Presentation - The Future of Home HealthC Sam Smith
"Instead of it being described as home healthcare, in a few years the services performed by home health care agencies will simply be known as "modern healthcare".
-Dr. Steve Landers, VNA Health Group, New Jersey
Geraldine Strathdee and Jen Hyatt: Technology innovation for supporting patie...Nuffield Trust
Geraldine Strathdee, Oxleas NHS Foundation Trust,and Jen Hyatt, Big White Wall, present in a breakout session on using technology to support people with mental health issues at home.
Patient engagement is a critical element of successful transitions of care. Without it, patients are improperly educated about their condition and inadequately prepared to self-manage.
Healthcare organizations need effective and scalable ways of engaging patients post-discharge.
Presentation - The Future of Home HealthC Sam Smith
"Instead of it being described as home healthcare, in a few years the services performed by home health care agencies will simply be known as "modern healthcare".
-Dr. Steve Landers, VNA Health Group, New Jersey
Geraldine Strathdee and Jen Hyatt: Technology innovation for supporting patie...Nuffield Trust
Geraldine Strathdee, Oxleas NHS Foundation Trust,and Jen Hyatt, Big White Wall, present in a breakout session on using technology to support people with mental health issues at home.
Patient engagement is a critical element of successful transitions of care. Without it, patients are improperly educated about their condition and inadequately prepared to self-manage.
Healthcare organizations need effective and scalable ways of engaging patients post-discharge.
Promoting Healthy Employees - Embrace the technology !Bernie McCann
This free webinar, sponsored by Screening for Mental Health looks at the importance of including mental health aspects in a workplace wellness approach and features examples from two work organizations which have embraced technology to encourage employees in healthier lifestyles.
What is patient engagement? How do we create it? This talk proposes that focusing on human qualities and applying user experience design processes can help health information technology professionals with this key goal.
Goals: The goal of this training is to help participants develop their knowledge, skills and abilities as Substance Use Screenng, Brief Intervention, and Referral to Treatment (SBIRT) Trainers.
At the end of this training participants will be able to understand the information screening does and does not provide,define brief intervention, describe the goals of conducting a BI, understand the counselor's role in providing BI, describe referral to treatment, identify SBIRT as a system change initiative, introduce the public health approach, and understand the continuum of substance use.
Audience: Social Workers, counselors and other behavioral health providers from all settings can benefit from understanding substance use across a continuum and its impact on clients behavioral health and other psychosocial interactions.
Unleashing Data: The Key To Driving Massive ImprovementsHealth Catalyst
Tom shares how investing in analytics training and infrastructure will help prepare for massive improvements in healthcare outcomes leading to sustained and distributed improvements throughout entire organizations.
Attendees will learn:
1. The key team roles and skillsets required for driving and sustaining massive improvements.
2. How to assess improvement opportunities from an effort and value perspective.
3. The most common mistakes in leveraging analytics and how to avoid them.
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
Three Strategies to Deliver Patient-Centered Care in the Next NormalHealth Catalyst
Juggling financial demands, uncertain healthcare legislation, and COVID-19 can distract healthcare leaders from the most important aspect of care—patients. Delivering patient-centered care in this volatile market can be challenging, especially when traditional healthcare methods (e.g., in-person visits) are on hold. These sudden disruptions to routine care have highlighted the importance of keeping patients at the center of care, whether care delivery is in-person or virtual. Health systems can manage competing priorities, adjust to pandemic-induced changes, and deliver patient-centered care by focusing on three strategies:
Improve the patient experience.
Implement the Meaningful Measures Initiative.
Transition in-person visits to virtual.
Presented by Steve Mills, IBM Senior Vice President, Group Executive, Software & Systems Group
Learn more: http://www.ibm.com/software/products/en/category/health-social-programs
Upping the "Total" in Total Rewards. Incentivizing your employees with the most sophisticated wearable technology, measuring more biomarkers than any other device, and the only device meriting being reviewed as a medical device. Included in the cost of the device - customized wellness programs designed on your employees biometrics. Our commitment to provide the most personalized corporate wellness programs, at the most affordable price and everyone gets the ultimate wearable technology. We will happily help you design a true program of reward - employee/employer contribution - rewarding commitment and motivation.
The Paradigm Shift from Healthcare to Population HealthPractical Playbook
The Practical Playbook
National Meeting 2016
www.practicalplaybook.org
Bringing Public Health and Primary Care Together: The Practical Playbook National Meeting was at the Hyatt Regency in Bethesda, MD, May 22 - 24, 2016. The meeting was a milestone event towards advancing robust collaborations that improve population health. Key stakeholders from across sectors – representing professional associations, community organizations, government agencies and academic institutions – and across the country came together at the National Meeting to help catalyze a national movement, accelerate collaborations by fostering skill development, and connect with like-minded individuals and organizations to facilitate the exchange of ideas to drive population health improvement.
The National Meeting was also a significant source of tools and resources to advance collaboration. These tools and resources are available below and include:
Session presentations and materials
Poster session content
Photos from the National Meeting
The conversation started at the National Meeting is continuing in a LinkedIn Group "Working Together for Population Health" and Twitter. Use #PPBMeeting to provide feedback on the National Meeting.
The Practical Playbook was developed by the de Beaumont Foundation, the Duke University School of Medicine Department of Community and Family Medicine, the Centers for Disease Control and Prevention (CDC), and the Health Resources & Services Administration (HRSA).
From Patients to ePatients Driving a new paradigm for online clinical collabo...ddbennett
CareTech eHealth Innovation Series
From Patients to ePatients Driving a new paradigm for online clinical collaboration and health management
David Bennett, SVP, Interactive Solutions
StayWell Custom Communications
Anthony Chipelo, Director, Portal Strategies
CareTech Solutions
This Webinar is the second of a three-part series synthesizing successful practices to engage hard-to-reach populations into HIV primary care. Lessons are drawn from SPNS population-specific initiatives, and speakers will offer insights relevant to a wide range of audiences, from clinicians to social workers. Presenters discussed the use of data to improve inreach.
Jane Herwehe, DeAnn Gruber, Betsy Shepard, and Debbie Wendell; Louisiana Public Health Information Exchange (LaPHIE)
Peter Gordon, MD; New York-Presbyterian Hospital/Columbia University
Jesse Thomas; RDE Systems
Promoting Healthy Employees - Embrace the technology !Bernie McCann
This free webinar, sponsored by Screening for Mental Health looks at the importance of including mental health aspects in a workplace wellness approach and features examples from two work organizations which have embraced technology to encourage employees in healthier lifestyles.
What is patient engagement? How do we create it? This talk proposes that focusing on human qualities and applying user experience design processes can help health information technology professionals with this key goal.
Goals: The goal of this training is to help participants develop their knowledge, skills and abilities as Substance Use Screenng, Brief Intervention, and Referral to Treatment (SBIRT) Trainers.
At the end of this training participants will be able to understand the information screening does and does not provide,define brief intervention, describe the goals of conducting a BI, understand the counselor's role in providing BI, describe referral to treatment, identify SBIRT as a system change initiative, introduce the public health approach, and understand the continuum of substance use.
Audience: Social Workers, counselors and other behavioral health providers from all settings can benefit from understanding substance use across a continuum and its impact on clients behavioral health and other psychosocial interactions.
Unleashing Data: The Key To Driving Massive ImprovementsHealth Catalyst
Tom shares how investing in analytics training and infrastructure will help prepare for massive improvements in healthcare outcomes leading to sustained and distributed improvements throughout entire organizations.
Attendees will learn:
1. The key team roles and skillsets required for driving and sustaining massive improvements.
2. How to assess improvement opportunities from an effort and value perspective.
3. The most common mistakes in leveraging analytics and how to avoid them.
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
Three Strategies to Deliver Patient-Centered Care in the Next NormalHealth Catalyst
Juggling financial demands, uncertain healthcare legislation, and COVID-19 can distract healthcare leaders from the most important aspect of care—patients. Delivering patient-centered care in this volatile market can be challenging, especially when traditional healthcare methods (e.g., in-person visits) are on hold. These sudden disruptions to routine care have highlighted the importance of keeping patients at the center of care, whether care delivery is in-person or virtual. Health systems can manage competing priorities, adjust to pandemic-induced changes, and deliver patient-centered care by focusing on three strategies:
Improve the patient experience.
Implement the Meaningful Measures Initiative.
Transition in-person visits to virtual.
Presented by Steve Mills, IBM Senior Vice President, Group Executive, Software & Systems Group
Learn more: http://www.ibm.com/software/products/en/category/health-social-programs
Upping the "Total" in Total Rewards. Incentivizing your employees with the most sophisticated wearable technology, measuring more biomarkers than any other device, and the only device meriting being reviewed as a medical device. Included in the cost of the device - customized wellness programs designed on your employees biometrics. Our commitment to provide the most personalized corporate wellness programs, at the most affordable price and everyone gets the ultimate wearable technology. We will happily help you design a true program of reward - employee/employer contribution - rewarding commitment and motivation.
The Paradigm Shift from Healthcare to Population HealthPractical Playbook
The Practical Playbook
National Meeting 2016
www.practicalplaybook.org
Bringing Public Health and Primary Care Together: The Practical Playbook National Meeting was at the Hyatt Regency in Bethesda, MD, May 22 - 24, 2016. The meeting was a milestone event towards advancing robust collaborations that improve population health. Key stakeholders from across sectors – representing professional associations, community organizations, government agencies and academic institutions – and across the country came together at the National Meeting to help catalyze a national movement, accelerate collaborations by fostering skill development, and connect with like-minded individuals and organizations to facilitate the exchange of ideas to drive population health improvement.
The National Meeting was also a significant source of tools and resources to advance collaboration. These tools and resources are available below and include:
Session presentations and materials
Poster session content
Photos from the National Meeting
The conversation started at the National Meeting is continuing in a LinkedIn Group "Working Together for Population Health" and Twitter. Use #PPBMeeting to provide feedback on the National Meeting.
The Practical Playbook was developed by the de Beaumont Foundation, the Duke University School of Medicine Department of Community and Family Medicine, the Centers for Disease Control and Prevention (CDC), and the Health Resources & Services Administration (HRSA).
From Patients to ePatients Driving a new paradigm for online clinical collabo...ddbennett
CareTech eHealth Innovation Series
From Patients to ePatients Driving a new paradigm for online clinical collaboration and health management
David Bennett, SVP, Interactive Solutions
StayWell Custom Communications
Anthony Chipelo, Director, Portal Strategies
CareTech Solutions
This Webinar is the second of a three-part series synthesizing successful practices to engage hard-to-reach populations into HIV primary care. Lessons are drawn from SPNS population-specific initiatives, and speakers will offer insights relevant to a wide range of audiences, from clinicians to social workers. Presenters discussed the use of data to improve inreach.
Jane Herwehe, DeAnn Gruber, Betsy Shepard, and Debbie Wendell; Louisiana Public Health Information Exchange (LaPHIE)
Peter Gordon, MD; New York-Presbyterian Hospital/Columbia University
Jesse Thomas; RDE Systems
Innovation in commissioning and provisioning of community healthcare - Counti...Clever Together
Benedict Hefford is Director of Primary and Community Services at Counties Manukau Health, where he is also the executive lead for integrated care:
http://www.countiesmanukau.health.nz/AchievingBalance/System-Integration/system-integration-home.htm. As Director, Benedict is responsible for both operational delivery and commissioning of health and social care services in South Auckland – a culturally diverse and economically deprived area of New Zealand with over 500,000 residents.
Benedict has 20 years healthcare experience encompassing senior management, commissioning, and strategic roles in both New Zealand and the UK. Prior to joining CM Health, he was Director of Commissioning (Social Care and Health) in central London. Benedict’s previous experience also includes re-designing community care services at Hammersmith and Fulham PCT and Capital Coast Health, as well as developing national health strategies as a Senior Policy Analyst with the NZ Ministry of Health. Benedict holds an MSc in Public Services Policy & Management from King’s College London; a Postgraduate Diploma in Health Services Management; and a BSW (Hons).
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...CHC Connecticut
The COVID-19 pandemic has resulted in significant shifts in the mode of care from face-to-face to virtual interactions. Join us as we discuss the challenges currently facing behavioral health care and at least one strategy for each. Along with these strategies, panelists will go over what integrated behavioral health care was and is before and following COVID-19, as well as what actions should be taken going forward to increase access to comprehensive care.
Panelists:
• Dr. Tim Kearney, PhD, Chief Behavioral Health Officer, Community Health Center, Inc.
• Melinda Gladden, LCSW, PMHC, Behavioral Health Clinician, Community Health Center, Inc.
• Jodi Anderson, LMFT, Virtual Telehealth Group Coordinator, Community Health Center, Inc.
In search of a digital health compass: My data, my decision, our powerchronaki
Knowledge is power. Despite extensive investments in digital health technology, navigating the health system online is challenging for most citizens. Also for eHealth, the “Inverse Care Law” proposed by Hart in 1971, seems to apply. Availability of good medical or social care services and tools online, varies inversely with the need of the population. The low adoption of eHealth services, and persistent disparities in health triggers a call for multidisciplinary action.
Barriers and challenges are not to be underestimated. Culture, education, skills, costs, perceptions of power and role, are essential for multidisciplinary action. This comes together in digital health literacy, which ought to become an integral part to navigate any health system. Patients living with an implanted device or coping with persistent, chronic disease such as diabetes, as well as citizens engaged in self-care, caring for an elderly relative, a neighbor, or their child with illness or deteriorating health, need a digital health compass.
The panel will engage the audience to elaborate on a vision for this personal, digital health compass and drive advancement in health informatics and digital health standards. The transformative power of health data fueled by targeted digital health literacy interventions can be leveraged by open, massive, and individualized delivery. This way, digital health literate, confident patients and citizens join health professionals, researchers and policy makers to address age-related health and wellness changes to shape the emerging precision medicine and population health initiatives.
From a panel in the eHealthweek 2016. http://www.ehealthweek.org/ehome/128630/hl7-efmi-sessions/
Dr. Ostrovsky describes the promise and concerns surrounding the precision medicine initiative and the importance of taking into account all determinants of health.
Sj47 -The State of Youth Mental Health in VirginiaAnne Moss Rogers
Children’s Mental Health: Challenges and Opportunities--This is the presentation by Margaret Nimmo Crowe to a special subcommittee of the commonwealth, Executive Director for Voices for Virginia’s Children. More info here: http://1in5kids.org/2014/10/29/sj-47-workgroup-takes-childrens-mental-health/
This webinar discussed how to educate Nurse Practitioners who have completed Community Health Center. Inc’s NP Residency or NPs who have significant experience as a Primary Care Provider on the integration of specialty care for key populations, including:
• HIV care
• Hepatitis C management
• Medication-assisted treatment for opioid use and other substance use disorders
• Sexually transmitted disease (STI) screening and management
• Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual (LGBTQIA+) health, including hormone replacement therapy and gender affirming care.
Panelists:
• Charise Corsino, MA, Program Director, Nurse Practitioner Residency Programs, Community Health Center, Inc.
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
Well Care Health Plans, Inc.
Presentation to Georgia House Children's Mental Health Study Committee
October 20, 2015
Dauda Griffin, MD
Behavioral Health Medical Director
Remedios Roderiguez, Senior Director
Behavioral Health Operations
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Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Cold Sores: Causes, Treatments, and Prevention Strategies | The Lifesciences ...The Lifesciences Magazine
Cold Sores, medically known as herpes labialis, are caused by the herpes simplex virus (HSV). HSV-1 is primarily responsible for cold sores, although HSV-2 can also contribute in some cases.
Feeding plate for a newborn with Cleft Palate.pptxSatvikaPrasad
A feeding plate is a prosthetic device used for newborns with a cleft palate to assist in feeding and improve nutrition intake. From a prosthodontic perspective, this plate acts as a barrier between the oral and nasal cavities, facilitating effective sucking and swallowing by providing a more normal anatomical structure. It helps to prevent milk from entering the nasal passage, thereby reducing the risk of aspiration and enhancing the infant's ability to feed efficiently. The feeding plate also aids in the development of the oral muscles and can contribute to better growth and weight gain. Its custom fabrication and proper fitting by a prosthodontist are crucial for ensuring comfort and functionality, as well as for minimizing potential complications. Early intervention with a feeding plate can significantly improve the quality of life for both the infant and the parents.
KEY Points of Leicester travel clinic In London doc.docxNX Healthcare
In order to protect visitors' safety and wellbeing, Travel Clinic Leicester offers a wide range of travel-related health treatments, including individualized counseling and vaccines. Our team of medical experts specializes in getting people ready for international travel, with a particular emphasis on vaccines and health consultations to prevent travel-related illnesses. We provide a range of travel-related services, such as health concerns unique to a trip, prevention of malaria, and travel-related medical supplies. Our clinic is dedicated to providing top-notch care, keeping abreast of the most recent recommendations for vaccinations and travel health precautions. The goal of Travel Clinic Leicester is to keep you safe and well-rested no matter what kind of travel you choose—business, pleasure, or adventure.
International Cancer Survivors Day is celebrated during June, placing the spotlight not only on cancer survivors, but also their caregivers.
CANSA has compiled a list of tips and guidelines of support:
https://cansa.org.za/who-cares-for-cancer-patients-caregivers/
DECODING THE RISKS - ALCOHOL, TOBACCO & DRUGS.pdfDr Rachana Gujar
Introduction: Substance use education is crucial due to its prevalence and societal impact.
Alcohol Use: Immediate and long-term risks include impaired judgment, health issues, and social consequences.
Tobacco Use: Immediate effects include increased heart rate, while long-term risks encompass cancer and heart disease.
Drug Use: Risks vary depending on the drug type, including health and psychological implications.
Prevention Strategies: Education, healthy coping mechanisms, community support, and policies are vital in preventing substance use.
Harm Reduction Strategies: Safe use practices, medication-assisted treatment, and naloxone availability aim to reduce harm.
Seeking Help for Addiction: Recognizing signs, available treatments, support systems, and resources are essential for recovery.
Personal Stories: Real stories of recovery emphasize hope and resilience.
Interactive Q&A: Engage the audience and encourage discussion.
Conclusion: Recap key points and emphasize the importance of awareness, prevention, and seeking help.
Resources: Provide contact information and links for further support.
Under Pressure : Kenneth Kruk's StrategyKenneth Kruk
Kenneth Kruk's story of transforming challenges into opportunities by leading successful medical record transitions and bridging scientific knowledge gaps during COVID-19.
Letter to MREC - application to conduct studyAzreen Aj
Application to conduct study on research title 'Awareness and knowledge of oral cancer and precancer among dental outpatient in Klinik Pergigian Merlimau, Melaka'
Trauma Outpatient Center is a comprehensive facility dedicated to addressing mental health challenges and providing medication-assisted treatment. We offer a diverse range of services aimed at assisting individuals in overcoming addiction, mental health disorders, and related obstacles. Our team consists of seasoned professionals who are both experienced and compassionate, committed to delivering the highest standard of care to our clients. By utilizing evidence-based treatment methods, we strive to help our clients achieve their goals and lead healthier, more fulfilling lives.
Our mission is to provide a safe and supportive environment where our clients can receive the highest quality of care. We are dedicated to assisting our clients in reaching their objectives and improving their overall well-being. We prioritize our clients' needs and individualize treatment plans to ensure they receive tailored care. Our approach is rooted in evidence-based practices proven effective in treating addiction and mental health disorders.
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in CardiologyR3 Stem Cell
Dr. David Greene, founder and CEO of R3 Stem Cell, is at the forefront of groundbreaking research in the field of cardiology, focusing on the transformative potential of stem cell therapy. His latest work emphasizes innovative approaches to treating heart disease, aiming to repair damaged heart tissue and improve heart function through the use of advanced stem cell techniques. This research promises not only to enhance the quality of life for patients with chronic heart conditions but also to pave the way for new, more effective treatments. Dr. Greene's work is notable for its focus on safety, efficacy, and the potential to significantly reduce the need for invasive surgeries and long-term medication, positioning stem cell therapy as a key player in the future of cardiac care.
4. 3.3k
IVCs
38k
SMI
66k
2+ ED
Visits
2017 ED Patient Milieu
2017 Emergency Department (ED)
Presentations
89,364
BHSU
Encounters
193,277
Non-Behavioral Health
& Substance Use (BHSU)
The Challenge In Our Community Today
4
Average Daily Inpatient Census (ADC)
Baseline ADC = 140 – 160
Current ADC = 100 – 120
% ADC Decrease = 25 – 30 %
(7,200 ABD Saved)
9. BHSU Outpatient
Network
Traditional Outpatient Services
Group Therapy Services
Behavioral Health Urgent Care
(BHUC)
Mediation Assisted Therapy (MAT)
Community Based
Organization (CBO)
Network
CBO’s focused on insecurities
related to food, transportation
& housing
Inpatient BHSU
Network
WakeMed Services
Crisis & Assessment
ED Psychology Program
WPP Providers
Transitional Care Management
Community Case Management
Behavioral Health Network
POTENTIALLY FUNDED BY PHILANTHROPIC PARTNERS SUCH AS:
• WakeMed / WakeMed Foundation
• Inpatient Network Partners
• Outpatient Network Partners
• Duke / Duke Foundation
• UNC Healthcare
• Wake County
• Other community care
organizations
• Other behavioral health
providers
• Other NC health systems
• Health Plans
• Philanthropic partners
9
10. (BHSU Outpatient Network)
* All members have signed agreements committing to both quality and operational KPI’s. 10
12. Governance/Ops Structure
Board of Managers
Clinical /
Operations
Committee
Executive Director
Transitional Care
Specialists
Community
Care
Managers
Program
Improvement
Specialist
Network
Committee
• 2 Year Terms
• Oversight/Strategic Direction
• Professionally Managed
• Balance of Provider and
WakeMed Representation
12
13. The Chassis
Network alignment, goals, and governance. Working committees with
concrete charters and roadmaps. Linked to shared services and
sister networks.
Standardized triage, screening, and referral protocols. Common
assessment tools to front-load care transitions. Socialized clinical care
pathways.
Provider-level process and outcome KPI’s leveraging accessible data.
Impact data shows OpEx and community savings as well as network
performance and adequacy.
Shared e-referral and care coordination platforms for clinical and
social services. Embedded decision support, compliance monitoring,
and bi-lateral communications.
Behavioral Health Network
13
14. Patient Acuity Drives Timely
Access to Care
14
• 71% adherence to advanced access metrics/goals to date!!
– and 4% adherence by non-NABH members…
Tier 1 Tier 2 Tier 3 Tier 4
Self-Managed Routine OP F/U Advance Access to OP Services Advance Access & TCM Maintain IP Plan. Not Yet
Ready for OP plan
ED/Admitted Either Either Either Either
IVC No May meet criteria but due to
protective factors, motivation,
etc. voluntary, can be considered
Terminated/ending soon; no
active SI/HI
Not stable
Medical Stable. Not in need of medical detox Stable. No need of medical
detox
Stable / on track for clearance. No
need of medical detox
Not stable or needs medical
detox
Mental Health Status,
(If app.)
May have active psychosis but
otherwise functional in community
May have active psychosis but
functional in community
Active psychosis but not
impaired/or psychosis has
continued to improved
Psychosis causing functional
impairments in the
community
Substance Use Status
(if app.)
Actively attempting recovery with
concrete support system and plan
Actively attempting recovery
with concrete support system
Interested in recovery but lacks
support system and plan
Needs medical detox or use
behavior is immediate
danger to self/others
Discharge Status Ready. Can self-manage care.
Concrete support system and plan.
Ready. May need help managing
care transition or relapse risk
while awaiting OP appointment
Ready or ready in 1-2 days with
solid outpatient plan and TCM
F/U
Continues to have significant
barriers to be addressed
Social Determinant of
Health (SDOH) Barriers to
Care
None significant. Has access to
social and support resources.
Known SDOH barriers that
impede outpatient follow up
that require mitigation at
discharge
Needs plan and TCM support to
mitigate significant SDOH barriers
Significant SDOH obstacles
which can be addressed by
TCM as patient progresses
Referral to NABH
partners
7 Business Days 2 Business Days 1 Business Days Direct Transfer
16. Addressing SDOH
• Connecting Hospital, Providers, &
Community Based Organizations
• Transitional Care Management to “Fill the
Gap” before services start
• Link person to resources to improve
health/community outcomes.
Advanced access to services.
• Shared Care/Crisis Plans to minimize
unnecessary 911
• Care compliance alerts identify at-risk
behaviors early
• Use accountable partnerships to steer
referrals and funding
16
17. “Medical Meets Mission”
Care Management:
● Links to Medical, Clinical, and
Social Services
● Shares documents/Referrals
● Patient Surveillance/Alarms
● Community Resource Directory
● Referral Decision Support
Hospital/Network:
● CBO/Provider encounters visible
● Assess Need
● Initiate Transitional Care
● Convene Accountable Networks
Community Based Org:
● Track incoming referrals
● Communicate with care team
● Engage patient in self-care
● Target resources and
measure impact.
Provider
CBO
CBO
Housing support and shelters
Food security programs
Faith Based Community Care
PAP and mobile pharmacy programs
NAMI/AA/NA, etc. 17
21. Data Provided by:
Jody Webster, RN-BC
Associate Chief Nursing Officer
Division Of State Operated Healthcare Facilities,
Central Regional Hospital
N.C. Department of Health and Human Services
21
* 71.4 % decrease in state hospital referrals
WakeMed Referral to Central Regional Hospital (CRH)
0
20
40
60
80
100
120
140
160
Referrals
22. Avoidable Bed Days (ABD)
22
* 70% increase in getting patients to the treatment they need and deserve! (12/18)
0_5
Mont
h
Aver
age
17-
Nov
17-
Dec
18-
Jan
18-
Feb
18-
Mar
18-
Apr
18-
May
18-
Jun
18-
Jul
18-
Aug
18-
Sep
18-
Oct
18-
Nov
18-
Dec
Avoidable Bed Days 1281 1272 598 622 822 1226 916 747 813 774 802 368 679 507 391
ABD Goal 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033 1,033
0
200
400
600
800
1000
1200
1400
Avoidable Bed Days
25. Some Key Next Steps…
1. Fully Implement WakeMed’s Behavioral Health Network
Working with the Department of Health and Human Services (DHHS), Wake County,
ACO’s, and Payers on sustainable funding models for our Network.
2. Short and Long Term Funding for Connected Community
Continue to work with the Philanthropic Partners, DHHS, Payers, and Wake County for
funding options for our Connected partners.
3. Technology, Automation, and Artificial Intelligence (AI)
Act as an innovation incubator for emerging technology and analytics. Engage support
for using Artificial Intelligence (AI) technology for advancing care (suicidal ideation
detection, depression, anxiety, etc).
4. Behavioral Health Network “Engine”– get the Network fully engaged
and running efficiently
• Recruit Network leadership team (Tom Klatt, Executive Director)
• Deeper Clinical Integration and Transparency
• Decrease “Time to Treatment” and increase Patient Engagement
• Primary Care Integration
• Begin Connected Community Network operations 25
26. Key next steps…(cont.)
5. Getting the NABH “engine” fully engaged and running efficiently
- Operational refinement
- Technology enhancements developed and in the work flow
- Develop clear score keeping tools /dashboards, etc.
- Further development of the governance process
- Begin CBO Network
- Recruit NABH leadership team
6. Further accelerate the philanthropic and sustainable funding options (DHHS /
Wake County / Alliance) to support the NABH long-term
7. Evening at the Gibson’s on August 21st
26
then so is
Hope!!
If Fear is
contagious…
26
TCM. PDCA call is opportunity to learn in all settings. The biggest impact on Riley. . .treat and release at hospital with linkage to community showers and meals and detox. EMS and MCM engagement and a strong ACTT team
As a side benefit to the connected community and referral and communication tools, we can track the patient as they migrate through the community. Rather than send a Care Manager out to the community to figure out where “Jim” is, we can first go to these tools to see if he has visited the foodbank today as expected. With this information, we can begin to run risk segmentation reports that alert care teams when a patient disappears or does not follow through as expected. These alerts can trigger an outreach before the patients ends up in crisis.
In addition, we are looking at eHRS tools that can be used between providers in this network, streamlining paperwork but also ensuring that referrals are followed up on in a timely fashion.