Technology transfer plan & exhibit Akshay Nehe
1. The presentation describes the steps for performing a successful technology transfer in the pharmaceutical industry, including feasibility studies, scale-up, exhibit batches, stability studies, and process validation batches.
2. A key part of the technology transfer is developing a technology transfer plan that describes the items and contents being transferred along with detailed procedures and a transfer schedule.
3. Successful technology transfers require effective communication, overcoming challenges through risk assessment, and commitment between the transferring and receiving parties.
The document discusses the growing interest in coordinated and integrated healthcare delivery through models like patient-centered medical homes (PCMHs) and accountable care organizations (ACOs). It notes the potential benefits of these models, including improved quality of care and reduced costs. Specifically, it cites evidence that Geisinger Health System achieved a 9% reduction in total healthcare costs and lower hospital admission and readmission rates through implementing a PCMH-based accountable care model. The long-term goal is for PCMHs and ACOs to transform healthcare delivery in the US to a more coordinated, high-value system focused on primary care.
Meaningful Use Stage Two: The Future of Care CoordinationGreenway Health
The future of Meaningful Use has many over-arching effects on the health care industry beyond Stage Two measures. Care coordination teams, technology partnerships, data capture, practice redesign, and provider assessment are a few others to be considered when moving forward.
This document discusses the need for person-centered care approaches in long term care settings for individuals with dementia. It outlines key concepts of person-centered care including validating individual experiences and meeting underlying needs to reduce behaviors. Effective training models like VIPS and assessments like Dementia Care Mapping are described. Barriers to implementation include staff turnover, but research shows person-centered care can improve outcomes for residents and staff.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the care plan. Learn the essential components of a resident-centered care plan, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.
1. Gain an understanding of the purpose of a Care Plan.
2. Learn to define the purpose of the discharge Care Plan and Summary.
3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.
4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.
How to care plan: when, where, how, why, who. Learm how to create person centered care plans that imporve quality of life, satisfy regulators, and make areal difference
Presentation made by Lynne Seward, CEO, A Grace Place Adult Care Center and Jay White, MS, Virginia Commonwealth University, Department of Gerontology, October 31, 2012. Review recording of webinar at www.alzpossible.org
Technology transfer plan & exhibit Akshay Nehe
1. The presentation describes the steps for performing a successful technology transfer in the pharmaceutical industry, including feasibility studies, scale-up, exhibit batches, stability studies, and process validation batches.
2. A key part of the technology transfer is developing a technology transfer plan that describes the items and contents being transferred along with detailed procedures and a transfer schedule.
3. Successful technology transfers require effective communication, overcoming challenges through risk assessment, and commitment between the transferring and receiving parties.
The document discusses the growing interest in coordinated and integrated healthcare delivery through models like patient-centered medical homes (PCMHs) and accountable care organizations (ACOs). It notes the potential benefits of these models, including improved quality of care and reduced costs. Specifically, it cites evidence that Geisinger Health System achieved a 9% reduction in total healthcare costs and lower hospital admission and readmission rates through implementing a PCMH-based accountable care model. The long-term goal is for PCMHs and ACOs to transform healthcare delivery in the US to a more coordinated, high-value system focused on primary care.
Meaningful Use Stage Two: The Future of Care CoordinationGreenway Health
The future of Meaningful Use has many over-arching effects on the health care industry beyond Stage Two measures. Care coordination teams, technology partnerships, data capture, practice redesign, and provider assessment are a few others to be considered when moving forward.
This document discusses the need for person-centered care approaches in long term care settings for individuals with dementia. It outlines key concepts of person-centered care including validating individual experiences and meeting underlying needs to reduce behaviors. Effective training models like VIPS and assessments like Dementia Care Mapping are described. Barriers to implementation include staff turnover, but research shows person-centered care can improve outcomes for residents and staff.
In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the care plan. Learn the essential components of a resident-centered care plan, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.
1. Gain an understanding of the purpose of a Care Plan.
2. Learn to define the purpose of the discharge Care Plan and Summary.
3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.
4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.
How to care plan: when, where, how, why, who. Learm how to create person centered care plans that imporve quality of life, satisfy regulators, and make areal difference
Presentation made by Lynne Seward, CEO, A Grace Place Adult Care Center and Jay White, MS, Virginia Commonwealth University, Department of Gerontology, October 31, 2012. Review recording of webinar at www.alzpossible.org
Evaluating Transitions of Care Processeshedavidson
This document discusses evaluating improvements in care transitions between healthcare settings. It provides an overview of common issues during care transitions like medication errors and lack of communication. The document then proposes evaluating the transition of patients from nursing homes to hospitals and back using a framework involving structure, process, and outcome measures. Key parts of the evaluation are identifying areas to measure like information transfer, developing an evaluation matrix, assessing current performance over time, and ensuring proper IRB review.
Patients are receiving disjointed care in the present expensive system. Changing the model:
- Identifying the components of The Transformed System; affordable, accessible, seamless, and coordinated plus high quality, person and family centered, and clinically supportive
- Listing ways to develop partnerships that create strong symbiotic teams
- Creating Care and Operation Interventions that integrate with Care Transitions, Guided Care in the PCMM(H), and ACO models
This presentation was developed by the Texas Culture Change Coalition to serve as a tool to inform others about the background and principles of culture change in long term care.
Please feel free to use it as a whole or in part to inform others about the benefits of culture change.
The document summarizes changes to the 2016 requirements for meaningful use of electronic health records (EHRs). Key changes include replacing core and menu objectives with a single set of objectives and measures for eligible professionals (EPs) and hospitals. EPs have 10 objectives and hospitals have 9 objectives. The objectives focus more on patient outcomes than technology use. Providers will also have more flexibility to customize goals. Audits of EHR meaningful use attestations will continue to ensure compliance. Providers should maintain documentation for at least 6 years to support any audits.
- Evidence-based practice uses systematically reviewed scientific evidence to make nutrition practice decisions by integrating best available evidence, professional expertise, and client values.
- Implementing evidence-based practice provides benefits like improved quality of care, increased patient safety, and enhanced professional status and confidence.
- The evidence-based practice process involves defining questions, reviewing literature, analyzing evidence, developing conclusions and recommendations, and disseminating results.
The document provides an overview of the introductory session of an ICT integration course. It includes instructions for students to sign in, update their details, browse course resources online, and set up a group blog. An outline of the course content is also given, covering topics like what is ICT, why integrate ICT, and MOE's IT masterplans. Students are required to introduce themselves on the course wiki and describe a meaningful learning experience.
Nursing theory provides a framework to organize nursing knowledge and explain phenomena in nursing practice. Theories are composed of concepts and propositions, and can be classified based on their scope, purpose, and philosophical underpinnings. Historically, nursing relied on theories from other disciplines but has increasingly developed its own theories over the past century. Key developments include Nightingale's Environmental Theory in 1860, Henderson's Definition of Nursing in 1955, and theories by Rogers, Orem, Roy, and Watson from the 1970s onward. Nursing theory continues to evolve as the profession seeks consensus on its conceptual foundations.
This document discusses 20 different nursing theories and 3 moral theories. It provides an overview of each theory, including the theorist and key concepts. Some of the major nursing theories covered include Florence Nightingale's focus on the patient's environment, Faye Abdellah's 21 nursing problems, Virginia Henderson's 14 basic human needs, and Betty Neuman's health care systems model. The moral theories briefly discussed include Freud's superego, Erickson's virtues, and Kohlberg's stages of moral development.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The document summarizes a presentation by Paul Grundy on extracting value from the patient centered medical home model. It discusses:
1) How the patient centered medical home model creates partnerships across the healthcare system to drive primary care redesign, offer population health management, and move away from an episodic, fee-for-service model.
2) Studies that show improvements in costs, quality, access, and utilization from implementing the patient centered medical home model, including reduced hospital and ER use.
3) How payment models are shifting towards value-based purchasing tied to quality, utilization, and patient satisfaction outcomes rather than volume of services.
Imagine a healthcare system where people live long, healthy lives, receiving quality, affordable care, with clinicians nationwide collaborating to improve outcomes. That's Accountable Care! Learn the benefits of becoming an ACO in this insightful eBook.
The document outlines an agenda for a presentation on new models for aligning value-based incentives with physicians, systems, and payers. The agenda includes discussions on Humana's commitment to population health, Transcend's partnership framework and value-based reimbursement models, a physician perspective from Chauhan Medical Center in Florida, and how Saint Luke's Health System in Kansas City is preparing for the transition from fee-for-service models. An interactive session will examine organizational readiness to transform from volume-based to value-based care through discussions on clinical integration, leadership capabilities, physician engagement, market strength, and relationships with business partners.
A preliminary proposal for an application to the Health Care Innovation Challenge sponsored by CMS. Focus of this proposal include gestational diabetes, maternal obesity, postpartum weight loss, and as well as patient engagement / health literacy
Innovation in Care Delivery: The Patient JourneyJane Chiang
The document describes innovations in care delivery at Massachusetts General Hospital aimed at improving the patient experience. It discusses the implementation of innovation units to test changes to care delivery and identifies three key areas of focus: implementing relationship-based care, enhancing the role of the attending nurse, and standardizing processes. The goals are to improve patient and staff satisfaction, clinical quality, and reduce costs.
The changing landscape of health care in the US -- drivers and outcomesGregory Travis
The United States has the worst health care outcomes among its OECD peers. It also has the highest health care costs within the OECD. What are the reasons for this and what changes can we anticipate going forward?
This document discusses the patient-centered medical home (PCMH) model and its benefits. It provides examples of organizations that have implemented PCMH initiatives to improve care coordination, access, costs and outcomes. Key points include:
- PCMH aims to strengthen primary care through care coordination, enhanced access, quality improvement and payment reform.
- Studies show PCMH can reduce costs by decreasing ER visits and hospital days while improving outcomes.
- Several large employers, the Department of Defense, and state governments have adopted PCMH models for the populations they insure.
- Successful PCMH models integrate primary care, specialists, hospitals, and community resources through use of health IT, data sharing and care
Evaluating Transitions of Care Processeshedavidson
This document discusses evaluating improvements in care transitions between healthcare settings. It provides an overview of common issues during care transitions like medication errors and lack of communication. The document then proposes evaluating the transition of patients from nursing homes to hospitals and back using a framework involving structure, process, and outcome measures. Key parts of the evaluation are identifying areas to measure like information transfer, developing an evaluation matrix, assessing current performance over time, and ensuring proper IRB review.
Patients are receiving disjointed care in the present expensive system. Changing the model:
- Identifying the components of The Transformed System; affordable, accessible, seamless, and coordinated plus high quality, person and family centered, and clinically supportive
- Listing ways to develop partnerships that create strong symbiotic teams
- Creating Care and Operation Interventions that integrate with Care Transitions, Guided Care in the PCMM(H), and ACO models
This presentation was developed by the Texas Culture Change Coalition to serve as a tool to inform others about the background and principles of culture change in long term care.
Please feel free to use it as a whole or in part to inform others about the benefits of culture change.
The document summarizes changes to the 2016 requirements for meaningful use of electronic health records (EHRs). Key changes include replacing core and menu objectives with a single set of objectives and measures for eligible professionals (EPs) and hospitals. EPs have 10 objectives and hospitals have 9 objectives. The objectives focus more on patient outcomes than technology use. Providers will also have more flexibility to customize goals. Audits of EHR meaningful use attestations will continue to ensure compliance. Providers should maintain documentation for at least 6 years to support any audits.
- Evidence-based practice uses systematically reviewed scientific evidence to make nutrition practice decisions by integrating best available evidence, professional expertise, and client values.
- Implementing evidence-based practice provides benefits like improved quality of care, increased patient safety, and enhanced professional status and confidence.
- The evidence-based practice process involves defining questions, reviewing literature, analyzing evidence, developing conclusions and recommendations, and disseminating results.
The document provides an overview of the introductory session of an ICT integration course. It includes instructions for students to sign in, update their details, browse course resources online, and set up a group blog. An outline of the course content is also given, covering topics like what is ICT, why integrate ICT, and MOE's IT masterplans. Students are required to introduce themselves on the course wiki and describe a meaningful learning experience.
Nursing theory provides a framework to organize nursing knowledge and explain phenomena in nursing practice. Theories are composed of concepts and propositions, and can be classified based on their scope, purpose, and philosophical underpinnings. Historically, nursing relied on theories from other disciplines but has increasingly developed its own theories over the past century. Key developments include Nightingale's Environmental Theory in 1860, Henderson's Definition of Nursing in 1955, and theories by Rogers, Orem, Roy, and Watson from the 1970s onward. Nursing theory continues to evolve as the profession seeks consensus on its conceptual foundations.
This document discusses 20 different nursing theories and 3 moral theories. It provides an overview of each theory, including the theorist and key concepts. Some of the major nursing theories covered include Florence Nightingale's focus on the patient's environment, Faye Abdellah's 21 nursing problems, Virginia Henderson's 14 basic human needs, and Betty Neuman's health care systems model. The moral theories briefly discussed include Freud's superego, Erickson's virtues, and Kohlberg's stages of moral development.
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The document summarizes a presentation by Paul Grundy on extracting value from the patient centered medical home model. It discusses:
1) How the patient centered medical home model creates partnerships across the healthcare system to drive primary care redesign, offer population health management, and move away from an episodic, fee-for-service model.
2) Studies that show improvements in costs, quality, access, and utilization from implementing the patient centered medical home model, including reduced hospital and ER use.
3) How payment models are shifting towards value-based purchasing tied to quality, utilization, and patient satisfaction outcomes rather than volume of services.
Imagine a healthcare system where people live long, healthy lives, receiving quality, affordable care, with clinicians nationwide collaborating to improve outcomes. That's Accountable Care! Learn the benefits of becoming an ACO in this insightful eBook.
The document outlines an agenda for a presentation on new models for aligning value-based incentives with physicians, systems, and payers. The agenda includes discussions on Humana's commitment to population health, Transcend's partnership framework and value-based reimbursement models, a physician perspective from Chauhan Medical Center in Florida, and how Saint Luke's Health System in Kansas City is preparing for the transition from fee-for-service models. An interactive session will examine organizational readiness to transform from volume-based to value-based care through discussions on clinical integration, leadership capabilities, physician engagement, market strength, and relationships with business partners.
A preliminary proposal for an application to the Health Care Innovation Challenge sponsored by CMS. Focus of this proposal include gestational diabetes, maternal obesity, postpartum weight loss, and as well as patient engagement / health literacy
Innovation in Care Delivery: The Patient JourneyJane Chiang
The document describes innovations in care delivery at Massachusetts General Hospital aimed at improving the patient experience. It discusses the implementation of innovation units to test changes to care delivery and identifies three key areas of focus: implementing relationship-based care, enhancing the role of the attending nurse, and standardizing processes. The goals are to improve patient and staff satisfaction, clinical quality, and reduce costs.
The changing landscape of health care in the US -- drivers and outcomesGregory Travis
The United States has the worst health care outcomes among its OECD peers. It also has the highest health care costs within the OECD. What are the reasons for this and what changes can we anticipate going forward?
This document discusses the patient-centered medical home (PCMH) model and its benefits. It provides examples of organizations that have implemented PCMH initiatives to improve care coordination, access, costs and outcomes. Key points include:
- PCMH aims to strengthen primary care through care coordination, enhanced access, quality improvement and payment reform.
- Studies show PCMH can reduce costs by decreasing ER visits and hospital days while improving outcomes.
- Several large employers, the Department of Defense, and state governments have adopted PCMH models for the populations they insure.
- Successful PCMH models integrate primary care, specialists, hospitals, and community resources through use of health IT, data sharing and care
Working with Regulators: A Focus on CMS | June 24, 2014 | All SlidesCancerSupportComm
CMS is seeking input from patient advocacy groups like the Cancer Support Community on developing quality measures that focus on issues that matter most to patients and caregivers. CMS measures quality of cancer care across different settings and aims to align measures across public and private payers to reduce reporting burden and consistently focus on important patient issues. CMS oversees large healthcare programs that impact over 100 million Americans and seeks to transform the healthcare system to make it more patient-centered, outcomes-focused, coordinated, and sustainable.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
The document discusses various perspectives on quality healthcare including those of the government, patients, and healthcare providers. It outlines the government's national strategy for quality improvement and focuses on better care, healthy communities, and affordable costs. The patient perspective values compassionate care, time with physicians, timely appointments, and preventative programs. Providers value proven outcomes and reduced errors. The document also discusses opportunities to lower costs through standardized care and reducing unnecessary variations in treatment and costs. It provides examples of accountable care organizations and bundled payments that aim to improve care coordination and reduce costs.
Roundtable on Critical Care 2013 Summit Jon Broyles
The Coalition to Transform Advance Care (C-TAC) is a national nonprofit alliance of various healthcare stakeholders united to improve end-of-life care. C-TAC's vision is for all Americans with advanced illnesses to receive high-quality, personalized care consistent with their goals and values. Its mission is to transform end-of-life care through empowering consumers, improving healthcare delivery and policies, and enhancing provider training. C-TAC addresses key issues like care planning, education, quality standards, and payment reforms to overcome barriers like uncoordinated care and a lack of standards.
The documents discuss changes in the US healthcare system focusing on quality improvement initiatives. It summarizes frameworks from the Institute for Clinical Systems Improvement (ICSI) and Regional Health Improvement Collaboratives (RHIC) that provide guidelines and coordinate multi-stakeholder efforts to reform payment systems, improve care delivery, and increase community health. It also describes the Quality Alliance Steering Committee's (QASC) work measuring healthcare quality nationally through organizations like MN Community Measurement. The overall goal is to shift focus from sickness to prevention by increasing access to high-quality, coordinated care.
An Insider's Guide to Working with CMS - Shari LingCancerSupportComm
This document summarizes a presentation given by Shari Ling, Deputy Chief Medical Officer at CMS, to the Cancer Policy Institute at the Cancer Support Community. Some key points:
- CMS is focused on developing more patient-centered quality measures that assess outcomes important to patients and caregivers. They welcome input from patient advocacy groups.
- CMS aims to align quality measures across different healthcare settings to reduce reporting burden and focus measurement on the issues that matter most to patients.
- CMS is responsible for administering Medicare, Medicaid, and other large healthcare programs, and uses quality measurement to incentivize higher quality, more coordinated care, and payment reform efforts like value-based purchasing.
VBP, Delivery System Reform, and Health and Social ServicesAndré Thompson, MPA
This document discusses the transition from fee-for-service to value-based payment models in healthcare. It explains that fee-for-service results in poor outcomes and high costs. Value-based payment ties provider reimbursement to outcomes like quality and cost. The document outlines key components of value-based payment implementation including delivery system reform, payment reform, performance measurement, and population health management. It notes that social services organizations will need to demonstrate their value and be accountable for outcomes as the healthcare system shifts its focus to addressing social determinants of health.
The document discusses the patient-centered medical home (PCMH) model of care delivery. It provides evidence that PCMH is associated with improved outcomes, lower costs, and a better experience of care compared to the traditional fee-for-service model. The document argues that widespread adoption of PCMH is needed to transform healthcare delivery and address issues of cost, quality and access.
Similar to ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health (20)
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
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Digital Artefact 1 - Tiny Home Environmental Design
ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health
1. ACOs, Transitions of Care, Patient Centered
Medical Homes, Care Transitions: What Do
They Mean for Home Health?
Presented by:
Susan Carmichael
MS, RN, CHCQM, COS-C, ICM, FAIHQ
EVP, Chief Compliance Officer
SELECT DATA
2. Objectives
Patients are receiving disjointed care in the present
expensive system. Changing the model:
– Identifying the components of The Transformed
System; affordable, accessible, seamless, and
coordinated plus high quality, person and family
centered, and clinically supportive
– Listing ways to develop partnerships that create
strong symbiotic teams
– Creating Care and Operation Interventions that
integrate with Care Transitions, Guided Care in the
PCMM(H), and ACO models
3. THE STATE OF HEALTH CARE
Scary, Expensive, and Inconsistent
4. The Scary: Safety is an issue
– Airline Safety: > 99.999999
• Airline Baggage Handling: > 99.999
• B-Blocker p MI: 70 – 99%
• Immunization: 55 – 94%
• MD Hand Hygiene in ICU: 3 – 40% REALLY!
5. Quality, Safety, Efficiency
– Imagine:
• Imagine an industry (or a company within an industry) with poor
quality (or safety); would you invest ?
– Categories of Poor Quality (Safety) in Healthcare
• Underuse: Vaccines, Beta-Blockers
• Overuse: Spine Surgeries, Cardiac Procedures
• Misuse: Calcium Channel Blockers as First-Line for Hypertension
• Safety: Healthcare Associated Infections, Medication Errors
– Inefficiencies may mean different things to payors,
providers and patients due to misaligned incentives . . .
– High Performance, Safer Care most efficient for all,
especially in the emerging “limited warranty” environment
of healthcare
6. INTRODUCTION
As a percentage of GDP, health care
expenditures are about 18%. By 2019, the
national health care expenditures will be
19.3% and approaching an unsustainable level.
Innovative approaches to quality healthcare must
be found.
Let’s discuss these new Chronic Care Models in
general and Transitions in Care, ACOs, and the
Patient Centered Medical Model in particular
7. Chronic Illness in the US
– The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do better.
– Over 145 million people - almost half of all Americans -
suffer from asthma, depression and other chronic conditions.
– Over eight percent of the U.S. population has been diagnosed
with diabetes.
– All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as
healthy as possible through planning, proven strategies and
management.
We must find new meaningful REAL interventions
8. The Experts Say…
– That in 10 years hospitals will essentially focus as ICUs
– Med Surg will basically be provided in the home
– Expect costs to be bundled into episodes; from
hospital admission to post acute to home care
– Expect costs to be measured in full care of clinically
defined episodes
– Clinical continuums will replace length of stay based
care
– Agencies will be measured by care transition
capabilities and the value of their outcomes
11. Mrs. Ruth Smith
• 77 year old widow alert oriented
• Retired school teacher, lives alone
• Receives pension, SS, Medicare
• 4 chronic conditions
• Three physicians
• Son lives 12 miles away with wife and 3 children
• Mrs Smith is a part of a disjointed healthcare
system
12. Mrs. Ruth Smith: In 2012
• 14 prescriptions, 9 meds
– 10 physician and clinic visits
– 1 hospital admit
– 1 23 hour observation
– 4 weeks sub acute care
– 2 nursing homes
– 6 months home health care
– 2 home health agencies
– Overseen by: 7 physicians, 6 social workers, 5 PTs,
3 OTs, 42 nurses
– Who is coordinating her care?
14. Everyone is in a Hurry
– No one individual sits with her
and hears her concerns and needs.
– Hurried, one problem physician visits
– Discharges from each level of care with
discontinuity through the transitions of care
– As a nation, it is felt that we can do better and it is
expected that we will.
15. Let’s Look at Care Another Way
• Presently, here is what is driving healthcare:
• Policy and Regulation What do you think of when the surveyor arrives?
• Payment Methodology means
• Provider Care = The Patient’s Health Care?
•
• Future Delivery of Care Must be Driven in the Following Order:
• Patient’s Health Needs
• Provider Care
• Payment Methodology
• Policy and Regulation
•
•
•
16. Research Showing…..
– Current Healthcare Delivery System is ineffective
and Riddled with Gaps
– Trying Harder Using the Present System will
Change Little
– THERE IS A NEED TO CHANGE THE HEALTHCARE
SYSTEM
– Technology is Not the Solution. It is a Tool for the
New Care Delivery Systems
17. Chronic Care Needs
– Almost half of all Americans - suffer from
asthma, depression and other chronic conditions
such as Heart Failure, COPD, CAD, and over
eight percent of the U.S. population has
been diagnosed with diabetes.
– All of this is possible by transforming what is
currently a reactive health care system into one
that is health driven through planning, proven
strategies and management: proactive.
– The US health system is geared for Acute Care
NOT Chronic Care and that is about to Change
18. What we do know……
• Chronic Disease continues to Rise yet our
healthcare system is geared toward ACUTE care
• Care Complexity will Rise
• Poor Transition between Levels of Care
• Poor Coordination between Levels of Care
• Poor Use of Evidenced- Based Care
• Care is Provider Directed not Patient Centered
• Clinicians Attempt to “Teach” Patients with Poor
Understanding of How Individuals Learn
19. CMS Mandates Quality Initiatives
The CMS “Triple Aim” Goals
1. Better Health for the Population
2. Better Care for Individuals
3. Lower Cost through Improvement of
Care Delivery
20. Institute of Medicine 2012
– Need to improve re Falls, Medication
Reconciliation, Pressure Ulcers, Depression, and
NUTRITION Yes, NUTRITION
– Medicare Patients now see average of 7
physicians, including 5 specialists amongst 4
different practices (Pham et al, 2008)
– Multiple providers means poor coordination,
confusion as to care, and poor accountability
21. The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians, yes,
Clinicians
22. CMS Created the INNOVATION
CENTER
The purpose is to “test innovative payment and service
delivery models to reduce program expenditures…while
preserving or enhancing the quality of care furnished.”
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move
them to the national level
http://www.healthcare.gov/center/programs/partnership/joinin/index.html
23. Method of Payment
F Fee-for Service- For a specific volume of service there will be a
negotiated fee
Sharing of Savings- CMS and the investing provider will share if
interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume
of care plus additional incentives for managing costs, quality, and
patient experience
Risk –Sharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
25. Innovations
Federal Coordinated Care: 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for
Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core
Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable
Care Organizations
26. Several Innovative Projects
Community-based Care Transitions Program
(CCTP) and 6 models
= 1.Care Transitions Programs
= 2.Patient-Centered Medical Home
= 3.Guided Care Nurse-Physician Models
= 4.Comprehensive Care Coordination
Models
= 5.Innovative Academic Partnerships
= 6.Coaching Role Skill Transfer
27. The Shift is
– Moving from Volume to Value
– Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an
expected outcome
– Knowing how to operate at the granular level
– To post acute care within 12-24 hours
– Moving toward Self care management
– Data Integration with specific outcomes
measurement
– Specific education in home care
28. inadequate information and training at discharge were themes
that spanned all groups,
– Transitions
– To home
30. Care Transition Model
– Where did the model originate? Colorado, 2000
– Dr Eric Coleman wrote extensively and validated
research regarding the model. It has solid aims:
• Support patients and families
• Increase skills among healthcare providers
• Enhance ability of health information technology to promote
health information exchange across care settings
• Implement system level interventions to improve quality and
safety
• Develop performance measures and public reporting
mechanisms and
• Influence health policy at a national level
• DO YOU RECOGNIZE MANY OF THESE MEASURES?
31. American Geriatrics Society defines
Transitional Care as…
– A set of actions designed to ensure the coordination and
continuity of health care as patients transfer between
different locations or different levels of care within the same
location. May include (but not limited to) hospitals, sub acute
and post acute nursing facilities, the patient’s home, primary
and specialty care offices, and long term care facilities.
Transitional care is based on a comprehensive plan of care and
the availability of health care practitioners who are well
trained in chronic care and have current information about the
patient’s goals, preferences, and clinical status. It includes
logistical arrangements, education of the patient and family, and
coordination among the health professionals involved in the
transition.
32. The Coleman Model
– Heavily funded by both the John A. Hartford and
Robert Wood Johnson Foundation, this is a
patient-centered, interdisciplinary intervention
model consisting of a structured preparation
checklist used when moving from one level to
another and includes a patient self-activation and
management session with a TRANSITION COACH
who is an RN which includes follow up visits to
either the SNF or home
33. The Four Pillars of the Model
– 1. Medication self management. Patient is
knowledgeable about their meds and has a med
management system
– 2. Uses a dynamic patient-centered record.
Understands and uses their record to facilitate
communication and ensure continuity
– 3. Patient schedules and completes follow up with the
primary care physician and specialists and is
empowered to be active participant in interactions
– 4. Knowledge of RED Flags or indicators that their
condition may be worsening and how to respond
34. Sample items on Discharge
preparation checklist
I have been involved in decisions about what will take
place after I leave the facility
I understand where I am going after I leave the facility
and what will happen once I arrive
I have the name and phone number of a person I
should contact if a problem arises during my transfer
I understand the potential side effects of my
medications and whom I should call if I experience
them
I understand how to keep my health problems from
becoming worse.
And there are a few more…
35. Transitional Care is…
– The movement of patients from one health care
practitioner or setting to another in care of
conditions and patients changing needs should be
complete
– Within settings: Primary Care to Specialty Care
– Between Settings: Acute to Sub-acute facilities to
Ambulatory clinics
– Across Health Care Settings: Curative Care to Palliative
Care to Hospice to Home to Assisted Living
36. Obtain more information
Dr. Eric Coleman on Transitional Coaching
http://www.caretransitions.org
Dr. Chad Boult on the Guided Care Nurse
http://www.guidecare.org
37. The Care Transition(TM) Coach
– This is a proprietary Training Program on the Care
Transitions Program
– Many programs using these concepts are also using a
coach
– If working with a Certified Care Transitions Program,
one will use the 15 item uni-dimensional measure to
assess quality of the care transition. This measure has
had psychometric testing to validate findings from one
location to another level
– Medication Discrepancy Tool
38. Care Transitions Interventions
– Recognized by Dr Eric Coleman
– One day course in Aurora, Co
– To become Trainer to Train others
• Must complete CTI training
• Be employed in Healthcare
• Complete app to become trainer and submit w DVD
conducting home visit using CTI
• Take trainer course
• Complete another 30 CTI and second home visit DVD
39. Another transitional care type
training: ICM
– Integrated Care Management provided by Sutter
Center for Integrated Care
– 1 day course
– To be qualified as Train the Trainer:
Must complete 1 day course
Must complete 4 on-line modules on
Heart failure
Diabetes
COPD
Depression
Must Complete online Exam and pass within 80%+
40. National Transitions of Care
Coalition
• Resources to assist to establish a Transitional Care Program
• NTOCC provides tools and resources
• www.ntocc.org
• NTOCC reports “Yesterday, May 22, 2012, the Patient-Centered Outcomes
Research Institute (PCORI) Board of Governors approved the final version
of its National Priorities for Research and Research Agenda, a framework
to guide the funding of comparative clinical effectiveness research that
seeks to give patients and those who care for them the ability to make
better-informed health decisions.”
41. NTOCC Seven Essential
Intervention Categories
1. Medication Management
2. Transition Planning
3. Patient/Family Engagement/Education
4. Information Transfer
5. Follow-up Care
6. Healthcare Provider Engagement
7. Shared Accountability across Providers and
Organizations
Http://www.ntocc.org/Toolbox/browse/?attributes=61
42. Partnership for Patients
Secretary Sebelius has launched a nationwide public-
private partnership to improve care transitions.
By the end of 2013, goals of preventable complications
during a transition from one care setting to another should be
decreased such that all hospital readmissions would be reduced
by 20% compared to 2010.
Achieving this goal would mean more than 1.6 million
patients from illness without suffering a preventable
complication requiring rehospitalization within 30 days of
discharge. Potential savings $35 B over 3 years.”
43. Expect
– To retrain the Workforce to Move to a Strategic
Outcome Focus
– If your Program is not Evidence Based or Best
Practice driven, expect not to be considered
– Residual and Preventive Care will be the focus
– Expect scrutiny at all levels
45. Vanguard Health Systems
– Already actively involved with fixed episodic
payment charges for knee and hip replacements
– Have obtained physician buy in
– Home health must provide evidenced based
programs with proven outcomes or not
considered
– Expect home care rehab in 3-7 visits
– Patients pay $150.00 co-pay to be a part of the
program
– Use of Care Navigating Nurse
46. CCTB
– For more information and guidance on starting
programs, visit
http://www.cms.gov/DemoProjectsEvalRots
/MD/itemdetail.asp?itemID-CMS1239313
– Direct questions to CMS regarding Care Transition
Programs at
– CareTransitions@cms.hhs.gov
47. Websites you may wish to explore
http://caretransitions.org
http://www.ipro.org/index/ct-care-transitions
http://www..cfmc.org/integratingcare/toolkit.htm
http://innovations.cms.gov/initiatives/Partnerships-for-
Patients/CCTP?index.html
http://nextstepincare.org
49. Dominican Sisters Family Health Service
– Looked at their Care Transition Intervention
Program
– They looked at reducing rehospitalizations
– 1 in 5 hospitalizations occur within 30 days of
hospital discharge
– 64% post acute care patients need visits sooner and
need to be at self-management level
– 1 in 4 hospitalizations are avoidable
– JAMA, April 10, Commonwealth Fund, 2009
50. They Looked at the Patient
Perspective
From the AARP Report on Chronic Care: A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post
hospital discharge
Nearly 1 in 5 said their transitional care was not well
coordinated (IPRO, 2011)
51. The Dominican Sisters Family Health
Program
Looked at:
Effective Medication programs, the PHR, PCP follow up
appointment, any Red Flags, and results
They looked at the reconciled Med list, Goals, if the
patient brought the PHR to all physician programs, any wt
gains because of the patient DX, and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool
and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme; a COACH
52. The Dominican Sisters Family Health
Service
Identified Goal: To “empower patients and caregivers to
have the skills, knowledge, and confidence to manage
their care and to communicate their needs effectively to
their health care team.”
Per Eric Coleman, MD, MPH, there were 20-40%
decrease in hospital readmissions with improved patient
confidence in managing their care
53. Care Transition Programs w Coaches
University of Colorado, Transition Coaches
Annual cost savings $300,000
At St Luke’s Hospital in Iowa, Enhanced
assessment of post discharge needs on
admission. Rate of compliance for Med
reconciliation increased 75%
Louisiana Health Care using a Health
Coach, day hospital readmission rates from
19% to 4%
Is there an opportunity for your home health
agency if coaches are being considered at the
hospitals? ARE they being considered?
55. Care Coordination Barriers
– Practitioner level barriers such as…
– System level barriers such as…
– Patient level barriers such as…
56. Many Physicians Believe
•There is a better way…
They are looking to transform their
primary care practices into Patient
Centered Medical Homes
What does that mean?
57. CMS and PCMH, rests on five pillars
1. Patient-centered orientation directed toward their unique
needs, culture, values, and preferences…
2. Comprehensive, team-based care that meets the majority of
each patient’s physical and mental health needs…
3. Care that is coordinated across all elements of a complex
health care system and connects patients to both medical
and social resources in the community
4. Superb access to care…
5. A systems approach to quality and safety…
58. Improving Care Transitions through PCMH
PCMH is intended to result in more personalized, coordinated,
effective, and efficient care by establishing an ongoing
relationship with a single physician who leads a team at a
single location by:
– Taking collective responsibility for patient care
– Providing for the patient’s health care needs; and
– Arranging for appropriate care with other qualified
clinicians.”
http://www.ncqa.org/Portals/0/PCMH%
59. Back to Mrs. Smith: The Patient and the Family
Mrs. Smith has no one plan to stay healthy and no one
plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her
care
He has called three pharmacists regarding her meds
He is upset and getting angry
60. Mrs. Smith and Disjointed care
Mrs. Smith has no main contact, no single practice monitoring her
condition
Has harried single problem office visits, poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs. Smith is at risk for care fragmentation resulting in an error or
poor care
Mrs. Smith is a prime candidate for a Patient-Centered Medical
Home
61. The PCMH
Patient-Centered Medical Homes are expected to
seek quality outcomes of healthcare
– Requires an interdisciplinary team to take
responsibility to improve access, continuity, and
coordination of care
– Patients and family members are engaged through
education and supporting self-care and disease
management
62. Mrs. Smith is referred to a PCMH
– The PCMH is patient centered providing
healthcare that is relationship based with an
orientation toward the whole person
– This program is comprehensive, team based
primary care reducing cost geared toward a
collaborative model, easy to implement, capable of
providing excellent care to patients with multiple
chronic conditions
– The physician applies to become a PCMH
– The application is indepth and patient centered
63. Guided Care
– Specially trained RNs based in the PCMH
physician offices as Guided Coaches
– The RN collaborates with 3-5 physicians in caring
for 45-60 high risk older patients with multiple
chronic conditions
– The nurse and her “back-up” RN partners with the
patient for the rest of the patient’s life
– This model was initiated in 2002 by John Hopkins
University
64. Guide and Coach are the words
RN will converse, assess, and create an
evidence-based Care Guide (notice they chose
“guide” not “plan”)
The Guided Care RN coordinates care with
other care providers, HH providers, clinics,
and hospitals
The Guided Care RN educates and supports
family and caregivers
This RN also identifies community services
that are most appropriate for this patient and
her needs
65. Guided Care Training John Hopkins
– A limited supply of the following resources are available for free to
organizations that plan to implement the principles of Guided Care
as they become ACOs:
– An online course for nurses. This six-week, 40-hour, web-based course
prepares registered nurses to become Guided Care Nurses. It features
self-paced modules, live webinars and support from expert faculty.
After passing an online exam, nurses receive a “Certificate in Guided
Care Nursing” from the American Nurses Credentialing Center (ANCC).
The course is offered by the Institute for Johns Hopkins Nursing.
– An implementation manual titled “Guided Care: A New Nurse-
Physician Partnership in Chronic Care” provides detailed, practical
information and advice on assessing practice readiness, preparing to
launch, providing and managing Guided Care.
An orientation booklet for patients and families titled
"Transformation: A Family's Guide to Chronic Care, Guided
Care, and Hope," that describes what Guided Care is and how
it can help them
66. Physicians planning Guided Care
Free Technical assistance is available at:
www.GuidedCare.org/adoption.asp
Online courses from John Hopkins Nursing available for RNs,
There are also Physician and family courses
Order the free Implementation Manual:
Guided Care: A New Nurse-Physician Partnership in
Chronic Care
There are also free books and material for families
68. NCQA PCMH Program
– Physician and Nurses become Patient-Centered
Medical Home Certified Content Experts
– Already 5,000 recognized practices nationwide
– Provides deliberate strategies and efforts to transform
a practice into a medical home with PCI content
experts
– Must attend 2 seminars 21/2 days:
– NCQA Facilitating Patient Centered Medical Home
Recognition (1.5 days covering standards)
– NCQA Advanced Topics in PCMH: Mastering NCQA’s
Medical Home Recognition
69. NCQA PCMH Program
– Complete online application after completion of
the seminars
– Prepare for and schedule your exam $395
– Prepare for the survey of the practice
– Keep up to date with NCQA PCMH Standards and
Guidelines
– Last Advanced Topics in PCMH: Mastering NCQA’s
Medical Home Recognition was in New Orleans
1/13
70. NCQA PCMH CONTENT EXPERT
AND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
71. NCQA PCMH CONTENT EXPERT
–Can receive certified status and work with
physicians in this model
–Review more on NCQA
–www.ncqa.org/Programs/REcognition/Patie
ntCenteredMedicalHomePCMH.aspx
72. Guided Care at John Hopkins
• Guided Care was developed by an interdisciplinary
team of health care professionals at Johns Hopkins
University in 2002. In creating the Guided Care model,
the group infused the most current evidence-based
guidelines for managing chronic conditions and the
most effective principles from case management,
disease management, self-management, transitional
care, geriatric evaluation, and caregiver support models
into primary care. Guided Care integrates these
successful innovations into primary care to make
evidence-based, state-of-the-art chronic care available
from professionals the patient trusts
73. Guided Care
– With Guided Care, a registered nurse, who is based
in a primary care office, works closely with 3-4
physicians and health information , as well as
technology to provide state-of-the-art care for 50-
60 chronically ill patients. In partnership with the
primary care physician, the Guided Care Nurse
Coach is responsible for the following clinical
processes:
–Assesses the patient at home, this will be
completed by the physician practice Guided
Care Nurse
74. Guided Care Continued
– Create an evidence-based comprehensive “Care Guide” (a tool
for providers that summarizes the patient’s conditions and
medications, care providers, family members, and other
important data in a succinct and professional format) and
“Action Plan” (a patient-friendly version of the Care Guide).
– Monitor the patient monthly.
– Promote patient self-management.
– Smooth the patient’s transitions between sites of care.
– Coordinate the efforts of all the patient’s health care providers.
– Assess, educate, and support family caregivers.
Facilitate access to community resources
– What is the role for home health?
75. Guided Care
– The Guided Care nurses used a secure web-based EHR that was
created to support Guided Care. The EHR incorporates
evidence-based guidelines for the 15 most prevalent chronic
conditions. The Guided Care nurses used the EHR to do the
following:
– Enter new information about their patients, such as initial
assessment data, changes in health status and medications,
laboratory test results, specialists’ reports, and reminders for
future events.
– Check patients’ medications for possible adverse interactions.
– Generate new and revised evidence-based Care Guides for
providers and Action Plans for patients.
– Document contacts with patients, families, and health care
providers.
– Check for reminders of events or actions scheduled for each day
76. Guided Care Training: John Hopkins
– Go to
http://www.ijhn.jhmi.edu/Images/Documents/FA
QGuidedCareNursing.pdf
– The course is 40 hours and costs $1900.00
77. Home Health Should
Be willing and available with leadership and clinicians to
“up-skill.” Be flexible. Be rapid in response.
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH
constructs
The HH agency should see improvements in goals
attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey?
78. PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed; specialized programs like
heart failure, MI follow up
Look at the most frequent diagnoses and programs you
can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive, prepared, practice teams
Be willing to break away from the traditional Medicare m
Model of care
Consider having Guided Coach Nurses
Consider shared risk
80. The ACO
– The Coker Group (2012) defined the ACO as an
“integrated healthcare delivery system that contracts
to provide a full continuum of services to a defined
patient population with specific financial incentives
established for meeting both quality and cost targets.”
– If you cannot provide Quality with Better Cost you
will not be invited to Participate in the ACO thus no
referrals
– ACOs will choose who they will work with to deliver
care. You need to have programs and outcomes they
need.
81. Looking for Excellence in Healthcare
• The Final Rule requires CMS to “assess the ACO’s
quality and financial performance based on a
population’s use of primary care services at the end of
each year to determine whether a particular ACO should
be credited with improving care and reducing growth in
expenditures compared to a benchmark
population.”(CMS, Summary of Final Rule Provisions
for ACOs under the Medicare Shared Savings Program
(SSP).
• What excellence can your agency demonstrate?
82. ACO Count
– There were 35 ACOs nationwide in June, 2012, over 50%
in California. As of 1/10/13, there were 106 New ACOs
announced by Medicare. As of 4/14 over 360.
– There are 33 quality measures that an ACO must report on
to CMS. These measures are collected by: Patient surveys
(7 measures), data calculated using claims (3 measures),
determined via EHR (1 measure), and via Group Practice
Reporting Option Web Interface (22 measures). These 33
measures are a part of reporting for this year but in years
following the ACOs performance will be directly tied to
certain of the quality measures as well as the following of
one of two tracks.
– There are now over 300 +ACOs nationwide and growing
83. Risk: TRACKS
Various CMS approved risk programs:
In Track 1, the one sided model, ACOs will h
have an upside shared savings opportunity
with no downside risk. but the shared
savings opportunity is less with this model.
– Track 2 is a two sided model requiring the
ACO to share in 60% of both savings and
losses with a cap.
84. ACOs
– At HomeCare 100 in January, 2013, there were several
speakers discussing new ACOs or other care transitions
involving themselves and several hospital groups. The
landscape is changing and changing fast.
– You must conduct an analysis as to needs in your
community then conduct an internal agency gap analysis
as to what is needed, what you plan to do, what resources
you have, and what resources you need. Then make a plan,
choose the strategy, and BEGIN! BEGIN!
–
–
85. ACOs
– Tim Rowan, Editor of Home Care Technology
Report stated at HomeCare 100, “ Through lower
reimbursement rates and more aggressive Z-PIC
audits, CMS seems to be trying to reduce the
number of certified HHAs from the current about
11,000 to as few as 6,000. Survival will largely
depend on ACO partnerships, but two speakers
told of two ACOs that elected to work with only 4
of the 104 HHA in their area” (January, 2013).
86. Be Proactive
– It was stated at HomeCare100 that “as a home
health leader, you need to become more educated
and more aggressive in recognizing the changes
that are taking place in your service area and you
must initiate strategies that position your agency
to be one of the chosen four in your area.”
87. What other leaders are saying…
– Bob Fazzi recently stated, “As a home health
leader, you need to become more educated and
more aggressive in recognizing the changes that
are taking place in your service area and you must
– Initiate strategies that position your agency to be
one of the chosen in your area” (February, 2013).
– Don’t be passive…start gathering data. Be
proactive. BEGIN!
88. Leaders say
– Make reducing hospitalization the Key to your
partnering strategy with ACO or PCMH leaders
– Hospitals are being financially penalized for having
excessive rehospitalization rates
– Home Health can provide excellent care in the home
at a variety of levels.
– We need to demonstrate creatively the extent of the
care with significant outcomes that can be quantified
– You need to know the cost to deliver that care so you
can negotiate smartly
90. Hospital Readmissions Reduction Program
– Payment reduction to hospitals capped at 1%FY
2013, 2% FY2014, 3% FY 2015
– Readmission measures apply first to:
– Acute MI 30 day risk standardized readmission
measure;
– Heart failure 30 day risk standardized readmission
measure;
– Pneumonia 30 day risk standardized readmission
measure
91. Readmission Measures
– Readmission measures are National Quality Forum
endorsed measures
– CMS began counting the specific readmissions
1//1/2012 that occurred within 30 days of
discharge from the index hospitalization
92. Home Health Responses
– MI post acute follow up programs, evidenced-based
as well as collaborative prevention oriented programs
– Heart Failure post acute follow up programs,
evidenced-based as well as prevention oriented
programs
– Pneumonia as above
– Be certain agency coding is at highest level of
specificity with the best sequencing possible and be
certain there is accurate complete documentation to
support EACH code, not just the primary diagnosis.
93. Transitioning into Homecare
– Let’s look at Heart Failure
– Hospitals are motivated to have patients
discharged to post acute care with a commitment
to quality, positive outcomes, and maintaining
patient in the home safely
– That means a strong post acute heart failure
program at your home health agency
94. Visualize the Value
– Don’t throw out the great things you are doing
now…Just show the stats in a stronger manner:
– Med reconciliation what was found? What
interventions? What outcomes? Share the info!
– Show the powerful holistic evaluation of the
patient in their home; 2 floors, 4 dogs, son-in-law
who smokes and lives there. Physical, Social ,
Emotional, Environmental challenges and
supports need to be shown
95. Visualize the Value
– Keep the Focus on programs that support:
– The Quality Measures: Ambulation and transferring as
well as med management
– All outcome measures at or above 85%
– The Process Measures: The Heart Failure Program,
The Wound Care Program,
– The Pressures Ulcer Prevention Program, The
Medication Teaching Program,
– The Falls Risk Program, The Depression Risk Program.
The Immunization Program, The Diabetic Foot Care
Program or the Diabetic/Systemic Care Program
96. Visualize the Value
– The Patient Experience (HHCAHPS): Make certain
clinicians are talking about Pain, Medications
(What they are, What they do, When to Take,
What symptoms are green, yellow, red- What to
do and who to call for each)
97. Initiate an Accelerated Strategic Plan
• You must be strategically focused. Gather
your team together. Brainstorm.
• Conduct the community gap analysis.
• Note augmented programs that you can
make possible
• You have choices. Create new programs that
reduce hospitalizations or augment present
hospital programs or create new outcome
oriented programs that bring additional
value
98. IT IS AN EXCITING TIME!!!
It is a Time of Opportunities
99. Things to DO
– Assess your community. What is needed? Where
can/does your agency fit?
– Assess your agency. What are the strengths;
operationally, compliance wise, financially, HR
wise
– Assess the gap between need and have. List the
assets and those needed
– Assess Technology and Touch. Now look at gaps
again.
100. Integrated Chronic Care Managed Model
Four Pillars
– Build Relationships in community, with patients
and personnel. High Touch Care is achieving High
Results.
– Change Behavior: Supporting Patient Self
Management means few smart not many goals,
– Accessing Expertise: Means Coordinating Care,
Learning motivational interviewing (Sutter Home
Health and Hospice Care and All Maine Health
Agencies)
– Maximizing Technology such as telemonitoring
101. Exciting Changing Times
– Hospitals need Home Care but they need to see
your value. Visit the CEOs, COOs, CNOS
– Demonstrate Your Value
– Be Prepared for their changes
Be Creative, assertive with new programs that
augment theirs with TRUE VALUE
– Do you know that over 30% of clinicians are
expected to be certified in Integrated Chronic Care
Management by end of year? Will you employ
some of those?
102. Self Management
Will you be able to state and prove you promote self
management of patients and that you
Assess Patient/Families for
Current level of self management, for health literacy, for
readiness to change, and for problem solving ability
Teach and coach on needed strategies and activities such
as
Community support groups, provide written material
based on EBP, Life style modifications and health
promotion/ maintenance needs
103. Be PROACTIVE
– Care Transition, Patient Centered Medical Models,
ACOs and Home Care…It is an exciting time. Be a
proactive part of the exciting time.
– Look at the new seamless, coordinated, quality,
person/family-centered model with your
administrative and clinical teams. Where does
your agency fit now? Where will it fit in the
future?
– You must BEGIN!