NTTAP Webinar Series - December 7, 2022: Advancing Team-Based Care: Enhancing the Role of the Medical Assistant and Nurse through Implementation of Care Management to Improve Chronic Conditions: Enrollments
Join us as expert faculty outline the differences between case management, care coordination and complex care management to frame up a discussion on strategies to leverage effective models for both in-person and remote services.
Expert faculty will discuss the role of the medical assistant and the nurse in care management, as well as how standing orders and delegated orders support this work. This session will discuss how telehealth and remote patient monitoring enhancements can support complex care management for patients with chronic conditions.
Participants will leave this session with the knowledge and tools to begin or enhance implementation of chronic care management by enhancing the role of the medical assistant, nurse and the technology that supports the clinical care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer, Community Health Center, Inc.
• Tierney Giannotti, MPA, Senior Program Manager, Population Health, Community Health Center Inc.
Implementation of Timely and Effective Transitional Care Management ProcessesCHC Connecticut
Join us to discuss best practices for integrating daily follow-ups for patients recently hospitalized for health emergencies. Effectively following up with patients is a critical responsibility for integrated care teams.
Experts will share how their teams respond to patients to identify care gaps and support the transition of care. Workflow descriptions will provide participants with the tools to support their work to adapt specific steps into their model of team-based care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, FAAN, Chief Nursing Officer, Community Health Center, Inc.
• Veena Channamsetty, MD, FAAFP, Chief Medical Officer, Community Health Center, Inc.
• Bibian Ladino-Davis, Behavioral Health Coordinator, Weitzman Institute
Implementation of Timely and Effective Transitional Care Management ProcessesCHC Connecticut
Join us to discuss best practices for integrating daily follow-ups for patients recently hospitalized for health emergencies. Effectively following up with patients is a critical responsibility for integrated care teams.
Experts will share how their teams respond to patients to identify care gaps and support the transition of care. Workflow descriptions will provide participants with the tools to support their work to adapt specific steps into their model of team-based care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, FAAN, Chief Nursing Officer, Community Health Center, Inc.
• Veena Channamsetty, MD, FAAFP, Chief Medical Officer, Community Health Center, Inc.
• Bibian Ladino-Davis, Behavioral Health Coordinator, Weitzman Institute
GESTÃO EM SAÚDE: Valor, Processos e DesperdíciosRafael Paim
Ao ir para falar, vi e ouvi práticas incríveis. A palestra apresentou casos, resultados e explicou conceitos como Lean Health Care como catalizador: Segurança, Agilidade, Produtividade e Melhorias na Saúde .
Três mensagens centrais foram dadas sobre como os fluxos dos processos produzem valor e são o locus nos quais as perdas e desperdícios não só ocorrem, mas, em especial, podem ser reduzidas e podem nos levar a repensar como podemos produzir Saúde para Saudáveis, Pacientes, Profissionais e Atores econômicos e sociais.
Advancing Team-Based Care: Building Your Primary Care Team to Transform Your ...CHC Connecticut
Advancing Team-Based Care: Building Your Primary Care Team to Transform Your Practice
Presented 2/18/2016 as part of the CHC Primary Care Workforce Development National Cooperative Agreement
Enhancing Quality of Care: The Role of Case Management in a Value-Based Healt...Conference Panel
Case management is a critical component of healthcare that has not always been fully recognized for its potential to enhance patient and provider satisfaction, quality of care, and cost containment. However, in today's healthcare landscape, with Value-Based Purchasing holding providers, health systems, and other professionals accountable for the quality and efficiency of their work, case managers have a unique opportunity to demonstrate the value they bring to patients, healthcare teams, and payers.
In this upcoming webinar, Anne Llewellyn will discuss practical strategies for case managers to leverage data and outcomes to illustrate the significant impact they can make in the complex and ever-changing healthcare system. By showcasing the results of their work, case managers can prove their worth and demonstrate how they can contribute to achieving the goals of Value-Based Purchasing, including improved patient outcomes, higher satisfaction rates, and reduced costs. Don't miss this opportunity to learn how case management can help drive success in a value-based healthcare system!
Register Now,
https://conferencepanel.com/conference/demonstrating-the-role-of-case-management-in-a-value-based-healthcare-system
2021-2022 NTTAP Webinar: Building the Case for Implementing Postgraduate NP R...CHC Connecticut
Join us as we discuss the drivers and processes of implementing a postgraduate nurse practitioner residency program at your health center, the benefits of implementing a postgraduate residency program, and the residency tracks for Family, Psychiatric/Mental Health, Pediatric, and Adult-Gerontology Nurse Practitioners.
We will be joined by Charise Corsino, Program Director of the Nurse Practitioner Residency Program, and Nicole Seagriff, Clinical Program Director of the Primary Care Nurse Practitioner Residency Program, from the Community Health Center Inc.
Behavioral Health Staff in Integrated Care SettingsCHC Connecticut
Webinar broadcast on Feb 27, 2019 - 3:00PM EST
Delivering behavioral health services as a part of an integrated team is crucial to providing comprehensive primary care services. Focusing on the vital role of behavioral health, experts will share the key elements that maximize the contributions of these team members through structured approaches to screening, the use of “warm hand offs” to ensure connection to primary care, and implementing a robust group of treatment programs to enhance access and improve outcomes. This session will also discuss the day-to-day operation of a behavioral health program and detail the data and clinical dashboard that supports the work of these vital team members. There has been tremendous progress from health centers across the country in the integrating behavioral health, this webinar will share how integrated behavioral health can advance the team’s capability to provide effective and high quality care to complex patient populations.
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.
Measuring Family Experience of Care Integration to Improve Care Delivery LucilePackardFoundation
The family perception of care integration is essential in identifying opportunities to improve processes of care coordination and care management. This June 15 webinar introduced the Pediatric Integrated Care Survey (PICS), a validated instrument developed by Richard Antonelli, MD, MS, Medical Director of Integrated Care at Boston Children's Hospital, and his team. The instrument assesses family experience of care integration. It asks family respondents to identify the members of their child's/youth's care team and report on their experiences with integration across disciplines, institutions, and communities.
AHRQ pbrn webinar electronic health record functionality needed to better sup...Vince Pereira, MHA
Feb 28, 2014 presentation by AHRQ - "Electronic health record functionality needed to better support primary care: Joint Statement AAFP, AAP, ABFM, and NAPCRG"
GESTÃO EM SAÚDE: Valor, Processos e DesperdíciosRafael Paim
Ao ir para falar, vi e ouvi práticas incríveis. A palestra apresentou casos, resultados e explicou conceitos como Lean Health Care como catalizador: Segurança, Agilidade, Produtividade e Melhorias na Saúde .
Três mensagens centrais foram dadas sobre como os fluxos dos processos produzem valor e são o locus nos quais as perdas e desperdícios não só ocorrem, mas, em especial, podem ser reduzidas e podem nos levar a repensar como podemos produzir Saúde para Saudáveis, Pacientes, Profissionais e Atores econômicos e sociais.
Similar to NTTAP Webinar Series - December 7, 2022: Advancing Team-Based Care: Enhancing the Role of the Medical Assistant and Nurse through Implementation of Care Management to Improve Chronic Conditions: Enrollments
Advancing Team-Based Care: Building Your Primary Care Team to Transform Your ...CHC Connecticut
Advancing Team-Based Care: Building Your Primary Care Team to Transform Your Practice
Presented 2/18/2016 as part of the CHC Primary Care Workforce Development National Cooperative Agreement
Enhancing Quality of Care: The Role of Case Management in a Value-Based Healt...Conference Panel
Case management is a critical component of healthcare that has not always been fully recognized for its potential to enhance patient and provider satisfaction, quality of care, and cost containment. However, in today's healthcare landscape, with Value-Based Purchasing holding providers, health systems, and other professionals accountable for the quality and efficiency of their work, case managers have a unique opportunity to demonstrate the value they bring to patients, healthcare teams, and payers.
In this upcoming webinar, Anne Llewellyn will discuss practical strategies for case managers to leverage data and outcomes to illustrate the significant impact they can make in the complex and ever-changing healthcare system. By showcasing the results of their work, case managers can prove their worth and demonstrate how they can contribute to achieving the goals of Value-Based Purchasing, including improved patient outcomes, higher satisfaction rates, and reduced costs. Don't miss this opportunity to learn how case management can help drive success in a value-based healthcare system!
Register Now,
https://conferencepanel.com/conference/demonstrating-the-role-of-case-management-in-a-value-based-healthcare-system
2021-2022 NTTAP Webinar: Building the Case for Implementing Postgraduate NP R...CHC Connecticut
Join us as we discuss the drivers and processes of implementing a postgraduate nurse practitioner residency program at your health center, the benefits of implementing a postgraduate residency program, and the residency tracks for Family, Psychiatric/Mental Health, Pediatric, and Adult-Gerontology Nurse Practitioners.
We will be joined by Charise Corsino, Program Director of the Nurse Practitioner Residency Program, and Nicole Seagriff, Clinical Program Director of the Primary Care Nurse Practitioner Residency Program, from the Community Health Center Inc.
Behavioral Health Staff in Integrated Care SettingsCHC Connecticut
Webinar broadcast on Feb 27, 2019 - 3:00PM EST
Delivering behavioral health services as a part of an integrated team is crucial to providing comprehensive primary care services. Focusing on the vital role of behavioral health, experts will share the key elements that maximize the contributions of these team members through structured approaches to screening, the use of “warm hand offs” to ensure connection to primary care, and implementing a robust group of treatment programs to enhance access and improve outcomes. This session will also discuss the day-to-day operation of a behavioral health program and detail the data and clinical dashboard that supports the work of these vital team members. There has been tremendous progress from health centers across the country in the integrating behavioral health, this webinar will share how integrated behavioral health can advance the team’s capability to provide effective and high quality care to complex patient populations.
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.
Measuring Family Experience of Care Integration to Improve Care Delivery LucilePackardFoundation
The family perception of care integration is essential in identifying opportunities to improve processes of care coordination and care management. This June 15 webinar introduced the Pediatric Integrated Care Survey (PICS), a validated instrument developed by Richard Antonelli, MD, MS, Medical Director of Integrated Care at Boston Children's Hospital, and his team. The instrument assesses family experience of care integration. It asks family respondents to identify the members of their child's/youth's care team and report on their experiences with integration across disciplines, institutions, and communities.
AHRQ pbrn webinar electronic health record functionality needed to better sup...Vince Pereira, MHA
Feb 28, 2014 presentation by AHRQ - "Electronic health record functionality needed to better support primary care: Joint Statement AAFP, AAP, ABFM, and NAPCRG"
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...CHC Connecticut
Join us for a webinar on quality improvement in team-based care!
Building a quality improvement (QI) infrastructure within team-based care is an organizational strategy that will establish a culture of continuous improvement across departments and improve quality in all domains of performance.
Participants will learn about:
• QI infrastructure
• Facilitating QI committees
• Coach training within health centers
Faculty will also provide an example of how trained coaches use QI tools to test and implement changes within an organization.
Patient Satisfaction
Patient Satisfaction Today
• Has become an important buzzword in health
care.
• Patients have access to hospital “report card”
patient satisfaction and quality scores.
– Ex: Hospital Compare
• Hospital placing high priority for patient
satisfaction due to scores being tied to
reimbursement rates.
Patient Satisfaction Today
• Patients are better informed.
• Patients want to understand their medical
care and be a part of the decision-making
process.
• Health care is featured almost daily in the
media, increasing patient expectations of the
care provided.
How is Patient Satisfaction Measured?
• Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) Survey.
• Standardized survey to gather and compare data across
the nation.
• 27 questions based on:
– Physician/Nurse/Staff Communication
– Hospital Environment
– Pain Management
– Overall rating
– Recommendation of Hospital
• Conducted through mail and/or telephone.
• Conducted after patient discharge.
Sample HCAHPS Questionnaire
• During this hospital stay, how often did nurses treat you with courtesy and
respect?
1. Never 2. Sometimes 3. Usually 4. Always 5. Non Applicable
• During this hospital stay, how often did doctors treat you with courtesy
and respect?
1. Never 2. Sometimes 3. Usually 4. Always 5. Non Applicable
• During this hospital stay, how often was the area around your room quiet at night?
1. Never 2. Sometimes 3. Usually 4. Always 5. Non Applicable
• Would you recommend this hospital to your family and friends?
1. Definitely No 2. Probably No 3. Probably Yes 4. Definitely Yes
• Using any number from 0–10, where 0 is worst hospital possible and 10 is
the best hospital possible, what number would you use to rate this
hospital?
Hospital Compare
Impact of ACA on Patient Satisfaction
• Pay For Performance (P4P).
• DRG payments are adjusted based on
performance on HCAHPS (30%) and clinical
process measures (70%).
• Patient satisfaction makes up 30% of hospital’s
score.
– Recommend Hospital
– Rate Hospital 9–10
Excellent Patient Satisfaction
• Excellent customer satisfaction goes beyond
patient interaction during hospital stay.
• Organizations judged on customer service the
instant contact is made with patient or family
member (phone, face-to-face, email, etc.).
• Higher patient satisfaction with inpatient care
and discharge planning is associated with
lower 30-day readmission rates.
» Source: AM J Managed Care, 2011; 17(1): 41-48
Trickle Down Effect of Excellent Service
• Providing excellent service leads to happy
patients who are less anxious.
• Less anxious patients are more cooperative,
leading to positive results.
Patient Needs
• Customer-friendly environment.
• Compassionate, caring, and individualized
care.
• Respect for privacy.
• Cultural sensitivity.
• Timely and proper explanations about ...
The HIMSS mHealth Physician Task Force's How-to-Guide will help both clinicians and C-suite executives identify which mobile tools are needed and worth investing in.
As new payment models emerge that emphasize value over volume, providers are being compelled to look more closely at how to motivate patients—especially those with multiple chronic conditions—to actively manage their care, make better decisions and change behaviors. This editorial webinar will explore the relationships between engagement and improved health outcomes, greater patient satisfaction and better resource utilization. Our panel of experts will share proven strategies for building patients' confidence, disseminating self-management tools and making the best use of your care team.
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...CHC Connecticut
Expert faculty will discuss the drivers, benefits, and processes of implementing a postgraduate residency training program at your health center. This session will dive deeper into a discussion on the responsibilities of key program staff, preceptors, mentors, and faculty for successful implementation. This webinar will equip participants with a road map to go from planning to implementation and offer an opportunity for coaching support.
Panelists:
• Program Director of the Nurse Practitioner Residency Program, Charise Corsino, MA
• Clinical Program Director of the Nurse Practitioner Residency Program, Nicole Seagriff, DNP, APRN, FNP-BC
Implement Behavioral Health Training Programs to Address a Crucial National S...CHC Connecticut
Health centers are uniquely positioned to address the unprecedented need for behavioral health services but are challenged by the workforce shortage. Participants will gain the knowledge needed to begin conceptualization of a training pathway.
Join us to discuss the considerations of sponsoring an in-house training program across all educational levels, including the benefits, program structure, design, curriculum, supervisors' role, and required resources.
Experts will provide participants with examples from practicum and postdoctoral level training programs to help them gain confidence in developing a behavioral health training pathway.
North highland himss_hardwiringclinicalfinancialperformance_041315North Highland
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The COVID-19 pandemic has created several challenges for our country’s health care infrastructure, and the community health center workforce is no exception. Join us as we describe strategies to get patients back into dental care. Along with these strategies, participants will learn how to recognize challenges in dental practices, as well as how to engage the interdisciplinary care team through role redesign and integration to increase access to comprehensive care.
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...CHC Connecticut
In order for health centers to provide compassionate and respectful HIV prevention, care, and treatment in comprehensive primary care settings, the clinical workforce must be knowledgeable, confident, and competent in their ability to do so.
We’ll explore the need to integrate HIV care into training and education for the clinical care team, as well as educational models to train the next generation. Using Community Health Center Inc.’s Center for Key Populations Fellowship for Nurse Practitioners (NPs) as a framework for best practices, experts will discuss how to implement specialty care for key populations in your training programs. Additionally, participants will gain awareness of the importance of training the clinical workforce on key population competencies in HIV programs (e.g. HCV, MOUD, LGBTQI+ health, homelessness, and harm reduction).
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...CHC Connecticut
Improve educational training experiences at your health center by assessing your capacity and infrastructure to host health professions students.
Join the upcoming hands-on interactive activity session to learn how to utilize the Readiness to Train Assessment Tool (RTAT™). This tool was developed by HRSA-funded National Training and Technical Assistance Partners (NTTAP) at Community Health Center, Inc. (CHC) to understand organizational readiness to host health professions student training programs.
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:
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• Melinda Gladden, LCSW, PMHC, Behavioral Health Clinician, Community Health Center, Inc.
• Jodi Anderson, LMFT, Virtual Telehealth Group Coordinator, Community Health Center, Inc.
HIV Prevention: Combating PrEP Implementation ChallengesCHC Connecticut
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This webinar discussed the various avenues of workforce development including:
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The discussion referenced CHC Chief Operating Officer Meredith Johnson and CHC Project Manager Megan Coffinbargar’s publication “Establishing an Administrative Fellowship Program: A Practical Toolkit to Support and Develop Future Community Health Center Leaders” for the National Association of Community Health Centers (NACHC).
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This webinar discussed the value of chiropractic treatment as a primary care intervention. Our panelists discussed the role of chiropractic specialists in the primary care team and reviewed the integration of chiropractic services.
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There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
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WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
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According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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NTTAP Webinar Series - December 7, 2022: Advancing Team-Based Care: Enhancing the Role of the Medical Assistant and Nurse through Implementation of Care Management to Improve Chronic Conditions: Enrollments
1. Advancing Team-Based Care Webinar:
Enhancing the Role of the Medical Assistant and Nurse through
Implementation of Care Management to Improve Chronic Conditions
Wednesday, December 7th 2022
2:00-3:00pm EST, 11:00am-12:00pm PST
2. Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be sent after
the end of the series, Summer 2022.
2
3. Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under
investigation (not FDA approved) and any limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $2,082,933 with 0% financed with non-
governmental sources. The contents are those of the author(s) and do not necessarily represent the official
views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov.
3
4. At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
4
5. National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity
sessions, trainings, research, publications, etc.
5
6. Speakers
• Mary Blankson, DNP, APRN, FNP-C
– Chief Nursing Officer, Community Health Center
• Tierney Giannotti, MPA
– Senior Program Manager, Population Health, Community Health
Center
6
7. Objectives
• Review models of complex care management, leveraging both in
person and remote teams
• Describe telehealth as an enhancement to complex care
management delivery
• Outline case examples of complex care management in action
• Discuss leveraging all team members to the fullest success of their
training
• Recognize practical examples of care management tools to ensure
success
7
8. Resource Allocation
• Role of RN
• Role of other team members
• Care Coordination vs. Case Management vs. Care Management
• Role of Risk Stratification
• Role of Payers
8
9. What is Care Coordination?
• “Deliberate organization of patient care activities between two or
more participants (including the patient) involved in a patient’s care
to facilitate the appropriate delivery of health care services” (AHRQ)
• An integral component of the National Committee for Quality
Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) model
• Patient-centered care coordination is a core professional standard
and competency for all nursing practice (ANA)
9
10. Case Management vs.
Care Coordination vs. Complex Care Word Soup
10 Source: Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)
13. Core Team Roles
Things to consider:
Centralization vs. site-level care
Generalization vs. Specialization
Hybrid models
Processes vs. People
13
14. Extended
Care Team
Core Team
Provider
MA
Teamlet
Provider
MA & RN
Teamlet
• Receptionist
• Health Coach
• Panel Manager
• Referral Coordinator
• RN Care Managers
• Behavioral Health
Specialists
• Administrative Staff
• Team RN
Virtual
Team
• Centralized Care
Manager
• Telehealth Triage
• Pharmacy
• Patient
Experience
Coordinators
• Digital Tech
Liaisons
• Scheduler
• Lay Caregivers/
CHWs
Primary Care Team
Care Teams
Virtual Care Team
15. 1
5
●Comprehensive, team-based
oral health care; preventive,
restorative, and transformative
●“Wherever You Are” (W.Y.A)
strategy to engage kids in school,
farmworkers, homeless in
community settings
●Integration with medical:
Diabetes prevention, fluoride
varnish application, etc.
●Comprehensive primary
medical care for all but the
most complex conditions
●Preventive health promotion
and chronic illness
management at every visit
●Chiropractors, Podiatrists,
Dieticians, OB-GYN, HIV
specialists all contribute to
meeting patient needs
●Behavioral health is central to
CHC’s primary care model
●Care may be initiated by patient
or by warm hand off-in person or
by “eWHO”
●SBHCs provides access to BH for
children and adolescents
●Trauma focused care, group
support, and access to integrated
medical/BH OUD
● Care delivered under standing and
delegated orders
● Nursing leads the team including
Medical Assistants and other
support members
● Focus on key populations such as
elderly (MAWVs, CCM), Homeless,
Transitions in Care
● Nurses also hold roles in triage,
Center for Key Populations,
leadership
Integration
16. Role of the Medical Assistant in Care Management
• Care gap closure
• Identifying patients lost to
follow up
• ER transition follow up
• Obtain hospital discharge
summaries and other important
documents
16
17. Role of Nurse
in Care Management
• Working with vulnerable patients
• Motivational interviewing and self
management goal setting
• Independent Nurse Visits under
standing and delegated orders
• Quality improvement leaders, coaches,
and team members
• Intensive coordination of community
resources, directly or through an
assigned case manager or community
worker
• Remote patient monitoring
• Telehealth nurse: transition of care
visit within seven days of discharge
• Population Health RN teams: support
care gap closure and other initiatives
17
18. Behavioral Health Collaboration
with RNs for Care Management
• Increased collaboration Psychiatry & RNs
– Safety
• Controlled substance visits
• Medication adherence
• Antidepressant f/u visits
• Long acting injectibles (LAI) Psychotropics
• Others
– Overall wellness
• Insomnia
• Diabetes management
• Others
18
22. Systems and Technology
to Support Care Management
• Integrated Scheduling System
• Call any CHC number and connected to same scheduling group
• Medical, dental, therapy and psychiatry services all scheduled through one system
• All Recalls visible at all points of contact
22
26. Remote Patient Monitoring
Initial Questions
• Which chronic illness are you planning to utilize RPM for?
• Which devices are you planning to use?
• Are you giving away the devices? Loaning? Prescribing?
–If yes, create a process/standing order
26
27. Remote Patient Monitoring
Once Device Selected
• Who will train the patient to use the device?
• How and where in the E.H.R. is the data coming back to the organization?
• Who is responsible to act on the data?
– By whose authority?
– How often?
• Who is responsible to manage abnormal values?
• Develop scripting for staff to talk about RPM and why it is important
– Add a checklist to support eligibility screening
27
28. Remote Patient Monitoring
Evaluation
• How each team member’s success be evaluated for their part of the work?
• How will the program processes be improved over time?
• How will the program be sustainable?
– In terms of staff time & satisfaction
– In terms of financial impact/ROI
• Ensure there is a little “gatekeeping” as possible
• Break down every measure into sub-parts to identify all process measures that
contribute to the final clinical outcome
• Create an iterative feedback loop to ensure best practice development
28
29. Standing Orders
• Planned Care:
– Publish Clinical Expectations for teams (part of the plan of care policy)
– Create a grid of all measures
• Denominators
• Numerators
• Frequency
• Explanation of data entry options
• Follow-up or care coordination required
29
30. Standing Orders
• Chronic Illnesses Care Management
– Select evidence/ensure it matches organizational clinical expectations
– Outline expected data collection
– Outline optional data collection/care delivery based on assessment
completed (think “menu”)
– Create a grid of all examples
• Who it applies to (i.e. age and symptom(s))
• Any exclusions?
• Don’t forget data entry issues
– i.e. order sets, templates, order link with diagnosis/ symptom, CPT codes
– What to do if something else comes up?
– References
30
32. E.H.R. Templates & Order Sets
Designed to ensure:
→ Minimum data set
→ Consistency in documentation of encounters
→ Emphasis on MI and SMG setting
→ Appropriate education
→ Ensures safety
→ Creates efficiency
32
34. Example: Patients with Diabetes
• Population: 7,440 patients with diabetes
• Subgroup: 866 patients whose last A1c > 9.0 who did not have an
upcoming visit scheduled and no visit in the prior 3 months
• Assign and Train: 5 Patient Service Associates to schedule telehealth
encounters
• Results: 32% of patients were scheduled for a visit with PCP.
• Any patient who had been seen by a PCP within the past 3 months
with last A1c > 9.0 were scheduled with an RN for care management
34
35. Telehealth Population Health Approach:
Patients with Chronic Conditions
• Define the population
• Scale the subgroup of patients to meet the operational capacity ->
highest of the high risk
• Develop and test scripts
• Identify who should see the patient (PCP, RN, CDCES, etc.)
• Obtain feedback iteratively from those reaching out to patients
35
36. Monthly IMZ File
• On a monthly basis the Population Health Team, with data from dashboards created
by Business Intelligence, sends two targeted lists of patients due for childhood
immunizations.
• The information is sent to Nurse Managers and include:
– The first list separated by site, identifies infants 12 to < 15 weeks who are due for
their first Rotavirus vaccine.
– The second list, also separated by site, identifies children 18-23 months old who
are not up to date on their 24 month old immunizations. The specific
immunizations that are due for the child are highlighted.
• Nurse managers are expected to review the information and outreach to patients as
needed. They report their follow up in the Excel file and return it to population
health.
36
37. Potential Points of Friction
• Physical plant space for longer teaching sessions vs. use of the
virtual environment
• Gatekeeping vs Top of license/training practice
• The art of medicine vs. evidence basis
• Duplicative work/duplication of efforts
• Feedback seen as punitive instead of routine
• Others?
37
38. Managing Culture
• Create an environment of team-based care that is based on the
value of every role (not just as a downstream catchall to support
providers)
• Focus on measurement in everything that you do
– Normalize feedback and data as an invitation to partner and troubleshoot
• Invite patients to help you test new technology
• Embrace failure as just another data point on the way to a best
practice
• Celebrate success (often!)
38
39. References
• Bauer, L., & Bodenheimer, T. (2017). Expanded roles of registered nurses in primary care delivery of the future. Nursing
Outlook, 65(5), 624-632.
• Bodenheimer, T., & Laing, B. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine, 5, 457-461.
• Community Health Center, Inc. & The MacColl Center for Health Care Innovation. (2016). HRSA National Cooperative
Agreement: Workforce Development: Complex Care Management in Primary Care. Retrieved from
https://www.slideshare.net/CHCConnecticut/advancingteambased-care-complex-care-management-in-primary-care
• Flinter, M., Blankson, M., & Ladden, M.J. (2016). Registered Nurses in Primary Care: Strategies that Support Practice at the Full
Scope of the Registered Nurse License. Registered Nurses: Partners in Transforming Primary Care. Recommendations from the
Macy Foundation
• Flinter, M., Hsu, C., Cromp, D., Ladden, M., & Wagner, E. (2017). Registered Nurses in Primary Care: Emerging New Roles and
Contributions to Team-Based Care in High-Performing Practices. Journal of Ambulatory Care Management, 40(4), 287-296.
• Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)
• Norful, A., Martsolf, G., de Jacq, k., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic
review. International Journal of Nursing Studies, 74, 15-23.
39
41. Interested in receiving coaching support to
move your health center from planning to
implementation of replicable models?
Our NTTAP offers learning collaborative
opportunities in Training the Next Generation,
Team-Based Care, and HIV Prevention!
For more information, please reach out to
Meaghan Angers (angersm@chc1.com)
41
42. Contact Information
42
For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca
Editor's Notes
Bianca (2:00-2:05)
Bianca (2:00-2:05)
Bianca (2:00-2:05)
Bianca (2:00-2:05)
Bianca (2:00-2:05)
Bianca (2:00-2:05)
Mary (2:05-2:20)
Mary (2:05-2:20)
Mary (2:05-2:20)
Mary (2:05-2:20)
Mary (2:05-2:20)
Mary (2:05-2:20)
CHC wholeheartedly believes in an evolving team-based model of care that we know will deliver improved clinical outcomes to support our complex patients—evolving because we have added telehealth and other roles related to the transformation that took place during the COVID-19 pandemic and analysis from our needs assessment. By empowering every member of the care team to be empaneled to a group of patients, we leverage their unique skill set to improve patient access to a variety of resources. Not only does this ensure compliance and ongoing improvement of our Patient Centered Medical Model and therefore our recognition, but it also reduces burnout by delineating each team member’s role and overall responsibilities. This allows us to have accountability for all of our operational and clinical metrics because we can break them into parts---each team member knows they are absolutely vital and valuable to the overall team, and also accountable for their individual contribution to the whole.
Mary (2:05-2:20)
Team RNs
Independently scheduled visits include visits for preventive care, chronic illness care, and acute care including visits conducted under standing orders, protocols, and delegated order sets
Both independent and conjoint visits with PCPs and other team members.
Triage, both electronic, telephonic and in-person
Transition Management post hospital or SNF discharge
Patient education
Medication reconciliation
Self management goal setting
Managing patient flow
Supervision of medical assistants and other team member
Strongly engaged in quality improvement activities
In some practices, incorporated complex care management into practice
Mary (2:05-2:20)
Mary (2:05-2:20)
Mary (2:05-2:20)
Mary (2:05-2:20)
Pop health nurse AWV
Mary (2:05-2:20)
Role for psych
Role for the therapist
Getting patients in – working with psych to make meds contigent on attending therapy- and RN pick up of meds.
No evidence in literature- perhaps we could add to thte lit- definitely able to get pts off of BZDs with this approach- may take a long time even a year. Works for some and not al.
Case of M.L trauma nect pt to try this with- setting alert no visit without therapy.
Mary (2:05-2:20)
Transition slide
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Make automatic what should be automatic, so huddle becomes less about getting pt a mammogram but how do we help the patient at 3pm get the support she needs to manage DM
Tierney (2:20-2:40)
Transition slide
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Tierney (2:20-2:40)
Planned Care = MA Standing Order