This document describes a pilot project evaluating the appropriateness and acceptability of Information, Advice and Support coordinators from The Stroke Association delivering six-month reviews to stroke survivors. The project found that coordinators identified an average of 3 unmet needs per patient and were able to address many needs through advice, referrals, or signposting. Both patients and coordinators found the reviews useful and comfortable. The reviews identified a diverse range of long-term problems experienced by stroke survivors.
Results from the National Chronic Care Management Survey 2015 offer insight into CCM adoption barriers and the challenge of physician & patient engagement.
Patient Centered Medical Homes are providing a pathway for healthcare delivery organizations pursuing value-based initiatives. As reimbursement models continue to transition at an accelerated pace, PCMH practices are well-positioned to achieve clinical targets and qualify for the associated financial incentives.
This webinar will provide an overview of the evaluation study being done at the Durham Clinic, an integrated health home run by Cherry Street Health Services in Grand Rapids, Michigan. The study seeks to determine whether the delivery of health care through a multi-disciplinary team using the chronic care management model delivers better symptom management and reduced impact of the
illness on patients’ desired functioning.
Patient engagement is a critical element of successful transitions of care. Without it, patients are improperly educated about their condition and inadequately prepared to self-manage.
Healthcare organizations need effective and scalable ways of engaging patients post-discharge.
Consumer Participation in Drug Treatment Services: Overview of Australian Res...Uniting ReGen
Keynote #iAOD16 presentation by Prof Carla Treloar. For more event information, see http://www.regen.org.au/more-events/724-2016-innovation-seminar-11-may.
Clinicspectrum is a healthcare service/consulting company helping Medical offices, Hospitals and ACOs to reduce operational cost up to 30% with its unique Hybrid Workflow Model™ with use of back office services and technology products.
We are happy to launch our unique web-based Chronic Care Management Platform and discuss details about Chronic Care Management in this presentation.
Results from the National Chronic Care Management Survey 2015 offer insight into CCM adoption barriers and the challenge of physician & patient engagement.
Patient Centered Medical Homes are providing a pathway for healthcare delivery organizations pursuing value-based initiatives. As reimbursement models continue to transition at an accelerated pace, PCMH practices are well-positioned to achieve clinical targets and qualify for the associated financial incentives.
This webinar will provide an overview of the evaluation study being done at the Durham Clinic, an integrated health home run by Cherry Street Health Services in Grand Rapids, Michigan. The study seeks to determine whether the delivery of health care through a multi-disciplinary team using the chronic care management model delivers better symptom management and reduced impact of the
illness on patients’ desired functioning.
Patient engagement is a critical element of successful transitions of care. Without it, patients are improperly educated about their condition and inadequately prepared to self-manage.
Healthcare organizations need effective and scalable ways of engaging patients post-discharge.
Consumer Participation in Drug Treatment Services: Overview of Australian Res...Uniting ReGen
Keynote #iAOD16 presentation by Prof Carla Treloar. For more event information, see http://www.regen.org.au/more-events/724-2016-innovation-seminar-11-may.
Clinicspectrum is a healthcare service/consulting company helping Medical offices, Hospitals and ACOs to reduce operational cost up to 30% with its unique Hybrid Workflow Model™ with use of back office services and technology products.
We are happy to launch our unique web-based Chronic Care Management Platform and discuss details about Chronic Care Management in this presentation.
Chronic Care Management (CCM): Understand how to capture incremental revenueDiagnotes, Inc.
By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.
This support manual describes the features of the CLUB 1509 HIV Navigation Program and provides sample demonstrations of the assessment tools, and program standards. It was written for the navigation teams who would like a point of reference for all CLUB 1509 service tools, client flow chart, and program standards.
This support manual is organized by task. It begins with the philosophy of care for all CLUB 1509 clients and progresses through more complex tasks such as client home visits, and biopsychosocial assessments. This supportive manual is not intended to replace your formal social work experience or your agency’s administrative protocol. This manual aims to introduce you to and support your journey in the CLUB 1509 program.
Figuring out telemedicine reimbursement can be tricky. The guidelines can vary based on your state, payer, and how you're using telemedicine. At eVisit, we're trying to demystify this process for physicians - so telemedicine makes it easier to increase your practice revenue!
Learn how telemedicine reimbursement works for Medicare, Medicaid, and Private payers - including specific CPT codes and tips for billing.
Improving patient referral management workflow between federally qualified he...GaryRichards30
A referral process may become inefficient and ineffective if the Federally Qualified Health Centers and the specialty clinics/imaging centers fail to communicate. When there is no proper communication from the specialty centers/imaging centers the community healthcare network finds it difficult to understand the progress of the referral. Let us see it from different perspectives to understand why there is a communication gap.
Chronic Care Management - Implemented By TimeDoc - May 2018Dan Wellisch
This is May's presentation of the Chicago Technology For Value-Based Healthcare Meetup - https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
State of the Independent Practice: What it Means For YouKareo
Join Kareo as we discuss the results from our recent nation-wide survey of 1,000 medical practices. We'll discuss our findings from the survey and how these insights will shape your billing company's future growth.
Guidance for commissioners of rehabilitation servicesJCP MH
This guide is about the commissioning of good quality mental health interventions and services for people with complex and longer term problems to support them in their recovery.
How can physicians benefit from HealthViewX chronic care management solutionGaryRichards30
Chronic Care Management program is indeed a good idea to track your patients regularly. But when done manually, it becomes another burden for the physician. This is when a Chronic Care Management software comes to play. It reduces the time and manual effort spent in giving the CCM services.
James McKillop, <a>Scottish Dementia Working Group</a>. Presentation for Alzheimer scotland Conference: Creativity and dementia – policy and practice. 18 June, Glasgow
Chronic Care Management (CCM): Understand how to capture incremental revenueDiagnotes, Inc.
By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.
This support manual describes the features of the CLUB 1509 HIV Navigation Program and provides sample demonstrations of the assessment tools, and program standards. It was written for the navigation teams who would like a point of reference for all CLUB 1509 service tools, client flow chart, and program standards.
This support manual is organized by task. It begins with the philosophy of care for all CLUB 1509 clients and progresses through more complex tasks such as client home visits, and biopsychosocial assessments. This supportive manual is not intended to replace your formal social work experience or your agency’s administrative protocol. This manual aims to introduce you to and support your journey in the CLUB 1509 program.
Figuring out telemedicine reimbursement can be tricky. The guidelines can vary based on your state, payer, and how you're using telemedicine. At eVisit, we're trying to demystify this process for physicians - so telemedicine makes it easier to increase your practice revenue!
Learn how telemedicine reimbursement works for Medicare, Medicaid, and Private payers - including specific CPT codes and tips for billing.
Improving patient referral management workflow between federally qualified he...GaryRichards30
A referral process may become inefficient and ineffective if the Federally Qualified Health Centers and the specialty clinics/imaging centers fail to communicate. When there is no proper communication from the specialty centers/imaging centers the community healthcare network finds it difficult to understand the progress of the referral. Let us see it from different perspectives to understand why there is a communication gap.
Chronic Care Management - Implemented By TimeDoc - May 2018Dan Wellisch
This is May's presentation of the Chicago Technology For Value-Based Healthcare Meetup - https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
State of the Independent Practice: What it Means For YouKareo
Join Kareo as we discuss the results from our recent nation-wide survey of 1,000 medical practices. We'll discuss our findings from the survey and how these insights will shape your billing company's future growth.
Guidance for commissioners of rehabilitation servicesJCP MH
This guide is about the commissioning of good quality mental health interventions and services for people with complex and longer term problems to support them in their recovery.
How can physicians benefit from HealthViewX chronic care management solutionGaryRichards30
Chronic Care Management program is indeed a good idea to track your patients regularly. But when done manually, it becomes another burden for the physician. This is when a Chronic Care Management software comes to play. It reduces the time and manual effort spent in giving the CCM services.
James McKillop, <a>Scottish Dementia Working Group</a>. Presentation for Alzheimer scotland Conference: Creativity and dementia – policy and practice. 18 June, Glasgow
Growth Hacking on Hardware & Software : Ideas for Startups with the Raspberr...Sam Ng Peng Aun
This was the slide from my sharing at the monthly Webcamp Penang meetups held at the Growth Hacking track at Piktochart today (30 Oct 2014).
Shared some background on Raspberry Pi, its relation to Hardware and Software ideas that startups can use.
This is the first version and the slide design and content is basic. May update with version 2 if demand is there.
A Needs Assessment is used by Community Health Centers to identify the needs of the communities they serve. It helps health centers understand specific health challenges, demographics and social economic factors that impact the patient population. This webinar will identify why needs assessments are important, the HRSA program requirements needed for compliance, and identify best practices for developing a needs assessment.
Involving patients in outcomes based commissioning in community services, pop...NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
To support your work, use scholarly sources and also use outside s.docxedwardmarivel
To support your work, use scholarly sources and also use outside sources. As in all assignments, cite your sources in your work and provide references for the citations in APA format.
Regulations in Long-Term Care
There are many federal and state regulations when it comes to long-term care. Using scholarly sources and the Internet research any four specific regulations related to long-term care and summarize them.
Based on the regulations you identified, respond to the following questions:
· What are the benefits and shortcomings of your identified regulations? Which of these shortcomings have an effect on the quality and the cost of health care services? How?
· Do you believe there is a link between regulations and better care? Why or why not?
· Why do you think long-term care services are subjected to so much external control by government agencies? Provide a rationale for your responses.
· How is quality measured in long-term care? Is there only one, or are there several approaches to measure quality? What are they? Who should be given the responsibility to measure quality?
Notes from class
The increasing need for long-term care has caused several public and private agencies to participate in its managing process. These public and private agencies are increasingly attempting to control costs, providing protection to consumers considered unable to protect themselves. Public controls are nonvoluntary and are imposed by government agencies through the implementation of laws and regulations. Private controls are provided by nongovernment agencies and organizations, and compliance is voluntary.
Public Control
Public control on long-term care is imposed by federal, state, or local (including county and municipal) government units. These units set laws, regulations, and standards to be followed by long-term facilities in order to:
· Give better care facilities to the poor, who are unable to take care of themselves, by making them formal or informal wards of the state.
· Provide quality health care facilities to consumers.
· Create awareness in consumers regarding the types of services provided in the facilities and let the consumers themselves judge the quality of the services.
· Set the minimum level of staffing, cleanliness, and safety, ensuring consumers needing long-term care are treated properly and receive the necessary services.
· Follow all long-term care regulations to provide quality care.
Private Control
Besides government agencies, several private organizations are involved in managing long-term care. Both public and private control focus on long-term care organizations as well as the individuals in those organizations. The only difference is public control can maintain both the cost and the quality of care, while private care can focus only on measuring, evaluating, and ensuring the quality of care.
Private control agencies focusing on the quality of care of long-term organizations are known as accreditation bodies, while those ...
As pharmaceutical and biopharmaceutical manufacturers are receiving more attention, legal scrutiny and activity from government and other entities regarding various components of their patient support services programs, this survey analyzes responses from close to 30 small, mid-size, and large pharmaceutical organizations (9 of the Top 20 pharmaceutical companies) to provide insights as it relates to risk mitigation and emerging strategies for managing patient interactions in a compliant manner.
DR TIM LEIGHTON AND KATHERINE JENKINS - WHAT CAN THE PAST TEACH US ABOUT THE ...iCAADEvents
The presentation and workshop will be a participatory session discussing the future of addictions counselling, and how decades of experience can inform best practice whilst also combining cutting edge research and treatment methods. Addictions counselling with individuals, couples, families and groups has become more complex and challenging. How can we de ne and describe the training and quali cations needed to ensure the best practice and the most e ective interventions? What is the relationship between the quality framework and the therapeutic work? The workshop will explore tensions that arise in practice as experienced by the audience, and suggest ways to get the training, support and continuing professional development you need. Tim and Katherine will be encouraging the audience to share their own thoughts and ideas.
This presentation was part of a discussion at Sheffield's Health and Wellbeing Board on 25 June 2015.
Read the papers from the Board meeting: http://sheffielddemocracy.moderngov.co.uk/ieListDocuments.aspx?MId=5993.
2. Registered Charity Number 211015
Background
NIHR CLAHRC for Greater Manchester: Collaboration for
Leadership in Applied Health Research and Care.
A collaboration between a leading university and its surrounding
NHS trusts that will…
• Conduct high quality health services research.
• Ensure knowledge gained from the research is translated into improved
health care in the NHS.
Mission: to improve the health of the people of Greater
Manchester by improving NHS quality of care and support for
patient self-management.
Focus on vascular conditions: Stroke, Diabetes, Chronic Kidney Disease, and
Heart Disease.
3. Registered Charity Number 211015
Background
Aimed to define the content of the six month
review and support the development and
implementation of local service models for
delivering the review.
GM-SAT: the Greater Manchester Stroke Assessment Tool.
An evidence-based, standardised post-stroke assessment tool.
4. Registered Charity Number 211015
Background
The Stroke Association
Information, Advice and Support (IAS) coordinators.
CLAHRC stakeholders (professionals and service users) thought
that IAS coordinators were well placed to deliver the six month
stroke review.
An important yet simple formalisation of the work they were
ordinarily doing.
5. Registered Charity Number 211015
Background
In June 2010, the CLAHRC for Greater Manchester and The
Stroke Association established a pilot project:
“To evaluate the appropriateness and acceptability of IAS
coordinators delivering the six month review”
10. Registered Charity Number 211015
Algorithms
• Flow diagrams to guide through the
review process
• Act as a reference guide
• One for each of the 35 problem areas
• Start with the ‘trigger’ question
• Finish with an action
13. Registered Charity Number 211015
Needs and Actions
137 reviews were complete during the pilot period.
Each IAS coordinator completed between 6 and 11 reviews.
All service users have been discharged approximately 6 months
prior to the review.
All reviews were delivered in the home setting using GM-SAT.
14. Registered Charity Number 211015
Needs and Actions
Total of 464 unmet needs identified
Average of 3 unmet needs (range= 0-14)
15. Registered Charity Number 211015
Needs and Actions
Unmet needs identified in 36 different areas.
Needs were identified in 34 of the 35 areas covered by GM-SAT.
16. Registered Charity Number 211015
Needs and Actions
Number (n)
of unmet
needs
identified
Percentage (%)
of individuals
presenting with
unmet need
Medication management 4 3
Medication compliance 18 13
Secondary prevention (non lifestyle) 30 22
Alcohol 7 5
Diet 9 7
Smoking 10 7
Exercise 18 13
Vision 8 6
Hearing 8 6
Communication 13 9
Swallowing 7 5
Nutrition 6 4
Weight management 8 6
Pain 12 9
Headaches/ Migraines 9 7
Seizures 0 0
Continence 13 9
Activities of daily living 13 9
Mobility 9 7
Number (n)
of unmet
needs
identified
Percentage (%)
of individuals
presenting with
unmet need
Falls 10 7
Depression 26 19
Anxiety 20 15
Emotionalism 4 3
Personality changes 16 12
Sexual health 4 3
Fatigue 47 34
Sleep pattern 11 8
Memory,concentn and attention 35 26
Driving 13 9
Transport and travel 7 5
Activities and hobbies 11 8
Employment 9 7
Benefits and finances 25 18
House and home 10 7
Carer/ Supporter needs 11 8
Other 3 2
TOTAL 464
17. Registered Charity Number 211015
Needs and Actions
Actions fell into 4 categories:
1. provision of information and advice.
2. refer to other services.
3. signpost to other services.
4. advise to make an appointment with primary care team.
19. Registered Charity Number 211015
Needs and Actions
92 (20%) of the unmet needs identified were addressed by signposting.
14% benefits services (e.g. CAB); 7% local exercise opportunities.
Others: carers’ centres, opticians, smoking cessation services, providers
of aids and adaptations.
20. Registered Charity Number 211015
Needs and Actions
Number of referrals
Audiology 3
Communication support service 3
Continence advisory service 5
Counselling service 2
Dietetics 1
Falls clinic 2
Falls prevention service 1
Occupational therapy 4
Physiotherapy 3
Psychology 2
Social services 5
Speech and language therapy 5
Visual impairment service 1
TOTAL 37
14% of all referrals were
made to each of the
following services:
Social services
Speech and language therapy
Continence advisory services
11% of all referrals were
made to:
Occupational therapy
21. Registered Charity Number 211015
Needs and Actions
To address 98 (21%) of the unmet needs identified service users
were advised to make an appointment with their primary care
team.
Primary reason was that the service user’s blood pressure was
not being checked on a ‘regular basis’.
22. Registered Charity Number 211015
Needs and Actions
Of all service users reviews:
- 10% directed to discuss side effects from their medication;
- 9% to discuss their pain;
- 4% depression; 3% falls; 3% problems with their memory,
concentration and attention.
23. Registered Charity Number 211015
Service User Feedback
74% response rate [101/137 completed questionnaires returned]
Service user review ratings:
24. Registered Charity Number 211015
Service User Feedback
“All my needs and concerns were addressed (at my review)”
o 46% strongly agreed; 49% agreed.
“ My Stroke Association Coordinator knew how to help me”
o 59% strongly agreed; 39% agreed.
“ I was given all the information and advice I needed”
o 98% strongly agreed or agreed.
25. Registered Charity Number 211015
Service User Feedback
Service users indicated that the review made them feel supported
They found the reviews useful and said that the comprehensive
nature of the review prompted them to discuss issues they
wouldn’t have otherwise discussed (e.g. those relating to sexual
health)
26. Registered Charity Number 211015
Service User Feedback
Service users felt comfortable and at ease during their reviews.
They appreciated the opportunity to talk to
someone who understood stroke and the
impact that it has on people’s lives.
27. Registered Charity Number 211015
IAS Coordinator Feedback
132 questionnaires completed and returned.
“I felt comfortable undertaking the review” and “I knew how to
address the needs and concerns expressed by the service user”
o 66% strongly agreed; 34% agreed.
“I found the assessment tool easy to use”
o 96% strongly agreed or agreed.
28. Registered Charity Number 211015
IAS Coordinator Feedback
Direct time with service user= average 74 minutes (range 20-195)
Indirect time= average 33 minutes
Additional time needed to undertake review compared to a
routine home visit= 33 minutes (range 0-150 minutes)
30. Registered Charity Number 211015
Discussion
Problems experience by stroke survivors in the long term are
diverse and, in some cases, numerous.
Span health and psychosocial domains.
Emphasis needs to be placed on identification and helping
people access any specialist help or advice they require.
31. Registered Charity Number 211015
Discussion
Coordinators were confident in their skills and abilities.
GM-SAT provided a structured, standardised framework.
Service users were had confidence in their coordinators abilities.
Stroke specialist knowledge and understanding highly valued.
Service users felt comfortable and at ease. Probably due to the
continuity of care offered by the IAS service.
32. Registered Charity Number 211015
Discussion
The review took longer to complete but varied significantly.
Additional benefits:
o actions could be aligned to long term goals.
o needs could be monitored.
o in complex cases, actions could be prioritised.
33. Registered Charity Number 211015
Discussion
IAS Coordinators are well placed to deliver post-stroke reviews,
using GM-SAT.
Several key cross organisational challenges will need to be
addressed if the benefits reported here are to be realised.
34. Registered Charity Number 211015
Discussion
This project has demonstrated that The Stroke Association’s IAS
coordinators provide a practical, appropriate, acceptable and
potentially cost-effective means of delivering the six month review in a
way that is highly valued by stroke survivors, their carers and families.