PASS Presentation
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This document discusses care transition interventions for accountable care organizations. It introduces Independent Living Systems, which offers various health and social support services, including care transitions programs to help reduce hospital readmissions. The key is providing a continuum of care as patients transition between settings like hospitals, nursing homes, and home. Independent Living Systems' PASS program adapts the Care Transition Intervention model to assign coaches who work in hospitals and coordinate with care managers. Data on previous programs show reductions in readmission rates and costs through these targeted transition supports. Successful programs require integration into existing workflows and partnerships across care settings.
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This document summarizes a short film called "Jeté" about a young ballet dancer dealing with normal social pressures while pursuing her talent. It discusses the director, characters, production schedule, cinematography, editing, music, representation of characters, locations, distribution plans targeting 12-30 year old women, drawing in the audience, technologies used, and skills developed through the project such as research, pre-production, teamwork, and software skills. The film challenges conventions through its narrative, conclusion, and representation of the dancers as girls in a stereotypical way.
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PASS Presentation
- 1. CARE TRANSITION INTERVENTIONS FOR ACCOUNTABLE CARE ORGANIZATIONS Jeffrey T. King, RN, MBA, CDE SVP, Clinical Operations | Independent Living Systems, LLC 5201 Blue Lagoon Drive, Suite 270 Miami, Florida33126 Tel: 888 262 1292 www.ilshealth.com
- 2. Care Transition Intervention for ACOsAgenda
- 4. Experience in Managed Long-Term Care, Population Care Management & Home & Community Based Services.
- 5. Non-traditional products & services proven to directly impact outcomes:
- 6. Care Transitions (Readmission Prevention)
- 7. Nutrition Management & Home Delivered Meals
- 8. Home & Community Based Service Coordination
- 11. Partnerships between hospitals and physicians / healthcare professionals.
- 12. Place the patient & family in the center of all activities.
- 14. Care Transition Intervention for ACOAccountable Care Organization Overview The Current Cycle (REALITY)
- 15. Care Transition Intervention for ACOAccountable Care Organization Overview The Cycle Where It Should Be
- 16. Care Transition Intervention for ACOAccountable Care Organization Overview The Care Transition Focus
- 18. Adapted from the Care Transition Intervention (CTI) model developed by Dr. Eric Coleman, University of Colorado.
- 19. Designed to integrate into existing medical management or operational processes:
- 20. Is Not a replacement for case management, discharge planning or home health
- 22. LPN, RN, LCSW
- 23. Assigned by facility (Hospital) and visit that facility each day
- 24. Program Supported by PASS Care Coordinators
- 26. Care Management & support service
- 28. Care Transition Intervention for ACOILS Care Transition Program - PASS PASS Core Pillars (* Original CTI Pillars)
- 30. 70 Hospitals, 277 SNFs, 316 HHAs, 1.1 M Medicare Beneficiaries
- 31. Florida QIO: FMQAI – Miami-Dade Community
- 32. 11 Hospitals, 45 SNFs, 12 HHA, 60,000 Medicare Beneficiaries
- 34. Home and Community Based Services; Florida Area Agency on Aging Community Living Program.CMS Project Added Components & Partnerships
- 35. Independent Living SystemsSample Program Outcomes – Readmission Rate
- 36. Independent Living SystemsSample Program Outcomes – Readmission Costs
- 37. Independent Living SystemsProgram Outcomes – Care Transition
- 38. Independent Living SystemsProgram Outcomes – Care Transition
- 39. Care Transition Intervention for ACOKeys to Successful Program The “Must Haves” of the Program
- 40. Care Transition Intervention for ACOKeys to Successful Program The “Must Haves” of the Program
- 41. Jeffrey T King, RN, MBA SVP, Clinical Operations Email: jking@ilshealth.com Thank You