1. Bringing Home the Continuum of Care:
Care Transitions & Personalized Medicine
HOME HEALTH
AGENCIES
HOSPITALS /
REHABS
PATIENT
S
PRIMARY CARE
PHYSICIANS,
SPECIALISTS &
OTHER
PROVIDERS
Managed Care (MCO)
Referral Process ,
Coordination of Care & MCO
RFP / Negotiation /
Implementation /
Compliance Cycle
HOSPITAL
D/C
PLANNERS
STRATEGIC
PARTNERSHIPS
Editor's Notes
PLEASE NOTE:
Hospitals and Rehabilitation facilities often refer patients to Home Health Agencies without notifying the appropriate PCPs.
Hospitals must provide D/C Summaries and D/C Medication reports to PCPs and Home Health Agencies. These can be delivered through EMR Fax Inboxes or accessed through RHIO and SHIN data bases.
Upon patient release, Rehabilitation Centers as standard protocol should contact all appropriate PCPs with designated Home Health Agency and provide D/C documentation to ensure a seamless continuum of care and appropriate care transition protocols.
Rehabilitation facilities must call PCPs upon D/C and denote the Home Health Agency of choice and provide D/C orders.
As crucial point of contacts, Home Health Agency representatives must visit D/C Planners and facilitate appropriate after-care with departments, depending upon hospital Centers of Excellence, that may include ICU, Cardiac, Neurology, Vascular, Orthopedic, Oncology, Neonatal Intensive Care, and all Med/Surg floors.
The Home Health Agency Representative must obtain crucial documents that include: Home Health Certification and Plan of Care, Physician Orders, Face-to-Face Sheets, and referral/consult documentation.
Home Health Representatives must also be aware of additional Care Transition/Continuum of Care Programs that are utilized by hospitals and PCPs. Such proactive programs include Health Home, PCMH, and Primary Care and Behavioral Health Care Integration programs.
Other crucial prospects include ALFs and retirement communities. I have visited such communities from the Villages to Ft. Myers.
Based on all of this information, I am confident that I will be able to build a pipeline that will deliver sustained organic growth while nurturing long-term business relationships with the Amedisys base clients.
Collaborate with strategic partnerships to mutually grow our businesses and transform patient care through evidence based outcomes that increase patient access and reduce hospital readmissions
I act as a liaison between sales and operations to deliver cutting-edge solutions per the “Voice of the Customer” – both internal and external. The patient comes first. As a consultative “patient advocate” it is my passion to provide each and every customer with services and products of uncompromising quality – error free, on time, every time.
