BrightStar offers private duty home care programs like HANDS and Clinical Pathways to reduce hospital readmissions and improve quality of life. HANDS provides home care after discharge to address issues that arise. Clinical Pathways is a condition-specific, transitional care program focused on reducing negative outcomes and optimizing quality of life through RN visits, education, and monitoring. These programs aim to address the top reasons for readmissions like medication management and lack of home support. They utilize technology, evidence-based practices, and specially trained staff to benefit patients, healthcare systems, and providers through better outcomes and efficiencies.
Avado CEO Dave Chase's presentation to the Collaborative Health Consortium's weekly Pilots and Collaborations Webinar. Dave is doing some leading edge thinking on collaborative care.
This document provides a summary of a presentation about palliative care efforts in Delaware. It discusses the difference between palliative care and hospice, current palliative care programs available in Delaware, and opportunities for expansion. Key points include:
- Palliative care aims to improve quality of life by relieving symptoms for patients with serious illnesses, while hospice focuses on the last 6 months of life after curative treatments stop.
- Delaware has several palliative care programs in hospitals, home care, and long-term care settings, but access could be expanded by having palliative specialists in all hospitals and outside of hospitals.
- Opportunities remain to improve palliative care in Delaware through increasing the number of board
A new mother experienced mild cramping and back/thigh pain during her pregnancy. She noticed clear discharge with blood streaks and asked the nurse questions about her symptoms. The nurse assessed the mother's knowledge deficit and created a care plan to address her short and long-term goals of understanding her physical and psychological changes during pregnancy. The nurse's interventions included education, addressing the mother's questions, and involving her in decision making.
Objectives:
1.To review the need for increased efforts to implement research evidence into bedside practice.
2.To review the need for measurement to identify gaps between best practice and actual practice.
3.To demonstrate why there is a need for increased knowledge translation efforts in critical care and how aCKTION Net proposes to fill this need.
Click the link to view the video http://bit.ly/YpJWTC
The document describes Tunstall's services for reducing avoidable hospitalizations and readmissions. Tunstall provides a range of connected care services including appointment scheduling and reminders, physician referral services, remote patient monitoring, and 24/7 after hours support. They handle nearly 2.5 million calls per year and are committed to supporting partners in delivering positive health outcomes through a dedicated, HIPAA compliant contact center.
Improving Discharge Care for Children with Special Health Care Needs through...LucilePackardFoundation
Being discharged from the hospital is a vulnerable time for families and caregivers of children with special health care needs (CSHCN). Appropriate resources and support are essential for care at home and can prevent complications or readmission. The California-based Nurse-led Discharge Learning (CANDLE) Collaborative brings together interdisciplinary clinicians to improve discharge care delivery for CSHCN. Learn about two new discharge practices: closed-loop medication reconciliation and tailored medication teaching, and multidisciplinary discharge rounds with early discharge notification. Speakers share how these innovative practices can be integrated into existing clinical workflows.
Spotlight on continuing health care in strokeNHS Improvement
Stroke patients often have complex needs that make them eligible for NHS continuing healthcare (CHC) funding. However, the CHC process can be time-consuming and delay discharge from hospitals. Several recommendations are provided to streamline the process, including designating a coordinator, integrating social workers into care teams, and conducting assessments in post-acute settings rather than hospitals. Examples from hospitals in England demonstrate how roles like discharge coordinators and computer systems can reduce duplication and speed up the process.
Bridget Keyes has over 20 years of experience in nursing and case management. She is currently the Manager of Case Management at Robert Wood Johnson University Hospital, where she oversees utilization management activities and works to ensure compliance with guidelines. Previously, she held case manager positions at Memorial Sloan Kettering Cancer Center, where she coordinated patient care across settings and payer systems. She has a Bachelor of Science in Nursing, a Bachelor of Arts, an Executive MPA, and is a certified case manager.
Avado CEO Dave Chase's presentation to the Collaborative Health Consortium's weekly Pilots and Collaborations Webinar. Dave is doing some leading edge thinking on collaborative care.
This document provides a summary of a presentation about palliative care efforts in Delaware. It discusses the difference between palliative care and hospice, current palliative care programs available in Delaware, and opportunities for expansion. Key points include:
- Palliative care aims to improve quality of life by relieving symptoms for patients with serious illnesses, while hospice focuses on the last 6 months of life after curative treatments stop.
- Delaware has several palliative care programs in hospitals, home care, and long-term care settings, but access could be expanded by having palliative specialists in all hospitals and outside of hospitals.
- Opportunities remain to improve palliative care in Delaware through increasing the number of board
A new mother experienced mild cramping and back/thigh pain during her pregnancy. She noticed clear discharge with blood streaks and asked the nurse questions about her symptoms. The nurse assessed the mother's knowledge deficit and created a care plan to address her short and long-term goals of understanding her physical and psychological changes during pregnancy. The nurse's interventions included education, addressing the mother's questions, and involving her in decision making.
Objectives:
1.To review the need for increased efforts to implement research evidence into bedside practice.
2.To review the need for measurement to identify gaps between best practice and actual practice.
3.To demonstrate why there is a need for increased knowledge translation efforts in critical care and how aCKTION Net proposes to fill this need.
Click the link to view the video http://bit.ly/YpJWTC
The document describes Tunstall's services for reducing avoidable hospitalizations and readmissions. Tunstall provides a range of connected care services including appointment scheduling and reminders, physician referral services, remote patient monitoring, and 24/7 after hours support. They handle nearly 2.5 million calls per year and are committed to supporting partners in delivering positive health outcomes through a dedicated, HIPAA compliant contact center.
Improving Discharge Care for Children with Special Health Care Needs through...LucilePackardFoundation
Being discharged from the hospital is a vulnerable time for families and caregivers of children with special health care needs (CSHCN). Appropriate resources and support are essential for care at home and can prevent complications or readmission. The California-based Nurse-led Discharge Learning (CANDLE) Collaborative brings together interdisciplinary clinicians to improve discharge care delivery for CSHCN. Learn about two new discharge practices: closed-loop medication reconciliation and tailored medication teaching, and multidisciplinary discharge rounds with early discharge notification. Speakers share how these innovative practices can be integrated into existing clinical workflows.
Spotlight on continuing health care in strokeNHS Improvement
Stroke patients often have complex needs that make them eligible for NHS continuing healthcare (CHC) funding. However, the CHC process can be time-consuming and delay discharge from hospitals. Several recommendations are provided to streamline the process, including designating a coordinator, integrating social workers into care teams, and conducting assessments in post-acute settings rather than hospitals. Examples from hospitals in England demonstrate how roles like discharge coordinators and computer systems can reduce duplication and speed up the process.
Bridget Keyes has over 20 years of experience in nursing and case management. She is currently the Manager of Case Management at Robert Wood Johnson University Hospital, where she oversees utilization management activities and works to ensure compliance with guidelines. Previously, she held case manager positions at Memorial Sloan Kettering Cancer Center, where she coordinated patient care across settings and payer systems. She has a Bachelor of Science in Nursing, a Bachelor of Arts, an Executive MPA, and is a certified case manager.
Ruli hospital map 12.253 presentation v11 1Wendy Leonard
The document provides an overview and assessment of data collection and usage processes at Ruli District Hospital in Rwanda. It finds that while the hospital has established a referral system with health centers, opportunities exist to improve data capture, analysis, and reporting. Key issues identified include inconsistent referral data collection, inefficient paper-based registration and reporting processes, and underutilization of available appointment and patient data. Recommendations propose transitioning to electronic logs, centralizing patient records, improving inter-departmental sharing, and modifying appointment setting and feedback processes to increase efficiency and analytical capabilities.
This document provides an overview and introduction to NHS Continuing Healthcare. It discusses the difference between health care and social care, and how the NHS Continuing Healthcare framework determines if a person has a "primary health need" and is eligible for fully funded NHS care. The key steps in the NHS Continuing Healthcare process include using the Fast Track Pathway Tool, Checklist, and Decision Support Tool to assess a person's needs and make a recommendation about their eligibility.
This document discusses patient satisfaction in healthcare. It outlines that patient satisfaction depends on meeting patient needs through high quality care, effective communication, and a caring attitude from staff. Key determinants of patient satisfaction include clinical competency, clean and comfortable facilities, respectful treatment, and addressing patient concerns. Maintaining patient satisfaction is important for positive health outcomes, compliance, and the financial and reputational well-being of healthcare organizations.
Urgent and emergency care remains a high priority across the NHS as demand, length of stay and variation in practice continues to increase. NHS Improvement has worked with a number of acute hospital sites to understand the complexity of urgent and emergency care attendances, and admissions. “Making connections with the challenges of unscheduled care” shares the issues, the outcomes and identifies some tried and tested solutions that can ease the burden of unscheduled care
This document outlines a presentation on state initiatives impacting physicians and patients related to controlled substances. It includes disclosures from presenters and planners, as well as learning objectives. The first presentation discusses Maryland's emergency preparedness plan for responding when a physician's license to prescribe controlled substances is suspended. The plan was developed after an incident where over 2,000 patients lost access to prescriptions. It involves coordinating state agencies, conducting surveys, developing response teams, and temporarily providing resources to mitigate public health impacts. Focus groups provided guidance on barriers, triaging patients, documenting for referrals, and estimating costs. The goal is to deploy temporary resources at the local level until normal care processes resume.
This document provides an overview of NHS Continuing Healthcare. It discusses the differences between health care and social care, and outlines the framework and tools used to determine eligibility for NHS Continuing Healthcare, including the Fast Track Pathway Tool, Checklist, and Decision Support Tool. The document emphasizes that eligibility is based on the level of an individual's care needs and whether their primary need is for health care rather than social care. It provides guidance on assessing needs against the criteria of nature, intensity, complexity and unpredictability to determine if someone has a primary health need.
The CALHN Memory Service provides a single integrated specialist memory service across the Central Adelaide Local Health Network. It has an interdisciplinary team that provides flexible age criteria assessment, diagnosis, care planning and support for people with cognitive concerns. The model of care aims for early diagnosis and intervention, as well as consumer-directed care and culturally safe care for vulnerable populations. It uses a systematic approach including patient history, cognitive assessment, medications review and brain imaging to diagnose conditions like mild cognitive impairment and dementia. Key performance indicators help evaluate the effectiveness and timeliness of the service. Prevention strategies aim to increase brain reserve and slow cognitive and functional decline through education, social engagement, exercise, diet and treating health risk factors.
This document provides an overview and recommendations for implementing NICE guidance on organ donation. It discusses identifying potential organ donors, obtaining consent, discussing donation with families, and the roles and skills of healthcare professionals. The guidance aims to improve identification of potential donors and fulfillment of donor wishes. It emphasizes patient-centered care, early identification of donors, and compassionate discussions with families to increase donation rates and access to transplants.
This document provides an overview and recommendations for implementing NICE guidance on organ donation. It discusses identifying potential organ donors, obtaining consent, discussing donation with families, and the roles and skills of healthcare professionals. The guidance aims to improve identification of potential donors and fulfillment of donor wishes. It emphasizes patient-centered care, early identification of donors, and compassionate discussions with families to increase donation rates and access to transplants.
The document discusses Narus Health's solution for providing care coordination and support for patients with life-limiting medical conditions. Narus Health uses technology to identify high-risk patients and provide comprehensive in-home assessments to understand patients' medical, social, and family care needs. Narus Health care partners work closely with physicians and provide 24/7 support to patients and their families to help manage symptoms, avoid unnecessary costs and hospitalizations, and ensure patients' goals and preferences are met. The solution aims to deliver better care experiences and lower costs compared to existing care models.
1) Engagement in HIV care ranges from fully engaged patients who regularly attend medical visits to non-engagers who are unaware of their HIV status or never enter into care.
2) Missing medical visits for HIV care can negatively impact health outcomes like increased viral load and drug resistance, and has been associated with higher mortality.
3) Strategies that have been shown to improve retention in HIV care include outreach programs, case management, addressing practical barriers, and strengthening the patient-provider relationship.
Barbara Casciola is a certified nursing assistant with over 25 years of experience providing patient care in various healthcare settings including hospitals, nursing homes, private duty care, and home health. She is skilled in geriatric care, chronic disease management, and ensuring patient safety and dignity. Her experience includes assisting with activities of daily living, medication administration, vital sign monitoring, and maintaining accurate medical records. She is committed to culturally competent, compassionate care and effective collaboration with healthcare teams.
This document provides information about Robert Patnell, a qualified social worker with 14 years of post-qualification experience in mental health. He has experience working for the Ministry of Defence, low and medium secure hospitals, community mental health teams, and local authorities. His experience includes assessments, risk management, statutory reports, care coordination, and transition support for patients being discharged from services. To arrange an interview with Robert Patnell, please call 0203 096 1500.
The document provides information about USBD Hospitalists & Consultants' mobile care transition team and community house call program. The program aims to safely transition patients from the hospital or nursing facility to home, reduce hospital readmissions, and improve the home care experience. The mobile care team includes physicians, nurses, therapists and other medical professionals who provide in-home medical visits and services.
Tonya Snyr is a registered nurse seeking full-time employment. She has over 20 years of nursing experience in various clinical settings including home health, mental health, case management, and clinical communications. Her experience includes performing assessments, medication management, care coordination, and utilizing various computer programs for documentation and patient care. She is licensed in Michigan and Ohio and maintains all necessary certifications.
The document provides an orientation for new employees at the Medical Center of McKinney. It outlines the hospital's mission to provide excellence in healthcare and improve standards of care in the community. It describes the vision to be the most comprehensive healthcare provider in North Texas. Key services highlighted include emergency care, orthopedics, neurosciences, and maternity. It also discusses accreditations, leadership, marketing initiatives, and upcoming employee events.
This document provides an overview of quality assurance and eligibility for female sterilization procedures. It defines quality assurance as a means to prevent defects and ensure solutions meet standards. It outlines eligibility criteria for different sterilization procedures based on provider training and lists conditions that would make a patient eligible, require caution, necessitate a delay, or require special consideration for the procedure. The timing of sterilization is also discussed in relation to a woman's menstrual cycle or other procedures she may have undergone. Informed consent processes are emphasized.
Spotlight on six month reviews in stroke treatmentNHS Improvement
1) Stroke patients are offered reviews of their health, social care needs, and prevention needs typically within 6 weeks and 6 months after being discharged from the hospital.
2) The reviews help ensure patients receive necessary care and support as well as identify areas for improvement in the assessment process.
3) Feedback from patients found the reviews were beneficial as they helped patients access important programs and support that aided their recovery.
BeHealth.Today | Mobile Psych Treatment TeamKevin Popović
The Mobile Psychiatric Treatment Team (MPTT) provides an alternative to emergency room boarding and inpatient psychiatric hospitalization. The MPTT consists of a multidisciplinary team including a psychiatrist, psychiatric nurse, licensed clinical social worker, mental health worker, and peer support specialist. They provide immediate mental health treatment, evaluation, medication management, therapy and safety planning to stabilize patients within 24 hours, allowing discharge from the emergency room to an appropriate level of care. The MPTT aims to address the problems of lack of treatment for patients boarding in emergency rooms while awaiting inpatient beds by bringing specialized mental health care directly to the patient.
For more information contact: Slideshare@marcusevans.com
Presentation delivered by Donna Medina, Regional Director,OSF Hospice and Homecare Foundation at the marcus evans Home Care Leadership Summit held on July 13 & 14 2015 in Palm Beach FL.
Testing Telehealth Solutions for Post Acute CareVSee
Telehealth Failures & Secrets to Success Conference 2017 by VSee
Speaker: Tomi Ryba & Margaret Wilmer
Senior Director of Integrated Care of El Camino Hospital
More info at: vsee.com/conference
Dual presentation delivered by Pat Posa, RN, FAAN, Population Health Clinical Integration Leader, St. Joseph Mercy Health System, Quality Excellence Leader, Trinity Health and Elizabeth Van Hoek, Population Health Leader, Quality Institute, St. Joseph Mercy Health System at the marcus evans ACO & Payer Leadership Summit Spring 2017 in Dallas, Texas
Ruli hospital map 12.253 presentation v11 1Wendy Leonard
The document provides an overview and assessment of data collection and usage processes at Ruli District Hospital in Rwanda. It finds that while the hospital has established a referral system with health centers, opportunities exist to improve data capture, analysis, and reporting. Key issues identified include inconsistent referral data collection, inefficient paper-based registration and reporting processes, and underutilization of available appointment and patient data. Recommendations propose transitioning to electronic logs, centralizing patient records, improving inter-departmental sharing, and modifying appointment setting and feedback processes to increase efficiency and analytical capabilities.
This document provides an overview and introduction to NHS Continuing Healthcare. It discusses the difference between health care and social care, and how the NHS Continuing Healthcare framework determines if a person has a "primary health need" and is eligible for fully funded NHS care. The key steps in the NHS Continuing Healthcare process include using the Fast Track Pathway Tool, Checklist, and Decision Support Tool to assess a person's needs and make a recommendation about their eligibility.
This document discusses patient satisfaction in healthcare. It outlines that patient satisfaction depends on meeting patient needs through high quality care, effective communication, and a caring attitude from staff. Key determinants of patient satisfaction include clinical competency, clean and comfortable facilities, respectful treatment, and addressing patient concerns. Maintaining patient satisfaction is important for positive health outcomes, compliance, and the financial and reputational well-being of healthcare organizations.
Urgent and emergency care remains a high priority across the NHS as demand, length of stay and variation in practice continues to increase. NHS Improvement has worked with a number of acute hospital sites to understand the complexity of urgent and emergency care attendances, and admissions. “Making connections with the challenges of unscheduled care” shares the issues, the outcomes and identifies some tried and tested solutions that can ease the burden of unscheduled care
This document outlines a presentation on state initiatives impacting physicians and patients related to controlled substances. It includes disclosures from presenters and planners, as well as learning objectives. The first presentation discusses Maryland's emergency preparedness plan for responding when a physician's license to prescribe controlled substances is suspended. The plan was developed after an incident where over 2,000 patients lost access to prescriptions. It involves coordinating state agencies, conducting surveys, developing response teams, and temporarily providing resources to mitigate public health impacts. Focus groups provided guidance on barriers, triaging patients, documenting for referrals, and estimating costs. The goal is to deploy temporary resources at the local level until normal care processes resume.
This document provides an overview of NHS Continuing Healthcare. It discusses the differences between health care and social care, and outlines the framework and tools used to determine eligibility for NHS Continuing Healthcare, including the Fast Track Pathway Tool, Checklist, and Decision Support Tool. The document emphasizes that eligibility is based on the level of an individual's care needs and whether their primary need is for health care rather than social care. It provides guidance on assessing needs against the criteria of nature, intensity, complexity and unpredictability to determine if someone has a primary health need.
The CALHN Memory Service provides a single integrated specialist memory service across the Central Adelaide Local Health Network. It has an interdisciplinary team that provides flexible age criteria assessment, diagnosis, care planning and support for people with cognitive concerns. The model of care aims for early diagnosis and intervention, as well as consumer-directed care and culturally safe care for vulnerable populations. It uses a systematic approach including patient history, cognitive assessment, medications review and brain imaging to diagnose conditions like mild cognitive impairment and dementia. Key performance indicators help evaluate the effectiveness and timeliness of the service. Prevention strategies aim to increase brain reserve and slow cognitive and functional decline through education, social engagement, exercise, diet and treating health risk factors.
This document provides an overview and recommendations for implementing NICE guidance on organ donation. It discusses identifying potential organ donors, obtaining consent, discussing donation with families, and the roles and skills of healthcare professionals. The guidance aims to improve identification of potential donors and fulfillment of donor wishes. It emphasizes patient-centered care, early identification of donors, and compassionate discussions with families to increase donation rates and access to transplants.
This document provides an overview and recommendations for implementing NICE guidance on organ donation. It discusses identifying potential organ donors, obtaining consent, discussing donation with families, and the roles and skills of healthcare professionals. The guidance aims to improve identification of potential donors and fulfillment of donor wishes. It emphasizes patient-centered care, early identification of donors, and compassionate discussions with families to increase donation rates and access to transplants.
The document discusses Narus Health's solution for providing care coordination and support for patients with life-limiting medical conditions. Narus Health uses technology to identify high-risk patients and provide comprehensive in-home assessments to understand patients' medical, social, and family care needs. Narus Health care partners work closely with physicians and provide 24/7 support to patients and their families to help manage symptoms, avoid unnecessary costs and hospitalizations, and ensure patients' goals and preferences are met. The solution aims to deliver better care experiences and lower costs compared to existing care models.
1) Engagement in HIV care ranges from fully engaged patients who regularly attend medical visits to non-engagers who are unaware of their HIV status or never enter into care.
2) Missing medical visits for HIV care can negatively impact health outcomes like increased viral load and drug resistance, and has been associated with higher mortality.
3) Strategies that have been shown to improve retention in HIV care include outreach programs, case management, addressing practical barriers, and strengthening the patient-provider relationship.
Barbara Casciola is a certified nursing assistant with over 25 years of experience providing patient care in various healthcare settings including hospitals, nursing homes, private duty care, and home health. She is skilled in geriatric care, chronic disease management, and ensuring patient safety and dignity. Her experience includes assisting with activities of daily living, medication administration, vital sign monitoring, and maintaining accurate medical records. She is committed to culturally competent, compassionate care and effective collaboration with healthcare teams.
This document provides information about Robert Patnell, a qualified social worker with 14 years of post-qualification experience in mental health. He has experience working for the Ministry of Defence, low and medium secure hospitals, community mental health teams, and local authorities. His experience includes assessments, risk management, statutory reports, care coordination, and transition support for patients being discharged from services. To arrange an interview with Robert Patnell, please call 0203 096 1500.
The document provides information about USBD Hospitalists & Consultants' mobile care transition team and community house call program. The program aims to safely transition patients from the hospital or nursing facility to home, reduce hospital readmissions, and improve the home care experience. The mobile care team includes physicians, nurses, therapists and other medical professionals who provide in-home medical visits and services.
Tonya Snyr is a registered nurse seeking full-time employment. She has over 20 years of nursing experience in various clinical settings including home health, mental health, case management, and clinical communications. Her experience includes performing assessments, medication management, care coordination, and utilizing various computer programs for documentation and patient care. She is licensed in Michigan and Ohio and maintains all necessary certifications.
The document provides an orientation for new employees at the Medical Center of McKinney. It outlines the hospital's mission to provide excellence in healthcare and improve standards of care in the community. It describes the vision to be the most comprehensive healthcare provider in North Texas. Key services highlighted include emergency care, orthopedics, neurosciences, and maternity. It also discusses accreditations, leadership, marketing initiatives, and upcoming employee events.
This document provides an overview of quality assurance and eligibility for female sterilization procedures. It defines quality assurance as a means to prevent defects and ensure solutions meet standards. It outlines eligibility criteria for different sterilization procedures based on provider training and lists conditions that would make a patient eligible, require caution, necessitate a delay, or require special consideration for the procedure. The timing of sterilization is also discussed in relation to a woman's menstrual cycle or other procedures she may have undergone. Informed consent processes are emphasized.
Spotlight on six month reviews in stroke treatmentNHS Improvement
1) Stroke patients are offered reviews of their health, social care needs, and prevention needs typically within 6 weeks and 6 months after being discharged from the hospital.
2) The reviews help ensure patients receive necessary care and support as well as identify areas for improvement in the assessment process.
3) Feedback from patients found the reviews were beneficial as they helped patients access important programs and support that aided their recovery.
BeHealth.Today | Mobile Psych Treatment TeamKevin Popović
The Mobile Psychiatric Treatment Team (MPTT) provides an alternative to emergency room boarding and inpatient psychiatric hospitalization. The MPTT consists of a multidisciplinary team including a psychiatrist, psychiatric nurse, licensed clinical social worker, mental health worker, and peer support specialist. They provide immediate mental health treatment, evaluation, medication management, therapy and safety planning to stabilize patients within 24 hours, allowing discharge from the emergency room to an appropriate level of care. The MPTT aims to address the problems of lack of treatment for patients boarding in emergency rooms while awaiting inpatient beds by bringing specialized mental health care directly to the patient.
For more information contact: Slideshare@marcusevans.com
Presentation delivered by Donna Medina, Regional Director,OSF Hospice and Homecare Foundation at the marcus evans Home Care Leadership Summit held on July 13 & 14 2015 in Palm Beach FL.
Testing Telehealth Solutions for Post Acute CareVSee
Telehealth Failures & Secrets to Success Conference 2017 by VSee
Speaker: Tomi Ryba & Margaret Wilmer
Senior Director of Integrated Care of El Camino Hospital
More info at: vsee.com/conference
Dual presentation delivered by Pat Posa, RN, FAAN, Population Health Clinical Integration Leader, St. Joseph Mercy Health System, Quality Excellence Leader, Trinity Health and Elizabeth Van Hoek, Population Health Leader, Quality Institute, St. Joseph Mercy Health System at the marcus evans ACO & Payer Leadership Summit Spring 2017 in Dallas, Texas
ChenMed is a privately held primary care group that focuses on low-income adults over 55 with multiple chronic conditions. Their care model includes 400-450 patients per physician, on-site pharmacy services, intensive care coordination, and global risk-based payments from Medicare Advantage plans.
ChenMed has achieved outcomes like lower hospitalization rates compared to national benchmarks. Their strategy for scaling includes developing a physician culture focused on relationships and accountability, value-based workflows supported by technology, and selective integration within local healthcare markets. Physician panel management tools, interdisciplinary care teams, and managing transitions of care across settings are key parts of their model.
This homecare agency provides a wide range of in-home medical, rehabilitation, and support services to help clients remain in their homes. They have a doctor-owned, nurse-managed model with strict safety standards. Services include skilled nursing, physical/occupational/speech therapy, medical social work, and 24/7 nurse support. They aim to improve outcomes through coordinated, compassionate long-term care that improves quality of life.
This document summarizes the benefits of highly organized primary care and medical homes. It discusses how organizing primary care into teams that focus on population health, care coordination, planned care for chronic conditions, and quality improvement can improve health outcomes, reduce costs, and enhance the patient experience. The document provides examples from Cambridge Health Alliance that show improved quality metrics, decreased hospital and emergency room use, and reduced costs after implementing a primary care reform model centered around medical homes and accountable care.
The document discusses expanding the role of registered nurses (RNs) in primary care settings. It describes how RNs can take on responsibilities like complex care management, active schedule management, using data to monitor patient outcomes, and conducting co-visits with providers to increase access to care. Co-visits allow RNs to address minor issues while providers briefly review cases. The approach has led to improved access and patient satisfaction at Community Health Center, Inc.
Presentation made by Celia Ingham Clark National Director for Reducing Premature Mortality, at Improving access to seven day services. Southampton 25 March 2015
Purpose of the Call:
By the end of this webinar you will: •Hear about the changes to the MedRec in Home Care GSK
•Hear about the broader home care concepts as it relates to MedRec
•Receive practical tips and insights from the field
ChenMed is a physician group focused on providing primary care to low-income Medicare patients over 55 with multiple chronic conditions. Their care model emphasizes strong patient relationships, care coordination, and on-site services to improve outcomes. Data shows patients have high rates of medication adherence, fewer hospital visits, and more visits with their primary care physician compared to typical patients. ChenMed aims to scale this model across multiple markets using global risk contracts that incentivize keeping patients healthy.
Nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge. Many readmissions appear preventable and add substantial costs to the Medicare system. Reducing readmissions requires understanding factors leading to initial admissions and coordinating care between inpatient and outpatient providers, through interventions like transitional care programs, self-management education, and coordinated care models. No one strategy will be effective - hospitals must work with nursing homes, physicians, and other providers to address readmissions.
1) Skilled nursing facilities often fail to meet Medicare discharge planning requirements, with 31% not meeting at least one requirement. Common deficiencies include lacking post-discharge plans of care and adequate discharge summaries.
2) The Office of the Inspector General recommended that CMS increase regulations on discharge planning, improve care planning and discharge processes, hold facilities accountable, and link payments to meeting requirements.
3) Poorly managed care transitions can diminish health and increase costs. Exceptional discharge planning that begins before admission and continues after discharge can improve health outcomes and decrease costs by ensuring patients and families have the knowledge and support needed for safe transitions to the next care setting or home.
Can we solve the adult primary care shortage without more physicians? CHC Connecticut
Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium
This document summarizes a presentation on optimizing the use of urine drug testing. It contains 4 learning objectives focused on identifying obstacles to appropriate urine drug testing, describing a clinical approach, explaining legal liability, and advocating for policy responses. The presentation consists of 4 speakers and a moderator and covers developing a consensus on urine drug testing, including general guidelines, test selection, use in diagnosis and treatment. It emphasizes individualizing decisions based on patient history and needs, using preliminary tests for quick results and definitive tests for accuracy, and documenting decisions in medical records.
The document describes the implementation of a patient centered medical home (PCMH) at Saint Peter's University Hospital (SPUH) Family Health Center in New Jersey. The PCMH aims to improve healthcare for New Jersey residents and decrease costs through a federally sponsored public health project. Key goals of the PCMH include reducing admissions and emergency room visits, improving care processes, and increasing patient satisfaction. Initial results show increased patient satisfaction and decreased wait times.
Advancing Team-Based Care: The Emerging Role of Nurses in Primary CareCHC Connecticut
In this webinar, we explored the emerging role of nurses in primary care. We explored the role of nurses in the team, in complex care management, and in independent nurse visits.
This webinar was presented March 31, 2016 2:00 PM ET
Strengthening Acute to Post Acute-Care Connection: Cohesively Manage CareCentralPAHEF
WellSpan Health is a large integrated health system in central Pennsylvania serving over 1 million people. It operates 6 hospitals, a medical group with over 1200 physicians, and provides various post-acute services including home health, rehabilitation, and long-term care. WellSpan is working to strengthen connections between acute and post-acute care by standardizing care, improving care coordination and transitions, and developing preferred partnerships with post-acute providers. The goal is to improve patient outcomes and experiences while decreasing healthcare costs through more cohesive management of care across settings.
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...Donte Murphy
This is a PowerPoint presentation from Dr. Khan, Medical Director, MedPeds Medical Clinic. He has a small practice and is a certified PCMH. In this presentation he shares his strategy that led to his success. This is a powerful presentation for practices of all sizes, whether large or small. For more information, feel free to email us at: marketing@amazingcharts.com.
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
Bcp inservice outreach linked in
1. The Role of Private Duty Home Care in Reducing Hospital Readmissions &
Enhancing Quality Of Life
Taking Private Duty Home Care to a Whole New Level
Hospital Assisted Nurse Discharge Service (HANDS)
and BrightStar Clinical Pathways
2. The Opportunity
• Hospital/Health System
As part of the Patient
Protection & Affordable
data will be scrutinized at a
Care Act (PPACA), there number of levels and
are a number of changes failure to achieve certain
that will impact
reimbursement to national CMS benchmarks
hospitals and other will result in
healthcare systems
– Financial Penalties
• Excessive Readmissions
National efforts are
underway to reduce – Less Robust Rewards
potentially preventable • Poor Customer Satisfaction
hospital readmissions and
optimize the patient • Poor Outcomes of Care
experience
3. *Centers for Medicare & Medicaid
Services, Public Affairs, April 2009
Medicare data shows that nearly 1 in 5
patients who leave the hospital are
readmitted within the next month
and that more than 75% of these
Healthcare readmissions are preventable*
systems need to
look for new
solutions since Research has demonstrated that many
existing of the return trips can be prevented
approaches are with an in-home care program
not solving the that includes proper education and
problem. supervision.
4. Top Reasons for 30-day hospital readmissions:
Failure to make follow-up appointments
Lack of communication
Failure to understand medication management
Absence of in-home support
Non-adherence to lifestyle recommendations
Failure to understand and actively participate in the
management of their chronic disease
5. At BrightStar we utilize a Best
Practice approach to care
following the
National Quality Standards of
The Joint Commission
6. Cutting Edge Clinical Programs
The Framework:
Making More Possible
BrightStar
We are companions on LifeCare
the healthcare journey BrightStar
our clients take. KidCare
Clinical
Pathways℠ Staffing
BrightStar’s clinical
programs allow us to HANDS
partner with the client,
their family and their Person-Centered Care
healthcare team to Clinical Expertise
enhance quality of life National Quality Standards
and improve care
outcomes.
7. BrightStar’s Clinical Pathways ℠ and HANDS
Program was inspired by nationally recognized
care transition programs:
Coleman Care Transition
Intervention Program
which reduced hospital readmissions by
50% at 30, 60 and 90 days
8. HANDS is a transitional care program focused
on a safe transition home
After leaving the hospital it is important that the patient
have a direct link to an accessible care provider.
HANDS provides that link, bridging the transition to
home and addressing issues and questions that arise.
Medicare agencies may not be able to be there within
the 1st - 24 hours and sometimes not for 2-4 days.
9. • BrightStar’s Hospital Accelerated Nurse
Discharge Service (HANDS) is a transitional
care program to facilitate a safe discharge
home.
– It is ideally the beginning of a journey we take
with the client and their healthcare team.
HANDS: • It begins at time of discharge and continues
for a minimum of 24 hours
– critical transition time for
What is it to re-engagement in the home setting.
• A visit by our Registered Nurse Care
Our Manager is the cornerstone of the program
– Assessment, Medication Reconciliation, Disease
Partners? State Education w/attention to Red Flag
Symptoms
• Person-centered services performed by our
CNA
– Transportation from hospital to home, Home
Safety Check, Light Housekeeping, Retrieval of
Simple Supplies (medications, groceries, etc),
Light Meal Prep, Transition Check List which
includes phone calls to loved ones,
arranging/confirming follow-up appointment with
discharging physician
10.
11. • HANDS Basic
– 3 hours CNA time
HANDS Basic
– 1 RN Home Visit w/i 4-8 hours of
Services hospital discharge
• HANDS Plus
– Everything included above
– Pre-discharge RN Visit at hospital
(meet & greet, chart review,
discharge instructions, etc)
– 1 additional RN visit
– 24/7 RN phone call availability for
HANDS Plus 30 days
Services – Detailed medication
instruction/med set-up if indicated
13. Simply put…
BrightStar Clinical Pathways ℠ is a
–patient centered
–condition-specific
–transitional care program
Focused on
–reducing negative outcomes
–optimizing quality of life
17. BrightStar Clinical Pathways ℠ :
Essentials Package
4 RN CPC Visits, 8 RN CPC Virtual Visits,
13 Specialty CNA Visits
Week 1 Week 2 Week 3 Week 4 TTL
RN Visit X X X X 4
RN Phone Call X X X X X X X X 8
CNA/HHA Visit X X X X X X X X X X X X X 13
25
Each face to face visit is a 2 hour condition-specific person-
centered interaction focused on empowering the client as well
as symptom surveillance
18. BrightStar Clinical Pathways ℠
MS DRGs and Frailty Factors
MS DRG MCC
*Frailty Factors
• Mult Diagnoses
Essentials
• Mult. Medications
MS DRG CC Plus • ADL/IADL Deficits
• Unintentional Wt Loss
• Limited Support
MS DRG Essentials
Frailty Factors*
19. BrightStar Clinical Pathways ℠ :
Essentials Plus Package
5 RN CPC Visits, 13 RN CPC Virtual Visits,
17 Specialty CNA Visits
Week 1 Week 2 Week 3 Week 4 TTL
RN Visit X X X X X 5
RN Phone Call X X X X X X X X X X X X X 13
CNA/HHA Visit X X X X X X X X X X X X X X X X X 17
35
Each face to face visit is a 2 hour condition-specific person-
centered interaction focused on empowering the client as well
as symptom surveillance
20. Other Essential Elements of
BrightStar Clinical Pathways℠ – Care Together
• Web based communication and calendar
tool for the client and their formal and
informal care team; also promotes the self-
management of chronic illness
Building a – PressGaney/Patient Impact
• National Patient Satisfaction Survey
Platform of comparable to what many hospitals
utilize
Clinical – We hold ourselves to a high service
standard
Excellence – 9 out of 10 clients would refer us to a friend
– ABS 2.0
• Data tracking of diagnosis, recent
hospitalizations, reasons for
admission/readmission;
• Staff assignment
21. ℠
Three key ways CareTogether enhances BCPs for clients & their families:
1. Condition specific
educational materials, care Families using with physicians and case
tools, resources managers can enhance communication
and understanding and adherence!
22. ℠
Three key ways CareTogether enhances BCPs for clients & their families:
3. Keeping the family involved
and updated is key part of
2. Calendar linked with ABS family and friends supporting
shows client + Care Team visit the care and “better choices” of
dates, times, name and more the Pathways program
23. HCAHPS vs BrightStar Press Ganey Survey
http://hcahpsonline.org/Files/HCAHPS%20V6%200%20Appendix%20A%20-
%20HCAHPS%20Mail%20Survey%20Materials%20(English)%202-16-2011.pdf
Discharge
Plan?
Which questions match between
HCAHPS & Press Ganey?
Which questions illustrate
opportunities for BrightStar to
help?
24. BrightStar Clinical Pathways ℠
Foundational Concepts
• Person Centered
– The individual is more than the sum of their parts
(or their diseases and medications)
• Patient Empowerment with
Self Management of Chronic Disease
• BrightStar Clinical Pathway℠ Team Leader
– Together
– Everyone
– Achieves
– More
25. Key BrightStar Clinical Pathways℠
Coordinator Goals
• Motivate Clients
– To become as independent as possible in monitoring
and maintaining their own health status
• Provide Clients with the knowledge and skills
– To make informed decisions about their healthcare
and quality of life
• Reduce negative outcomes
– Hospitalizations, Readmissions, Urgent Care Visits
,ER Visits, Falls, Med Errors, etc
• Maintain active communication
– BrightStar Clinical Pathway Team, Client’s Family and
Physician, Other Healthcare Providers
30. Benefit to Patient:
Continuous care for better outcomes
RN education
Earlier Discharge Reduce risk of falls
relationship
One on one help and Additional resources
Improved medication guidance in the home to provide care,
management from specially transportation, RX
trained CNAs pick up, cleaning, etc
Stay out the of
hospital and the ER
31. What this program will mean to
Healthcare Systems & Providers:
Better Patient
Outcomes Improve Efficiencies
Improved Identify high-risk patients
Communication Complements patient and
and target specific family preparation for
Improve flow of information interventions to mitigate discharge. Ensure a timely,
between hospital, their risks for adverse efficient and safe
0utpatient physicians and events. With timely post discharge and transition
provider. discharge in-home care to home.
management and follow
up.
Better Image
Improve patient and public Reduce likelihood of
perception of care and result in
higher satisfaction scores.
potentially
Promote customer loyalty &
confidence in St. Mary's and
preventable and
enhance patient overall costly readmissions
experience.
32. Why BrightStar?
Our Difference:
Joint Commission Accreditation Commitment to RN oversight
Fully Licensed by the Person centered approach
Press Ganey satisfaction survey CareTogether®
Licensed and insured for transport Flexible & responsive
RN DON trains & competency tests
Highly qualified and specially trained staff
all CNAs
Stringent screening and employment
All patients receive in-home risk
practices
assessment to help reduce falls
HANDS
Continuity of care and care
collaboration BrightStar Clinical Pathways
Ongoing services to maintain safety Locally owned & operated
and success
33. Ask Me How We Can
Make More Possible For You!
Kym.Guy@BrightStarCare.com
805.358.6022
Editor's Notes
.
President Obama proposed $320 billion in reductions to Medicare and Medicaid as part of his $3.8 trillion fiscal year 2013 federal budget proposal. The president’s plan, which is similar to a proposal the White House released in September, calls for cutting Medicare by $268 billion and Medicaid by $52 billion over 10 years.
With the HANDS program BrightStar caregivers would provide timely assistance upon hospital discharge, maybe even transporting the patient to their place of residenceSo we will facilitate a safe and supportive environment before a Medicare home health agency has the ability to take over care management, We will serve as an additional link in care coordination. When MC agency and therapy com in …collaborate with them supporting and reinforcing their teaching with the pt. - providing feedback , additional information they otherwise may not be able to obtain.- promoting even better outcomes than could have been possible before
ANDREW
it begins at the time of discharge and continues for a minimum of 4-weeks critical transition time for re-engagement in the home setting- matches the 30 readmission window associated with penalties
SHARON
Example, Daily Weight Calendar…
[explain Blue shows what Family schedules around the GREEN events that are those where BrightStar will be in the home]
DOUG
SHARON
SHARON
ANDREW
Family related/situation related/ afternoon evening dischargetimely visit by our RNCP Coord. Is the cornerstone of the program with safety assessment, med reconciliation, disease state education with attention to red flag symptoms.Person-centered services performed by our CNATransportation from hospital to home, Home Safety Check, Light Housekeeping, Retrieval of Simple Supplies (medications, groceries, etc), Light Meal Prep, following our Transition Check List which includes phone calls to loved ones, arranging/confirming follow-up appointment with discharging physician and so on …. Condition home may have been left inOut of the hospital -Until those unavoidable exacerbation of their chronic disease occurs
Our joint commission is firm evidence about the client care we provide. Both our accreditation and client satisfaction scores . At BS we have a wonderful asset in our PG reporting. We have an exclusive relationship with PG. our questions map those of HCAHPS and HHCAPSYou have a great deal of focus on client satisfaction and so do weSt BS we understand the importance of patient satisfaction-Our last PG survey revealed that 98% of our customers would refer us to family or friend.CareTogether. – we know you have a similar program in Caring Bridge -– Care Together is different and complementary. -The calendar/visit function and condition specific pt education materials that we’ve added to CareTogether really make it unique.