The document discusses strategies for community-based chronic illness management to reduce costs and improve outcomes. It outlines several programs that have shown promise, including transitional care programs and house call programs. Transitional care programs of varying intensity use nurses and nurse practitioners to coach patients after hospital discharge. House call programs provide primary care to high-risk elderly patients in their homes through visits from physicians and nurse practitioners. Evaluation of these programs has found reduced utilization, lower costs, and improved outcomes and quality of life.
Clinicspectrum is a healthcare service/consulting company helping Medical offices, Hospitals and ACOs to reduce operational cost up to 30% with its unique Hybrid Workflow Model™ with use of back office services and technology products.
We are happy to launch our unique web-based Chronic Care Management Platform and discuss details about Chronic Care Management in this presentation.
Chronic Care Management (CCM): Understand how to capture incremental revenueDiagnotes, Inc.
By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.
This webinar will provide an overview of the evaluation study being done at the Durham Clinic, an integrated health home run by Cherry Street Health Services in Grand Rapids, Michigan. The study seeks to determine whether the delivery of health care through a multi-disciplinary team using the chronic care management model delivers better symptom management and reduced impact of the
illness on patients’ desired functioning.
Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health and Seth VanEssendelft, Vice-President for Financial Services, Vidant Medical Center
Chronic Care Management - Implemented By TimeDoc - May 2018Dan Wellisch
This is May's presentation of the Chicago Technology For Value-Based Healthcare Meetup - https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
Clinicspectrum is a healthcare service/consulting company helping Medical offices, Hospitals and ACOs to reduce operational cost up to 30% with its unique Hybrid Workflow Model™ with use of back office services and technology products.
We are happy to launch our unique web-based Chronic Care Management Platform and discuss details about Chronic Care Management in this presentation.
Chronic Care Management (CCM): Understand how to capture incremental revenueDiagnotes, Inc.
By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.
This webinar will provide an overview of the evaluation study being done at the Durham Clinic, an integrated health home run by Cherry Street Health Services in Grand Rapids, Michigan. The study seeks to determine whether the delivery of health care through a multi-disciplinary team using the chronic care management model delivers better symptom management and reduced impact of the
illness on patients’ desired functioning.
Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health and Seth VanEssendelft, Vice-President for Financial Services, Vidant Medical Center
Chronic Care Management - Implemented By TimeDoc - May 2018Dan Wellisch
This is May's presentation of the Chicago Technology For Value-Based Healthcare Meetup - https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
Presentation by Kirby Farrell, President and CEO, Broad Axe Technology Partners and Andy Archer, MSc, MBA, Vice President, Broad Axe Technology Partners
Patient Resource: Medicare Observation Versus Admit DaysTerri Embry RN BS
This resource provides information a patient, their advocate or a health care professional can use to learn about this topic. Hyperlinks are embedded to allow for self guided research and is encouraged.
CareSync 1099 Medical Sales Opportunity !
JOIN US Thursday, Nov 17, 2016 1:30 PM - 2:30 PM EST to learn about the 1099 Chronic Care Medical Sales Opportunity with CareSync, the leading provider of technology & services for care coordination & chronic disease management. Platform provides in combination with our 24/7 nursing services facilitates care coordination for patients, their providers, family,& caregivers.
Check out the CareSync Slideshare to learn more about chronic care management. J
Join the Conference Call THURSDAY , Nov 17th 1:30 pm ( ET)
Call (213) 929-4232
Access Code: 226-975-231
Extending US Healthcare Capacity with ClickMedixClickMedix
As US begins its shift in healthcare payment and delivery models, technology-enabled solutions become ever-more relevant to achieve faster and better outcome-based care, with less resources. This presentation presents a mobile health system in the context of enabling health providers in the US to do more, with less.
Hospital Readmission Reduction: How Important are Follow Up Calls? (Hint: Very)SironaHealth
Starting in 2012, the Centers for Medicare and Medicaid Services (CMS) will begin withholding payments for potentially avoidable readmissions. This presentation reviews these new regulations, what causes excessive readmissions, and how hospitals can positively impact patient health by reaching out 24-72 hours after discharge.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Transitional Care Management: Five Steps to Fewer Readmissions, Improved Qual...Health Catalyst
Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:
Start discharge at the time of admission.
Ensure medication education, access, reconciliation, and adherence.
Arrange follow-up appointments.
Arrange home healthcare.
Have patients teach back the transitional care plan.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
Health Rosetta Case Study - City of Kirkland, WashingtonDave Chase
City of Kirkland, WA is a suburb of Seattle that was, like municipalities, struggling with healthcare costs and feared the coming Cadillac Tax. Their "moonshot" goal was to improve health benefits while eliminating healthcare cost inflation
Presentation by Kirby Farrell, President and CEO, Broad Axe Technology Partners and Andy Archer, MSc, MBA, Vice President, Broad Axe Technology Partners
Patient Resource: Medicare Observation Versus Admit DaysTerri Embry RN BS
This resource provides information a patient, their advocate or a health care professional can use to learn about this topic. Hyperlinks are embedded to allow for self guided research and is encouraged.
CareSync 1099 Medical Sales Opportunity !
JOIN US Thursday, Nov 17, 2016 1:30 PM - 2:30 PM EST to learn about the 1099 Chronic Care Medical Sales Opportunity with CareSync, the leading provider of technology & services for care coordination & chronic disease management. Platform provides in combination with our 24/7 nursing services facilitates care coordination for patients, their providers, family,& caregivers.
Check out the CareSync Slideshare to learn more about chronic care management. J
Join the Conference Call THURSDAY , Nov 17th 1:30 pm ( ET)
Call (213) 929-4232
Access Code: 226-975-231
Extending US Healthcare Capacity with ClickMedixClickMedix
As US begins its shift in healthcare payment and delivery models, technology-enabled solutions become ever-more relevant to achieve faster and better outcome-based care, with less resources. This presentation presents a mobile health system in the context of enabling health providers in the US to do more, with less.
Hospital Readmission Reduction: How Important are Follow Up Calls? (Hint: Very)SironaHealth
Starting in 2012, the Centers for Medicare and Medicaid Services (CMS) will begin withholding payments for potentially avoidable readmissions. This presentation reviews these new regulations, what causes excessive readmissions, and how hospitals can positively impact patient health by reaching out 24-72 hours after discharge.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Transitional Care Management: Five Steps to Fewer Readmissions, Improved Qual...Health Catalyst
Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:
Start discharge at the time of admission.
Ensure medication education, access, reconciliation, and adherence.
Arrange follow-up appointments.
Arrange home healthcare.
Have patients teach back the transitional care plan.
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
Health Rosetta Case Study - City of Kirkland, WashingtonDave Chase
City of Kirkland, WA is a suburb of Seattle that was, like municipalities, struggling with healthcare costs and feared the coming Cadillac Tax. Their "moonshot" goal was to improve health benefits while eliminating healthcare cost inflation
Any humanitarian or service project begins by
understanding a community’s needs. This crucial
first step identifies your beneficiaries’ needs as well
as the natural assets that will help you address them.
We will give you the knowledge and resources to
involve community members, inventory assets, build
relationships with local leaders, and more. Learn how
to maximize your project’s impact by deepening your
understanding of the communities you serve.
Moderator: Victor Barnes, Director of Programs and
Concept and definitions
Health education
Beliefs and approaches in health promotion
Health promotion strategies and priority actions
Public health, social movement, health inequity and millennium goals
Canadian experience in health promotion
Conclusion
Rob Reid: Redesigning primary care: the Group Health journeyThe King's Fund
Rob Reid, Senior Investigator at Group Health Research Institute, explains the journey taken by Group Health in support of integrated primary care. A case study in how primary care can be delivered effectively and efficiently to a population, Rob laid out the challenges facing general practice in the States, and how Group Health worked to improve the situation for both patients and the workforce.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Developing non-clinical approaches and are pathways to fundamental socioeconomic issues that are presented in the primary care and secondary care settings
The future of health care administrators, while seemingly daunting is also very promising. The attached presentation analyzes macro-trends and draws a parallel between trends and future health care manager occupational opportunities.
The Healthcare Team as the Healthcare Provider: A Different View of the Patie...guesta14581
Presentation to the Ohio State Society of Medical Assistant's annual convention about the Patient Centered Medical Home and the role of the medical assistant
Pittsburgh Nonprofit Summit - Health Care & Health Care Reform - Implications...GPNP
The health care act is difficult to navigate and nonprofits were written into the act under the auspices of small businesses, making it even more confusing to understand. Gain insights from experts about the intent of the act and the act in its current draft, how it will impact nonprofits as small businesses, the impact on staff, those we serve, and on society at large. Additionally, portions of the act are still being debated and amended; learn of the potential changes and points where the nonprofit sector can influence the outcome.
Polestar Oncology is the all-in-one product to assess and connect cancer patients to the psychosocial support they need, while exceeding new accreditation requirements set forth by the Commission on Cancer. With Polestar Oncology, the multidisciplinary cancer care team can efficiently navigate patients’ psychosocial needs in the context of their medical progress.
Predictive Risk Stratification: Using Analytics to Empower Change with Action...Health Catalyst
Effective population health initiatives are challenging to implement for a variety of reasons. Care teams are already overburdened, and healthcare data is challenging to aggregate and analyze. These factors make it difficult to accurately identify patients who are high-risk or have rising risk for poor outcomes and provide appropriate intervention. To manage patient populations effectively and efficiently, healthcare organizations must be able to automate predictive risk stratification based on claims data, clinical data, and social determinants of health. When care teams know which patients need the most help, which patients have rising risk, and which patients are healthy, they can focus their valuable time where it’s needed most. In this webinar, Dr. Welch shares best practice strategies for utilizing analytics that empower change with actionable workflows, like patient engagement, to ensure that clinically integrated entities can manage high-risk populations appropriately, while also caring for those with rising risk, and engaging with healthy populations mapped to the right targeted interventions.
Similar to Community-based Chronic Care Management (20)
Predictive Risk Stratification: Using Analytics to Empower Change with Action...
Community-based Chronic Care Management
1. Community-based Chronic Illness Management: Strategies and Tools to Reduce Costs and Improve Outcomes Steve H. Landers MD, MPH Director, Cleveland Clinic Center for Home Care and Community Rehabilitation [email_address] April 5, 2010 Brent T. Feorene, MBA President, House Call Solutions [email_address]
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3. Powerful Trends Impact Medical Practice Aging Population Chronic Illness Economic Pressures Consumer Expectations Technology
6. Chronic Illness Epidemic Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
7. Aging + Chronic Illness Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
9. “High Risk” 2005 MCR FFS stats from MedPAC DataBook June 2008 Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
10. Jencks SF et al. N Engl J Med 2009;360:1418-1428 Readmissions Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of Rehospitalized HF patients hospitalized due to another problem
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19. “Secret Weapons” Enhances view of patient and caregivers Reduces barriers to care Strengthens patient relationships Avoids hazards of hospitalization Costs less Desired more Enabling technology emerging
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25. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428
Figure 1. Rates of Rehospitalization within 30 Days after Hospital Discharge. The rates include all patients in fee-for-service Medicare programs who were discharged between October 1, 2003, and September 30, 2004. The rate for Washington, DC, which does not appear on the map, was 23.2%.
A major goal of our work is to help clinicians know who entering our EDs and hospitals today are at highest risk for poor outcomes who would benefit from more intensive service..not every one needs this intensity of services or level of support…