knowledge-Based 0.15 CEU/1.5 Hr Program Objectives for Pharmacists: Upon completion
More informationEnd-of-Life Care Action Plan
The Provincial End-of-Life Care Action Plan for British Columbia Priorities and Actions for Health System and Service Redesign Ministry of Health March 2013 ii The Provincial End-of-Life Care Action Plan
More informationImproving Transitions of Care
Improving Transitions of Care A Strategy to Defer Decline How the Foundation Got Started with Care Transitions First Quality Improvement Collaborative 2005-2006 Teams chose palliative care or transitions
More informationCAHPS Hospice Survey Podcast for Hospices Transcript Data Hospices Must Provide to their Survey Vendor
CAHPS Hospice Survey Data Hospices Must Provide to their Survey Vendor Presentation available at: Slide 1 Welcome to the CAHPS Hospice Survey: Podcast for Hospices series. These podcasts were created for
More informationRunning head: SMART APPS TO DECREASE CHF READMISSION RATES 1
Running head: SMART APPS TO DECREASE CHF READMISSION RATES 1 Use of Smartphone Applications in the Reduction of Hospital Readmissions of Heart Failure Patients in Short Term Acute Care Facilities Eleanor
More informationMAHP Annual Conference. October 18 th -19th
MAHP Annual Conference October 18 th -19th Learning Objectives Highlight UMMC s National Business strategy Provide MAHP members a UMMC Center for Telehealth update Understand the need for Telehealth services
More informationSTRATEGIES AND SOLUTIONS FOR REDUCING INAPPROPRIATE READMISSIONS
WHITE PAPER STRATEGIES AND SOLUTIONS FOR REDUCING INAPPROPRIATE READMISSIONS This paper offers a two-pronged approach to lower readmission rates and avoid Federal penalties. Jasen W. Gundersen, M.D., M.B.A.,
More informationStrategies for Effective Transition Care Management:
Strategies for Effective Transition Care Management: Practices good for your patients and good for your business Ann Loeffel, RN, BSN Objectives for today You will be able to: Evaluate systems and processes
More informationThinking Differently about Hospital Readmissions
Thinking Differently about Hospital Readmissions LaNita Knoke RN, BS, CMCN Healthcare Strategist Senior Care Continuum Each Home Instead Senior Care franchise office is independently owned and operated.
More informationFY 2016 PERFORMANCE PLAN
Program Purpose PERFORMANCE PLAN ADSD Amy Vennett x1714 Program Information Improve and then maintain the health status of adults with multiple chronic illnesses and/or disabilities so they successfully
More informationPost-Acute Care COMM UN I CATING T HE VA LU E L ES L IE MA RSH, CEO, L E X INGTON R EG I ONAL HEA LT H CE N T ER L E X I NGTON, N E BR ASKA
Post-Acute Care COMMUNICATING THE VALUE LESLIE MARSH, CEO, LEXINGTON REGIONAL HEALTH CENTER LEXINGTON, NEBRASKA Swingbed CMS Definition Initially communicated to patients as a way to avoid a premature
More information