This project aimed to improve pediatric care coordination between primary care physicians and three specialty practices (neurology, orthopedics, pulmonology) in Michigan. The project focused on five areas: referral guidelines, records transfer, communication modalities, referral management workflows, and co-management protocols. Outcomes after one year showed improvements in access such as decreased wait times, fewer denied referrals, and increased patient and physician satisfaction. The project demonstrated how integrating care across specialties can help reduce barriers to specialty access.
2018 TBC Learning Collaborative Session 1, May 09 2018CHC Connecticut
This document provides an introduction to a learning collaborative on implementing team-based care (TBC) at health centers. It outlines the agenda for the first session, including introductions from six participating health centers where they describe their team members and a recent improvement. The goals are to review the collaborative structure and resources on TBC models and assessment tools to help teams get started on action period assignments.
Clinical Workforce Development NCA Informational WebinarCHC Connecticut
Learn more about training and technical assistance offered through Community Health Center Inc.'s National Cooperative Agreement (NCA) on Clinical Workforce Development. Hear more about FREE Learning Collaboratives opportunities to enhance or implement a model of Team-Based Care at your Health Center, and how to implement a Post-Graduate Residency program for Nurse Practitioners and Post-Doc Clinical Psychologists.
An enhanced care management program achieved lower health care costs through broader outreach, personalized health coaching, and engagement of higher-risk populations. A randomized controlled trial of 175,000 individuals found that the enhanced program led to a $7.96 lower average monthly medical cost per member and over a 4:1 return on investment. Key aspects of the enhanced program included targeting a wider range of chronic and preference-sensitive conditions, more frequent outreach, and deeper health coaching relationships.
The survey found that care coordinators need more support and resources to help patients. Nearly 70% rely on colleagues and 60% use personally collected materials for referrals. 98% want additional support like online referral resources and networking. Over half preferred online referral resources. The survey identified needs for improved training, current information, and abilities to understand learning styles and listen to patients. Care coordinators help with various needs including education, appointments, insurance, and translation. More support is needed for their important role in improving health outcomes.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
Building the Case for Implementing Postgraduate Residency Training ProgramCHC Connecticut
Community Health Center, Inc. is proposing to implement postgraduate residency programs for nurse practitioners and clinical psychologists. Residencies would provide intensive clinical training over 12 months to address workforce shortages and reduce burnout. Core elements include precepted clinics, specialty rotations, didactics, and quality improvement training. Residencies aim to develop expert clinicians prepared to lead community health centers. While start-up costs are required, residencies may increase retention, productivity, and recruitment over time, providing a return on investment. Residencies can smooth new providers' transition to independent practice.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
2018 TBC Learning Collaborative Session 1, May 09 2018CHC Connecticut
This document provides an introduction to a learning collaborative on implementing team-based care (TBC) at health centers. It outlines the agenda for the first session, including introductions from six participating health centers where they describe their team members and a recent improvement. The goals are to review the collaborative structure and resources on TBC models and assessment tools to help teams get started on action period assignments.
Clinical Workforce Development NCA Informational WebinarCHC Connecticut
Learn more about training and technical assistance offered through Community Health Center Inc.'s National Cooperative Agreement (NCA) on Clinical Workforce Development. Hear more about FREE Learning Collaboratives opportunities to enhance or implement a model of Team-Based Care at your Health Center, and how to implement a Post-Graduate Residency program for Nurse Practitioners and Post-Doc Clinical Psychologists.
An enhanced care management program achieved lower health care costs through broader outreach, personalized health coaching, and engagement of higher-risk populations. A randomized controlled trial of 175,000 individuals found that the enhanced program led to a $7.96 lower average monthly medical cost per member and over a 4:1 return on investment. Key aspects of the enhanced program included targeting a wider range of chronic and preference-sensitive conditions, more frequent outreach, and deeper health coaching relationships.
The survey found that care coordinators need more support and resources to help patients. Nearly 70% rely on colleagues and 60% use personally collected materials for referrals. 98% want additional support like online referral resources and networking. Over half preferred online referral resources. The survey identified needs for improved training, current information, and abilities to understand learning styles and listen to patients. Care coordinators help with various needs including education, appointments, insurance, and translation. More support is needed for their important role in improving health outcomes.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
Building the Case for Implementing Postgraduate Residency Training ProgramCHC Connecticut
Community Health Center, Inc. is proposing to implement postgraduate residency programs for nurse practitioners and clinical psychologists. Residencies would provide intensive clinical training over 12 months to address workforce shortages and reduce burnout. Core elements include precepted clinics, specialty rotations, didactics, and quality improvement training. Residencies aim to develop expert clinicians prepared to lead community health centers. While start-up costs are required, residencies may increase retention, productivity, and recruitment over time, providing a return on investment. Residencies can smooth new providers' transition to independent practice.
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
This infographic speaks to the challenges Emergency Departments face in caring and following up with the growing population of patients they see, and demonstrates how some EDs are seeing measurable improvements in care, patient satisfaction and efficiency.
This document provides an overview of transitions of care, including definitions, models, and best practices. It describes transitions as the movement of patients between healthcare settings or providers. Poor transitions can lead to adverse outcomes for patients and increased costs. Several evidence-based models are described that aim to improve transitions through elements like medication reconciliation, discharge planning, and post-discharge follow up. These models have demonstrated reductions in readmissions and healthcare utilization. The document provides resources for additional information on improving the quality of patient transitions.
The document summarizes a team's proposal on universal access to primary health care. The team details their coordinator, members, and contact information. It then discusses definitions of primary health care, principles of PHC, services offered at health centers, strategies to improve quality PHC according to WHO, requirements for universal access, and proposed solutions focusing on patient-provider relationships and comprehensive, equitable care.
The Structure of a 12-month Residency Program and Stories from Former Residen...CHC Connecticut
The goal of the Postdoctoral Psychology Residency program is to train the next generation of psychologists in the Patient Centered Medical Home model. Through weekly seminars, group and individual supervision and clinical work with diverse, underserved populations, residents will fine-tune assessment and therapy skills.
This FREE learning collaborative opportunity will provide health centers with the support, resources and structure to implement a Postdoctoral Clinical Psychology Residency program at their organization.
Patient Engagement in Healthcare Improves Health and Reduces CostsM2SYS Technology
It’s been said that patient engagement develops naturally when there is a regular, focused communication between patient and provider and it leads to behaviors that meet or more closely approach treatment guidelines. It is also believed that patients engaged in their own care make fewer demands on the health care system and more importantly, they experience improved health. Patients who are educated about both their condition and their care are also patients who are most likely to get and stay healthy. In fact, many believe that empowering patients to actively process information, decide how that information fits into their lives, and act on those decisions is a key driver to improving care and reducing costs.
Research shows that informed and engaged patients take a more active role in their own care and furthermore, health care organizations are slowly discovering how patient engagement contributes to their financial and quality objectives. Patient engagement essentially revolves around the theory that if patients understand their condition, know the symptoms to watch for, know why they’re taking medication for example and how to implement the necessary lifestyle changes, the chances of them getting and staying healthy are significantly improved and when you proactively engage patients in their care, the quality of that care improves.
Listen in to our latest podcast with Brad Tritle, Director of Business Development for Vitaphone Health Solutions, chair of the HIMSS Social Media Task Force and contributing editor of the HIMSS book Engage! Transforming Healthcare through Digital Patient Engagement as we discuss the current state of patient engagement in healthcare, how it is defined, whether it really does have a significant impact on improving health and reducing the cost of care, what engagement initiatives are providers using and what the future of patient engagement may look like.
Closing the Loop: Strategies to Extend Care in the EDEngagingPatients
This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
Delivering value based_care_with_e_health_services.5Greg Bauer
The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
PFCC Methodology and Practice: Deliver Ideal Care Experiences and Outcomes…By...EngagingPatients
The document describes the Patient and Family Centered Care (PFCC) methodology used at UPMC, a large integrated health system. The six-step PFCC methodology involves: 1) defining the care experience, 2) forming a guiding council, 3) observing the current state through shadowing, 4) identifying touchpoints through a working group, 5) creating a shared vision for an ideal experience, and 6) implementing improvement projects. The methodology aims to improve outcomes and experiences by engaging patients and families in co-designing care and breaking down silos between care providers. Examples of successful PFCC projects that improved discharge processes and communication through bedside rounding are provided.
This document discusses approaches to personalizing quality measurement in healthcare. It outlines three fundamental approaches:
1) Integrating patient-reported outcome and experience measures (PROMs and PREMs) into clinical workflow to better capture patients' health status and perspectives.
2) Encouraging patients' and clinicians' joint generation of medical records, such as through the OpenNotes project, to improve patient engagement, communication, and safety reporting.
3) Measuring decision quality through shared decision making between clinicians and patients to respect patient autonomy and better account for individual risk-benefit preferences in medical decisions. The document argues for rapidly adopting these personalized approaches and incentivizing their use through payment reform.
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.
The document discusses various topics related to physical therapy (PT) practice. It notes that in 2014, PTs can avoid PQRS penalties by reporting 3 quality measures for 50% of patients, and the number of measures required to receive bonuses will increase from 3 to 9. It also eliminates reporting via measures groups through claims. The document discusses focusing on developing quality measures for PT, payment models that promote value, and public policy initiatives to advance the role of PT in areas like disease management. It also discusses improving access, eliminating self-referral profits, and ensuring an adequate PT workforce.
This document provides a summary of evidence on the impact of patient-centered medical homes (PCMHs) and primary care innovations on cost and quality from 2013-2014. It finds that PCMH interventions are associated with modest improvements in quality of care and reductions in utilization and costs. It also discusses challenges in evaluating PCMHs and outlines opportunities to further integrate primary care with other specialties and engage consumers. The future of the PCMH relies on continued financial support, training interprofessional teams, harnessing technology, and partnering with patients and communities.
Over half of patients at a rehabilitation hospital reported wanting greater involvement in their care decisions. To address this, the hospital conducted patient and family shadowing where observers followed patients to experience care from their perspective. This identified themes like explanations during rounds and involvement in discharge plans. A post-intervention survey found a statistically significant improvement in patients feeling involved in care decisions and clinically relevant improvements in understanding doctor explanations and recommending the hospital. Engaging medical leaders and balancing data with reflection time led doctors to change practices without formal rules.
Weitzman 2013: PCORI: Transforming Health CareCHC Connecticut
This document summarizes a presentation given by Joe Selby on the Patient-Centered Outcomes Research Institute (PCORI). It discusses PCORI's mission to fund comparative clinical effectiveness research that is guided by patients and other stakeholders. Key points include: PCORI's focus on research questions of interest to patients and providers; its criteria for funding proposals, including patient-centeredness and engagement; and its plans to significantly increase funding for such research over time. Examples are given of funded pilot projects involving community health centers.
The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Revie...CHC Connecticut
Dr. Nwando Olayiwola, Associate Director, Center for Excellence in Primary Care, Assistant Professor, University of California, San Francisco addresses the 2014 Weitzman Symposium on The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of Evidence
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
Improving hand offreportstudent namesteam name andssuser774ad41
The unit manager observed that change of shift reports were taking over 45 minutes and staff were leaving out vital patient information such as IV sites and DVT prevention measures. This was leading to errors, patients being left in disarray, and incomplete tasks. The goal is to propose a change to address these issues with timing and information handoffs between shifts. Implementing the SBAR communication tool as the standard for handoff reports could help reduce errors and decrease the time spent on reports by structuring the important information discussed.
Marita Schifalacqua, RN, MSN, NEA-BC, FAAN,
Chris Costello, MEng, MBA, and Wendy Denman, RNC, BBM, BSN, MSN
Roadmap for Planned Change, Part 2
Bar-Coded Medication Administration
hange—savored by some and feared by many.
How do you as nurse leaders use your
knowledge and insight to move forward and transfer
your vision for quality and safety into reality? What do
you need to do to get key stakeholders on the bus and,
in some cases, even drive the bus? The roadmap for
planned change allows for an infrastructure of thought
brought to increase the likelihood for successful
change. Successful change is important to our patients
and to us as providers of that care.
This article, the second of a two-part series,
focuses on the application of change theory and the
elements of project management most critical to
successfully implementing a bar-coded medication
administration (BCMA) program. Examples will be
from one hospital’s experience, Saint Francis Medical
Center in Grand Island, Nebraska, to a health
system’s (Catholic Health Initiatives, Denver, Colorado)
approach to planning for 30 hospitals.
The definition of the BCMA program includes a
consistent, integrated information technology strategy,
with a focus on point-of-care BCMA to ensure that the
right person receives the right medication, in the right
dosage, via the right route, at the right time (five
rights). The bar code on medication is scanned before
administration to patients.
C
April 200932 Nurse Leader
Nurse Leader 33www.nurseleader.com
APPLICATION OF CHANGE THEORY AND
PROJECT MANAGEMENT
The first article discusses concepts and tools of both change
leadership and project management that lend support in plan-
ning and managing large- or small-scale change. Change lead-
ership is a common methodology of theory and tools that,
when used routinely, are central to integrating a change man-
agement model with the people side of change.
Project management is an application of knowledge, skills,
tools, and techniques customized to the initiative.The project
management elements discussed in the first article that are
most critical to successfully implementing planned change are
project charter, project budget and budget management, proj-
ect plan and schedule management, project staff organization,
project communications management, and project risk and
issue management.
CURRENT STATE ANALYSIS
Changing a process as complex as BCMA can and will
impact a variety of stakeholders. It is important to review
the process of medication administration from the time the
medication enters the facility through the time that the med-
ication is billed to the patient. Employees working in depart-
ments that will experience change with BCMA need to
know that their role is important and that their viewpoint
is valued.
Leadership
The chief nursing officer and vice president of ancillary services
were the executive cosponsors of the project.There was a
BCMA stee ...
CASE STUDYAcquiring an EHR SystemValley Practice provides .docxdrennanmicah
CASE STUDY
Acquiring an EHR System
Valley Practice provides patient care services at three locations, all within a fifteen-mile radius, and serves nearly 100,000 patients. Valley Practice is owned and operated by seven physicians; each physician has an equal partnership. In addition to the physicians, the practice employs nine nurses, fifteen support staff, a business officer manager, an accountant, and a chief executive officer (CEO).
During a two-day strategic planning session, the physicians and management team created a mission, vision, and set of strategic goals for Valley Practice. The mission of the facility is to serve as the primary care “medical home” of individuals within the community, regardless of the patients' ability to pay. Valley Practice wishes to be recognized as a “high-tech, high-touch” practice that provides high-quality, cost-effective patient care using evidence-based standards of care. Consistent with its mission, one of the practice's strategic goals is to replace its current paper-based medical record with an EHR system. Such a system should enable providers to care for patients using up-to-date, complete, accurate information, anywhere, anytime.
Dr. John Marcus, the lead physician at Valley Practice, asked Dr. Julie Brown, the newest partner in the group, to lead the EHR project initiative. Dr. Brown joined the practice two years ago after completing an internal medicine residency at an academic medical center that had a fully integrated EHR system available in both the hospital and its ambulatory care clinics. Of all the physicians at Valley Practice, Dr. Brown has had the most experience using an EHR. She has been a vocal advocate for implementing an EHR and believes it is essential to enabling the facility to achieve its strategic goals. Dr. Brown contacted the Regional Extension Center (REC) in the community for assistance with the initiative.
Dr. Brown agreed to chair the project steering committee. She invited other key individuals to serve on the committee, including Dr. Renee Ward, a senior physician in the practice; Mr. James Rowls, the CEO; Ms. Mary Matthews, RN, a nurse; and Ms. Sandy Raymond, the business officer manager. Dr. Brown suggested that the committee work with the REC to guide committee members through the system acquisition process. The physician partners approved this request, and the committee made arrangements for a representative from the REC to work with them on the selection process.
After the project steering committee was formed, Dr. Marcus met with the committee to outline its charge and deliverables. Dr. Marcus expressed his appreciation to Dr. Brown and all of the members of the committee for their willingness to participate in this important initiative. He assured them that they had his full support and the support of the entire physician team.
Dr. Marcus reviewed with the committee the mission, vision, and strategic goals of the practice as well as the committee's charge..
This document provides an overview of transitions of care, including definitions, models, and best practices. It describes transitions as the movement of patients between healthcare settings or providers. Poor transitions can lead to adverse outcomes for patients and increased costs. Several evidence-based models are described that aim to improve transitions through elements like medication reconciliation, discharge planning, and post-discharge follow up. These models have demonstrated reductions in readmissions and healthcare utilization. The document provides resources for additional information on improving the quality of patient transitions.
The document summarizes a team's proposal on universal access to primary health care. The team details their coordinator, members, and contact information. It then discusses definitions of primary health care, principles of PHC, services offered at health centers, strategies to improve quality PHC according to WHO, requirements for universal access, and proposed solutions focusing on patient-provider relationships and comprehensive, equitable care.
The Structure of a 12-month Residency Program and Stories from Former Residen...CHC Connecticut
The goal of the Postdoctoral Psychology Residency program is to train the next generation of psychologists in the Patient Centered Medical Home model. Through weekly seminars, group and individual supervision and clinical work with diverse, underserved populations, residents will fine-tune assessment and therapy skills.
This FREE learning collaborative opportunity will provide health centers with the support, resources and structure to implement a Postdoctoral Clinical Psychology Residency program at their organization.
Patient Engagement in Healthcare Improves Health and Reduces CostsM2SYS Technology
It’s been said that patient engagement develops naturally when there is a regular, focused communication between patient and provider and it leads to behaviors that meet or more closely approach treatment guidelines. It is also believed that patients engaged in their own care make fewer demands on the health care system and more importantly, they experience improved health. Patients who are educated about both their condition and their care are also patients who are most likely to get and stay healthy. In fact, many believe that empowering patients to actively process information, decide how that information fits into their lives, and act on those decisions is a key driver to improving care and reducing costs.
Research shows that informed and engaged patients take a more active role in their own care and furthermore, health care organizations are slowly discovering how patient engagement contributes to their financial and quality objectives. Patient engagement essentially revolves around the theory that if patients understand their condition, know the symptoms to watch for, know why they’re taking medication for example and how to implement the necessary lifestyle changes, the chances of them getting and staying healthy are significantly improved and when you proactively engage patients in their care, the quality of that care improves.
Listen in to our latest podcast with Brad Tritle, Director of Business Development for Vitaphone Health Solutions, chair of the HIMSS Social Media Task Force and contributing editor of the HIMSS book Engage! Transforming Healthcare through Digital Patient Engagement as we discuss the current state of patient engagement in healthcare, how it is defined, whether it really does have a significant impact on improving health and reducing the cost of care, what engagement initiatives are providers using and what the future of patient engagement may look like.
Closing the Loop: Strategies to Extend Care in the EDEngagingPatients
This HIMSS15 presentation discusses the challenges faced in hospital emergency departments and offers insights for implementing a process to follow up with discharged ED patients to enhance outcomes and satisfaction,while optimizing utilization and reducing risk.
Delivering value based_care_with_e_health_services.5Greg Bauer
The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
PFCC Methodology and Practice: Deliver Ideal Care Experiences and Outcomes…By...EngagingPatients
The document describes the Patient and Family Centered Care (PFCC) methodology used at UPMC, a large integrated health system. The six-step PFCC methodology involves: 1) defining the care experience, 2) forming a guiding council, 3) observing the current state through shadowing, 4) identifying touchpoints through a working group, 5) creating a shared vision for an ideal experience, and 6) implementing improvement projects. The methodology aims to improve outcomes and experiences by engaging patients and families in co-designing care and breaking down silos between care providers. Examples of successful PFCC projects that improved discharge processes and communication through bedside rounding are provided.
This document discusses approaches to personalizing quality measurement in healthcare. It outlines three fundamental approaches:
1) Integrating patient-reported outcome and experience measures (PROMs and PREMs) into clinical workflow to better capture patients' health status and perspectives.
2) Encouraging patients' and clinicians' joint generation of medical records, such as through the OpenNotes project, to improve patient engagement, communication, and safety reporting.
3) Measuring decision quality through shared decision making between clinicians and patients to respect patient autonomy and better account for individual risk-benefit preferences in medical decisions. The document argues for rapidly adopting these personalized approaches and incentivizing their use through payment reform.
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.
The document discusses various topics related to physical therapy (PT) practice. It notes that in 2014, PTs can avoid PQRS penalties by reporting 3 quality measures for 50% of patients, and the number of measures required to receive bonuses will increase from 3 to 9. It also eliminates reporting via measures groups through claims. The document discusses focusing on developing quality measures for PT, payment models that promote value, and public policy initiatives to advance the role of PT in areas like disease management. It also discusses improving access, eliminating self-referral profits, and ensuring an adequate PT workforce.
This document provides a summary of evidence on the impact of patient-centered medical homes (PCMHs) and primary care innovations on cost and quality from 2013-2014. It finds that PCMH interventions are associated with modest improvements in quality of care and reductions in utilization and costs. It also discusses challenges in evaluating PCMHs and outlines opportunities to further integrate primary care with other specialties and engage consumers. The future of the PCMH relies on continued financial support, training interprofessional teams, harnessing technology, and partnering with patients and communities.
Over half of patients at a rehabilitation hospital reported wanting greater involvement in their care decisions. To address this, the hospital conducted patient and family shadowing where observers followed patients to experience care from their perspective. This identified themes like explanations during rounds and involvement in discharge plans. A post-intervention survey found a statistically significant improvement in patients feeling involved in care decisions and clinically relevant improvements in understanding doctor explanations and recommending the hospital. Engaging medical leaders and balancing data with reflection time led doctors to change practices without formal rules.
Weitzman 2013: PCORI: Transforming Health CareCHC Connecticut
This document summarizes a presentation given by Joe Selby on the Patient-Centered Outcomes Research Institute (PCORI). It discusses PCORI's mission to fund comparative clinical effectiveness research that is guided by patients and other stakeholders. Key points include: PCORI's focus on research questions of interest to patients and providers; its criteria for funding proposals, including patient-centeredness and engagement; and its plans to significantly increase funding for such research over time. Examples are given of funded pilot projects involving community health centers.
The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Revie...CHC Connecticut
Dr. Nwando Olayiwola, Associate Director, Center for Excellence in Primary Care, Assistant Professor, University of California, San Francisco addresses the 2014 Weitzman Symposium on The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of Evidence
This presentation explains the concept of the patient-centered medical home (PCMH), its function and its intended effects. A brief overview of the history of PCMH is also provided, as well as a discussion of its operational characteristics, its principles and outcomes, and what is expected in the future for the PCMH model.
Improving hand offreportstudent namesteam name andssuser774ad41
The unit manager observed that change of shift reports were taking over 45 minutes and staff were leaving out vital patient information such as IV sites and DVT prevention measures. This was leading to errors, patients being left in disarray, and incomplete tasks. The goal is to propose a change to address these issues with timing and information handoffs between shifts. Implementing the SBAR communication tool as the standard for handoff reports could help reduce errors and decrease the time spent on reports by structuring the important information discussed.
Marita Schifalacqua, RN, MSN, NEA-BC, FAAN,
Chris Costello, MEng, MBA, and Wendy Denman, RNC, BBM, BSN, MSN
Roadmap for Planned Change, Part 2
Bar-Coded Medication Administration
hange—savored by some and feared by many.
How do you as nurse leaders use your
knowledge and insight to move forward and transfer
your vision for quality and safety into reality? What do
you need to do to get key stakeholders on the bus and,
in some cases, even drive the bus? The roadmap for
planned change allows for an infrastructure of thought
brought to increase the likelihood for successful
change. Successful change is important to our patients
and to us as providers of that care.
This article, the second of a two-part series,
focuses on the application of change theory and the
elements of project management most critical to
successfully implementing a bar-coded medication
administration (BCMA) program. Examples will be
from one hospital’s experience, Saint Francis Medical
Center in Grand Island, Nebraska, to a health
system’s (Catholic Health Initiatives, Denver, Colorado)
approach to planning for 30 hospitals.
The definition of the BCMA program includes a
consistent, integrated information technology strategy,
with a focus on point-of-care BCMA to ensure that the
right person receives the right medication, in the right
dosage, via the right route, at the right time (five
rights). The bar code on medication is scanned before
administration to patients.
C
April 200932 Nurse Leader
Nurse Leader 33www.nurseleader.com
APPLICATION OF CHANGE THEORY AND
PROJECT MANAGEMENT
The first article discusses concepts and tools of both change
leadership and project management that lend support in plan-
ning and managing large- or small-scale change. Change lead-
ership is a common methodology of theory and tools that,
when used routinely, are central to integrating a change man-
agement model with the people side of change.
Project management is an application of knowledge, skills,
tools, and techniques customized to the initiative.The project
management elements discussed in the first article that are
most critical to successfully implementing planned change are
project charter, project budget and budget management, proj-
ect plan and schedule management, project staff organization,
project communications management, and project risk and
issue management.
CURRENT STATE ANALYSIS
Changing a process as complex as BCMA can and will
impact a variety of stakeholders. It is important to review
the process of medication administration from the time the
medication enters the facility through the time that the med-
ication is billed to the patient. Employees working in depart-
ments that will experience change with BCMA need to
know that their role is important and that their viewpoint
is valued.
Leadership
The chief nursing officer and vice president of ancillary services
were the executive cosponsors of the project.There was a
BCMA stee ...
CASE STUDYAcquiring an EHR SystemValley Practice provides .docxdrennanmicah
CASE STUDY
Acquiring an EHR System
Valley Practice provides patient care services at three locations, all within a fifteen-mile radius, and serves nearly 100,000 patients. Valley Practice is owned and operated by seven physicians; each physician has an equal partnership. In addition to the physicians, the practice employs nine nurses, fifteen support staff, a business officer manager, an accountant, and a chief executive officer (CEO).
During a two-day strategic planning session, the physicians and management team created a mission, vision, and set of strategic goals for Valley Practice. The mission of the facility is to serve as the primary care “medical home” of individuals within the community, regardless of the patients' ability to pay. Valley Practice wishes to be recognized as a “high-tech, high-touch” practice that provides high-quality, cost-effective patient care using evidence-based standards of care. Consistent with its mission, one of the practice's strategic goals is to replace its current paper-based medical record with an EHR system. Such a system should enable providers to care for patients using up-to-date, complete, accurate information, anywhere, anytime.
Dr. John Marcus, the lead physician at Valley Practice, asked Dr. Julie Brown, the newest partner in the group, to lead the EHR project initiative. Dr. Brown joined the practice two years ago after completing an internal medicine residency at an academic medical center that had a fully integrated EHR system available in both the hospital and its ambulatory care clinics. Of all the physicians at Valley Practice, Dr. Brown has had the most experience using an EHR. She has been a vocal advocate for implementing an EHR and believes it is essential to enabling the facility to achieve its strategic goals. Dr. Brown contacted the Regional Extension Center (REC) in the community for assistance with the initiative.
Dr. Brown agreed to chair the project steering committee. She invited other key individuals to serve on the committee, including Dr. Renee Ward, a senior physician in the practice; Mr. James Rowls, the CEO; Ms. Mary Matthews, RN, a nurse; and Ms. Sandy Raymond, the business officer manager. Dr. Brown suggested that the committee work with the REC to guide committee members through the system acquisition process. The physician partners approved this request, and the committee made arrangements for a representative from the REC to work with them on the selection process.
After the project steering committee was formed, Dr. Marcus met with the committee to outline its charge and deliverables. Dr. Marcus expressed his appreciation to Dr. Brown and all of the members of the committee for their willingness to participate in this important initiative. He assured them that they had his full support and the support of the entire physician team.
Dr. Marcus reviewed with the committee the mission, vision, and strategic goals of the practice as well as the committee's charge..
PHM Tools and Strategies to Support Care Coordination infomc
This document discusses population health management tools and strategies to support care coordination. It describes how InfoMC's InSpotlight tools can help identify at-risk individuals in a population for improved health outcomes through targeted care coordination. The tools aggregate data from multiple sources to stratify populations and identify factors contributing to poor health. This supports effective care plans and workflows to better integrate physical and behavioral healthcare across providers.
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive CareCHC Connecticut
Join us as we discuss the core concepts of team-based care and introduce elements of team-based care that builds upon these basics to support your teams in advancing their capability to provide satisfying and effective care to complex patient populations. .
We will be joined by Margaret Flinter, Senior Vice President/Clinical Director for Community Health Center, Inc., and both Thomas Bodenheimer, MD, Physician and Founding Director, and Rachel Willard Grace, Director, from the Center for Excellence in Primary Care.
System of Transition of Care Part 2 Paper.pdfsdfghj21
The document outlines an assignment for a paper on improving a system of transition of care from hospitals to skilled nursing facilities. It instructs the student to identify a transition of care, describe key stakeholders and leadership strategies, and explain how systems thinking would inform an improvement plan. It provides feedback from a previous assignment and asks the student to incorporate that feedback into an annotated bibliography on their selected transition of care.
The document discusses expanding the role of registered nurses (RNs) in primary care settings. It describes how RNs can take on responsibilities like complex care management, active schedule management, using data to monitor patient outcomes, and conducting co-visits with providers to increase access to care. Co-visits allow RNs to address minor issues while providers briefly review cases. The approach has led to improved access and patient satisfaction at Community Health Center, Inc.
76 CHAPTER 4 Assessing Health and Health Behaviors Objecti.docxpriestmanmable
76
CHAPTER 4
Assessing Health and Health Behaviors
Objectives
this chapter will enable the reader to:
1. Describe the expected outcomes of a nursing health assessment.
2. Identify the components of a nursing health assessment conducted for an individual client.
3. Examine life span, language, and culturally appropriate nursing health assessment tools for children, adults, and older adults.
4. Compare the similarities and differences among the various approaches to assessing the family, mindful of cultural influences.
5. Evaluate the criteria for conducting a screening in the community.
6. Compare the similarities and differences among the various approaches to assessing
the community.
Athorough assessment of health and health behaviors is the foundation for tailoring a health promotion-prevention plan. Assessment provides the database for making clinical judgments about the client’s health strengths, health problems, nursing diagnoses, desired health or behavioral outcomes, as well as the interventions likely to be effective. This information also forms the nature of the client–nurse partnership such as the frequency of con- tact and the need for coordination with other health professionals. The portfolio of assessment measures depends on the characteristics of the client, including developmental stage and cul- tural orientation. The nurse assesses age, language, and cultural appropriateness of the various measures selected.
Cultural competence is the ability to communicate effectively with people of different cultures. Providing culturally competent care is the cornerstone of the nursing assessment. The nurse’s aware- ness of her own attitude toward cultural differences and her cultural worldview and characteristics
Chapter4 • AssessingHealthandHealthBehaviors 77
are critical to her understanding and knowledge of various cultures. Recognizing that diversity exists in all cultures based on educational level, socioeconomic status, religion, rural/urban residence, and individual and family characteristics will ensure a more successful encounter (The Office of Minority Health, 2013). An online cultural educational program, designed specifically for nurses and featur- ing videotaped case studies and interactive tools, is available.
The Enhanced National Standards for Culturally and Linguistically Appropriate Services, based on a definition of culture expanded to include geography, spirituality, language, race and ethnicity, and biology, provides a practical guide to culturally and linguistically sensitive care (The Office of Minority Health, 2013).
Technology is having a significant impact on health care. The Electronic Health Record (EHR) promotes involvement of the client in developing a dynamic, tailored database. The EHR offers great promise to improve health and increase the client’s satisfaction with his care. Data aggregation, cross-continuum coordination, and clinical care plan management are critical com- ponents of the.
Why Electronic Health Records are Ill Suited for Population Health 012616infomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform functions like enrollment tracking, provider networking, utilization review, claims processing, and quality reporting that are beyond the scope of most EHRs. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems designed for the specific demands of population health management.
Why Electronic Health Records are Ill Suited for Population Healthinfomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform tasks like enrollment tracking, provider networking, utilization review, and claims adjudication across different clinical systems. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems with greater functionality for care coordination, quality monitoring, and financial reporting at a population level.
The document describes 4 projects that received Challenge Grants from 2008-2009 focused on improving patient-centered care:
1) The TAP project at UCSF developed a transition program for adolescents with chronic conditions moving to adult care including resident training, a transition handbook for patients, and found a need for improved transition preparedness.
2) The IPR project at Medical College of Georgia implemented and measured patient-centered rounds on medicine units, identifying strategies to overcome obstacles and a blueprint for wider adoption.
3) The Resident Performance project at Carillion Clinic adapted an evaluation tool for patients to assess residents' competencies, finding it reliable for comprehensive feedback.
4) The Patient-Centered
Regional extension centers (RECs) were created to help physicians implement electronic health record (EHR) systems and achieve meaningful use. However, RECs face limitations including short-term funding, endorsement of select EHR vendors, and lack of experience with all systems. The Veterans Health Administration (VHA) offers a successful example of large-scale EHR implementation through a collaborative development process tailored to clinician needs. While RECs aim to support physicians, their assistance may be constrained without long-term, sustainable support.
Electronic health records have limitations for supporting effective population health management and care coordination required by health homes. While EHRs are designed for documenting care within provider systems, health homes require sophisticated technology to perform comprehensive care planning, collect a wide range of health data, and support continuous care workflows across multiple provider systems. Specifically, EHRs lack functionality for enrollment tracking, network management, cross-system referrals, utilization review, claims adjudication, and quality reporting needed by health homes' risk-based population management approach.
Electronic health records have limitations for supporting effective population health management and care coordination required by health homes. While EHRs are designed for documenting care within provider systems, health homes require sophisticated technology to perform functions like comprehensive care planning, collecting a wide range of health data, and supporting continuous care workflows across multiple provider systems. Unlike EHRs, health management systems can enroll and track populations, establish networks, coordinate referrals, perform utilization review, and monitor quality/outcomes on a larger scale.
You will write two pages (not including your title page) expressin.docxdanielfoster65629
You will write two pages (not including your title page) expressing your current worldview in regard to the subject of Administration of Justice Organizations. This paper’s content will include how the presentation in the Module/Week 1 Reading & Study folder influences your worldview.
Marita Schifalacqua, RN, MSN, NEA-BC, FAAN,
Chris Costello, MEng, MBA, and Wendy Denman, RNC, BBM, BSN, MSN
Roadmap for Planned Change, Part 2
Bar-Coded Medication Administration
hange—savored by some and feared by many.
How do you as nurse leaders use your
knowledge and insight to move forward and transfer
your vision for quality and safety into reality? What do
you need to do to get key stakeholders on the bus and,
in some cases, even drive the bus? The roadmap for
planned change allows for an infrastructure of thought
brought to increase the likelihood for successful
change. Successful change is important to our patients
and to us as providers of that care.
This article, the second of a two-part series,
focuses on the application of change theory and the
elements of project management most critical to
successfully implementing a bar-coded medication
administration (BCMA) program. Examples will be
from one hospital’s experience, Saint Francis Medical
Center in Grand Island, Nebraska, to a health
system’s (Catholic Health Initiatives, Denver, Colorado)
approach to planning for 30 hospitals.
The definition of the BCMA program includes a
consistent, integrated information technology strategy,
with a focus on point-of-care BCMA to ensure that the
right person receives the right medication, in the right
dosage, via the right route, at the right time (five
rights). The bar code on medication is scanned before
administration to patients.
C
April 200932 Nurse Leader
Nurse Leader 33www.nurseleader.com
APPLICATION OF CHANGE THEORY AND
PROJECT MANAGEMENT
The first article discusses concepts and tools of both change
leadership and project management that lend support in plan-
ning and managing large- or small-scale change. Change lead-
ership is a common methodology of theory and tools that,
when used routinely, are central to integrating a change man-
agement model with the people side of change.
Project management is an application of knowledge, skills,
tools, and techniques customized to the initiative.The project
management elements discussed in the first article that are
most critical to successfully implementing planned change are
project charter, project budget and budget management, proj-
ect plan and schedule management, project staff organization,
project communications management, and project risk and
issue management.
CURRENT STATE ANALYSIS
Changing a process as complex as BCMA can and will
impact a variety of stakeholders. It is important to review
the process of medication administration from the time the
medication enters the facility through the time that the med-
ication is billed to the patient. Employ.
NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues.docxstirlingvwriters
This document provides instructions for a nursing student to develop a 20-minute presentation for colleagues on care coordination fundamentals. It includes an introduction defining care coordination and its importance. It also outlines key factors to address, such as community resources, ethics, policy issues, and change management. The student is instructed to create a 4-5 page script and record a video presentation. A reference list is also required.
Care Coordination - Northwest Medical Partnerspedenton
This document discusses care coordination in the medical home. It defines care coordination as organizing patient care activities between multiple participants to facilitate appropriate healthcare delivery. Effective care coordination involves numerous participants exchanging information and integrating care activities. The care coordination model aims to deliver the right services, in the right order and setting. Key elements of the model include assuming accountability for coordination, providing patient support, developing relationships and agreements with other providers, and improving connectivity through information sharing.
This document summarizes a research fellowship project analyzing medical guidelines websites. It introduces the purpose of medical guidelines and common issues with online guidelines like lack of accessibility and usability. The project developed a quality index to evaluate and compare features of different medical guidelines websites. Data was collected from various websites and analyzed to identify trends and opportunities to make guidelines more patient-centered and effective. The goal is to modify guidelines websites to be more accessible, understandable and user-friendly to better educate patients.
Michigan Hospital Association Governance meetingMary Beth Bolton
Patient centered medical home activities in MI and Nationally and the opportunity to improve quality outcomes by increased access to primary care doctors who outreach members who are missing preventive and chronic care services.
This document provides a case study on Lingraphica's online therapy software. It was used in a long-term care facility to improve patient outcomes and satisfaction. The study found improved cognitive function, mood, communication skills, and engagement for patients. Clinicians benefited from improved documentation and treatment tools. Administrators saw benefits from improved tracking of activities, outcomes and costs. Overall, the software was found to provide widespread benefits to patients, clinicians and administrators in the long-term care setting.
American Journal of Medical Quality-2015-Palacio-1062860614568646Joseph Messina
This document describes a study that evaluated the implementation of a point-of-care medication delivery system (POCMDS) in a primary care-led health system serving vulnerable populations. The study used a mixed-methods approach including interviews, site visits, patient surveys, and claims data to assess the reach, effectiveness, adoption, implementation, and maintenance of the POCMDS intervention based on the RE-AIM and CFIR frameworks. Key findings included that POCMDS has been implemented in 23 practices across 4 states, with high rates of patient satisfaction reported. Facilitators of implementation included leadership commitment, a culture of prevention, and a sustainable business model.
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