2013 PAFP Regional Lectures Series
Session 2 - Southeast
Learn about best practices for transitions of care, how to bill for the new management codes payable by Medicare.
Bonus: pick up great resources to improve management.
Speaker:
Lee Radosh, MD, FAAFP
Reading Hospital – Family Health Care Center
West Reading, PA
The document discusses challenges in medication reconciliation and potential benefits of using IT-enabled solutions. It describes research from McGill University that developed an electronic medication reconciliation application called RightRx, which integrated with the Quebec health insurance database to retrieve patient medication histories and automate communication of changes to community providers. The research found that automated retrieval of community medication lists and integration with computerized provider order entry can reduce medication discrepancies and potential adverse drug events.
The purpose of this call is to learn how the Department of Family Medicine at Queen’s University was able to:
•Raise awareness about medication safety issues ‐ specifically medication reconciliation in primary care.
•Highlight the need for better communication and connectivity between hospitals, pharmacies, and primary care. (And how we can help each other.)
•Suggest that primary care take on a leadership role in medication safety ‐ we can (and should!) "own" the list.
•Stress the importance of medication reconciliation as a continuous, interdisciplinary, and collaborative activity.
The document discusses proposed actions to improve emergency room wait times in Nova Scotia hospitals. It identifies several key issues contributing to long wait times, including a shortage of hospital beds, increased use of emergency rooms by aging patients and alternate level of care (ALC) patients, and government funding cuts. It then proposes several multi-pronged strategies to address wait times by improving patient flow, reducing overcrowding and overuse of emergency rooms, and decreasing the number of ALC patients. Specifically, it suggests implementing triage-driven patient placement, expanding fast-track areas, improving access to diagnostics, and enhancing patient transfers to reduce backlogs in emergency rooms.
The emerging healthcare environment requires expanded patient access while delivering optimal outcomes and cost. As healthcare moves form a fee for service model to alternative delivery and payment models, there are opportunities for physical therapy to revolutionize the delivery of musculoskeletal medicine. Physical therapists are uniquely qualified to spearhead musculoskeletal care through direct access with the potential to improve patient satisfaction and outcomes while limiting unneeded medical care. While this model has been described in the military, there are few descriptions of this PT First approach in the private payer arena. This session will provide the attendee with a multifaceted perspective on the impact of physical therapy in emerging, collaborative healthcare models. Approaches to payers and employers with the business implications will be presented that influence these new models. Key strategies to implement a scalable, best practice model will be discussed including the logistical challenges and corollary solutions in the private arena. We will discus our experience implementing novel delivery models for management of neck, back, shoulder and knee pain. The session will deliver practical solutions to the challenges of implementing, assessing, and adapting a theoretical construct to a working viable program. Finally, the session will discuss how the use of a a large Patient Outcomes Registry and analysis of “big data” can drive best practice and inform development of the program.
Top seven healthcare outcome measures of healthJosephMtonga1
The seven healthcare outcome measures are meant to understand the quality of health systems and how they could be measured and how quality care could be provided to clients.
This document introduces a new tool to assess the quality of admission medication reconciliation (MedRec) processes. The tool allows hospitals to collect patient-level data on key determinants of admission MedRec quality. It focuses on the three core steps of MedRec: collecting a best possible medication history, comparing it to admission orders, and correcting any discrepancies. The tool is designed for easy data submission and analysis through an online system. Using this tool, hospitals can identify specific areas in their MedRec processes needing improvement by quantifying how well each step is performed.
This document summarizes two presentations from a webinar on approaches to medication reconciliation using technology. The first presentation describes Toronto East General Hospital's implementation of electronic medication reconciliation using their Cerner EHR system. The second presentation describes Whitehorse General Hospital's use of Iatric Software's Patient Discharge Instructions system to conduct medication reconciliation at admission and discharge when an EHR is not available. Both implementations have improved medication reconciliation processes but also face challenges around physician engagement, customization of reports, and integration with other systems.
Lisa Rabideau presented on using SNOMED terminology to develop interdisciplinary care plans. Current nursing care plans are standardized and not customized to individual patients. The hospital is transitioning to problem-based care plans using SNOMED codes populated from nursing assessments in the EHR. Nursing orders and standards of care were developed for common clinical problems. The new care plans will be used for multidisciplinary rounds and aim to provide a more comprehensive patient story for providers.
The document discusses challenges in medication reconciliation and potential benefits of using IT-enabled solutions. It describes research from McGill University that developed an electronic medication reconciliation application called RightRx, which integrated with the Quebec health insurance database to retrieve patient medication histories and automate communication of changes to community providers. The research found that automated retrieval of community medication lists and integration with computerized provider order entry can reduce medication discrepancies and potential adverse drug events.
The purpose of this call is to learn how the Department of Family Medicine at Queen’s University was able to:
•Raise awareness about medication safety issues ‐ specifically medication reconciliation in primary care.
•Highlight the need for better communication and connectivity between hospitals, pharmacies, and primary care. (And how we can help each other.)
•Suggest that primary care take on a leadership role in medication safety ‐ we can (and should!) "own" the list.
•Stress the importance of medication reconciliation as a continuous, interdisciplinary, and collaborative activity.
The document discusses proposed actions to improve emergency room wait times in Nova Scotia hospitals. It identifies several key issues contributing to long wait times, including a shortage of hospital beds, increased use of emergency rooms by aging patients and alternate level of care (ALC) patients, and government funding cuts. It then proposes several multi-pronged strategies to address wait times by improving patient flow, reducing overcrowding and overuse of emergency rooms, and decreasing the number of ALC patients. Specifically, it suggests implementing triage-driven patient placement, expanding fast-track areas, improving access to diagnostics, and enhancing patient transfers to reduce backlogs in emergency rooms.
The emerging healthcare environment requires expanded patient access while delivering optimal outcomes and cost. As healthcare moves form a fee for service model to alternative delivery and payment models, there are opportunities for physical therapy to revolutionize the delivery of musculoskeletal medicine. Physical therapists are uniquely qualified to spearhead musculoskeletal care through direct access with the potential to improve patient satisfaction and outcomes while limiting unneeded medical care. While this model has been described in the military, there are few descriptions of this PT First approach in the private payer arena. This session will provide the attendee with a multifaceted perspective on the impact of physical therapy in emerging, collaborative healthcare models. Approaches to payers and employers with the business implications will be presented that influence these new models. Key strategies to implement a scalable, best practice model will be discussed including the logistical challenges and corollary solutions in the private arena. We will discus our experience implementing novel delivery models for management of neck, back, shoulder and knee pain. The session will deliver practical solutions to the challenges of implementing, assessing, and adapting a theoretical construct to a working viable program. Finally, the session will discuss how the use of a a large Patient Outcomes Registry and analysis of “big data” can drive best practice and inform development of the program.
Top seven healthcare outcome measures of healthJosephMtonga1
The seven healthcare outcome measures are meant to understand the quality of health systems and how they could be measured and how quality care could be provided to clients.
This document introduces a new tool to assess the quality of admission medication reconciliation (MedRec) processes. The tool allows hospitals to collect patient-level data on key determinants of admission MedRec quality. It focuses on the three core steps of MedRec: collecting a best possible medication history, comparing it to admission orders, and correcting any discrepancies. The tool is designed for easy data submission and analysis through an online system. Using this tool, hospitals can identify specific areas in their MedRec processes needing improvement by quantifying how well each step is performed.
This document summarizes two presentations from a webinar on approaches to medication reconciliation using technology. The first presentation describes Toronto East General Hospital's implementation of electronic medication reconciliation using their Cerner EHR system. The second presentation describes Whitehorse General Hospital's use of Iatric Software's Patient Discharge Instructions system to conduct medication reconciliation at admission and discharge when an EHR is not available. Both implementations have improved medication reconciliation processes but also face challenges around physician engagement, customization of reports, and integration with other systems.
Lisa Rabideau presented on using SNOMED terminology to develop interdisciplinary care plans. Current nursing care plans are standardized and not customized to individual patients. The hospital is transitioning to problem-based care plans using SNOMED codes populated from nursing assessments in the EHR. Nursing orders and standards of care were developed for common clinical problems. The new care plans will be used for multidisciplinary rounds and aim to provide a more comprehensive patient story for providers.
The document discusses methods for measuring performance and clinical outcomes in healthcare. It describes the major domains of patient safety measurement as harm, mortality, infections, readmissions, patient satisfaction, and safety culture. It then focuses on defining medical errors and adverse events, and explaining why measurement is important for evaluating current systems and improving outcomes. Different methods of data collection are outlined, including direct observation, cohort studies, record review, and incident reporting systems. The Global Trigger Tool for assessing harm using chart review is also summarized.
Purpose of the Call:
•Provide an overview of the MARQUIS toolkit components, informed by medication reconciliation best practices, designed to help hospitals improve the quality of their medication reconciliation processes
•Preview the preliminary results of the MARQUIS study in order to understand the effects of a mentored quality improvement intervention on medication reconciliation errors
•Discuss lessons learned from study sites that have implemented the MARQUIS program and how they might be applied to Canadian hospitals, including an exploration of barriers to implementation and how to overcome them
•Make the case for provinces, health systems, and hospitals to invest in medication reconciliation quality improvement efforts, and why physicians need to play a major role in these efforts.
Watch the webinar: http://bit.ly/1ji1voq
Adding Value to the EMR: A Clinical PerspectiveHealth Catalyst
Known for leading large-scale healthcare improvement using data and analytics to drive positive change, Dr. Charles Macias speaks to creating greater value in the EMR through analytics. This approach has done more to increase value than many other cost-reduction efforts.
In this webinar you will 1) Explore each component of the value equation, 2) learn how TCH has increased the value of its healthcare using data to drive quality an ever more important need of those facing capitated or value–based care reimbursements and 3) consider a new ROI equation for systems who have invested heavily in their EMRs
The document discusses how health systems can achieve standardized patient-centric care through clinician-led transformation. It highlights the success of Trinity Health in saving $20,000 per day and improving outcomes by empowering clinicians to lead collaborative efforts to develop and implement evidence-based standardized care protocols and monitor their impact. Key aspects that contributed to Trinity Health's success include creating an open forum for clinicians to develop solutions, proving rather than just stating that clinicians are decision-makers, using data to prioritize opportunities, and establishing rigorous project management and measurement of results.
WeCareTLC Risk Management White Paper 2015_1452008903358Kevin Cooksey
The document discusses how employer-sponsored on-site clinics can help manage healthcare costs if they implement a comprehensive medical risk management approach. It provides details on WeCare TLC, a company that operates on-site clinics using the patient-centered medical home model and analyzes data to identify savings opportunities and improve population health. WeCare TLC clinics have achieved high employee usage rates, reduced costs 15-25% for employers within 3 years, and improved health outcomes for conditions like diabetes and hypertension. Medical risk management is presented as the key to making on-site clinics successful in both improving health and reducing costs long-term.
This document discusses outcomes-based contracts between pharmaceutical companies and payers. It provides background on rising healthcare costs, describes the benefits of outcomes-based contracts for stakeholders, and gives examples of existing contracts linked to outcomes like reduced hospitalizations or reaching clinical targets. The document also outlines challenges, keys to success, and potential future applications in areas like specialty medications.
The document discusses how employer-sponsored on-site health clinics can help manage healthcare costs if run as patient-centered medical homes (PCMHs) using a team-based care and medical risk management approach, as done by WeCare TLC. It describes WeCare TLC's model of comprehensive primary care clinics that use data analytics to customize care and drive down costs. Research shows the PCMH model improves outcomes and satisfaction while reducing emergency visits, costs, and medical trend growth for employers who have their employees use the on-site clinic as their primary care provider. WeCare TLC clients have seen healthcare cost reductions of 15-25% within three years of implementing this approach.
This document describes the implementation and results of establishing an independent breast care clinic directed by an advanced practice clinician (APC) at a university hospital. The goals were to decrease wait times for appointments, improve financial viability, and increase patient, APC, and physician satisfaction. After applying "lean" principles to redesign clinic workflows, the APC began independently evaluating and treating patients under physician supervision. Results showed trends of decreased median wait times for new appointments, increased monthly charges billed by the APC from $388 to $30,800, and high patient satisfaction scores for both the APC and surgeon of over 95%. The study demonstrated how utilizing an APC can help meet goals of improved access, value, and satisfaction
At the Heart of the Matter: Medical NecessityPYA, P.C.
PYA Principal Denise Hall and Michael Spake, Vice President of External Affairs and Chief Compliance & Integrity Officer at Lakeland Regional Health System, co-presented “At the Heart of the Matter: Medical Necessity,” at the AHLA Institute on Medicare and Medicaid Payment Issues. They discussed:
Recent cases and legal actions
Impact of medical necessity when interpreting the regulations and guidelines for:
-Stents
-Pacemakers
-Automatic Implantable Cardiac Defibrillators (AICD)
-Electrophysiology Studies (EPS) and Ablations
Common areas of risk in applying local coverage determination (LCD)/national coverage determination (NCD) guidance to cardiac procedures: how to identify your risks and avoid vulnerability
Best practices for ensuring compliance with regulations
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.
Purpose of the Call:
By the end of this webinar you will: •Hear about the changes to the MedRec in Home Care GSK
•Hear about the broader home care concepts as it relates to MedRec
•Receive practical tips and insights from the field
5 Reasons the Practice of Evidence-Based Medicine Is a Hot TopicHealth Catalyst
Evidence-based medicine is an important model of care because it offers health systems a way to achieve the goals of the Triple Aim. It also offers health systems an opportunity to thrive in this era of value-based care. In specific, there are five reasons the industry is interested in the practice of evidence-based medicine: (1) With the explosion of scientific knowledge being published, it’s difficult for clinicians to stay current on the latest best practices. (2) Improved technology enables healthcare workers to have better access to data and knowledge. (3) Payers, employers, and patients are driving the need for the industry to show transparency, accountability, and value. (4) There is broad evidence that Americans often do not get the care they need. (5) Evidence-based medicine works. While the practice of evidence-based medicine is growing in popularity, moving an entire organization to a new model of care presents challenges. First, clinicians need to change how they were taught to practice. Second, providers are already busy with increasingly larger and larger workloads. Using a five-step framework, though, enables clinicians to begin to incorporate evidence-based medicine into their practices. The five steps include (1) Asking a clinical question to identify a key problem. (2) Acquiring the best evidence possible. (3) Appraising the evidence and making sure it’s applicable to the population and the question being asked. (4) Applying the evidence to daily clinical practice. (5) Assessing performance.
WHITEPAPER HURLEY LAUNCH OF HOMEWARD HEALTHTim Barrett
The document describes a 10-month pilot program conducted at Hurley Medical Center that used Homeward Health's Digital Discharge platform to help reduce potentially avoidable hospital readmissions. The program was administered to 324 patients on an iPad and provided personalized education and a risk score to help prioritize resources. Preliminary results found a promising reduction in readmissions of up to 47% for heart failure patients compared to the previous year's baseline rates.
Purpose of the Call:
Women's College Hospital is an academic ambulatory hospital. The speaker will share their hospital’s journey as they sought to implement best practices for medication reconciliation from other settings customized for the ambulatory environment.
Read more and watch the webinar recording: http://bit.ly/1sxHIUP
Observation medicine nursing considerationsmflitcraft
This document provides an overview and outline of topics related to observation medicine and nursing considerations at Ronald Reagan UCLA Medical Center. It discusses UCLA Health System and patient satisfaction scores. The outline covers observation review settings and examples, the business case for observation including data analysis and cost considerations, staffing mix and characteristics, daily operations, and quality metrics. It provides details on Medicare rules and coverage for observation, examples of retrospective data reviews for observation opportunities, and considerations for staffing and managing observation patients.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
Objectives:
By the end of this call, you will be able to:
•Describe the processes of Root-Cause Analysis (RCA) and Multi-Incident Analysis (MIA) and their role in quality improvement
•Compare and contrast the different approaches to collecting hospital-acquired VTE data
•Identify an approach suitable for improving patient safety at your institution
The document discusses inefficiency in emergency rooms. It identifies several contributing factors to overcrowding including non-emergency patients, uninsured patients, and patients using the ER for prescription refills or pain management. This inefficiency impacts quality of care, access to care, and wait times, negatively affecting patient satisfaction. An action plan is proposed to improve patient flow, maximize resources, implement education programs, and establish performance metrics to monitor goals. Facilitating change may require addressing challenges like culture shifts or staff resistance through reinforcement, education, and adjustments based on feedback. Both productivity and quality must be balanced for optimal patient treatment and satisfaction.
The document describes Always Events, which are practices that should always occur to improve the patient experience. It then summarizes initiatives from 20 organizations to address common healthcare challenges through Always Events. One area is care transitions, where several grantees developed Always Events focusing on hospital discharge, handoffs between providers, and reducing readmissions. For example, one organization implemented a "SMART Discharge Protocol" to ensure key information is discussed at discharge. Another developed a "Patient-Centered Bedside Shift-to-Shift Handoff" process to include patients in shift changes. The document provides contact information for each program to allow other organizations to learn from their work.
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.
The document discusses methods for measuring performance and clinical outcomes in healthcare. It describes the major domains of patient safety measurement as harm, mortality, infections, readmissions, patient satisfaction, and safety culture. It then focuses on defining medical errors and adverse events, and explaining why measurement is important for evaluating current systems and improving outcomes. Different methods of data collection are outlined, including direct observation, cohort studies, record review, and incident reporting systems. The Global Trigger Tool for assessing harm using chart review is also summarized.
Purpose of the Call:
•Provide an overview of the MARQUIS toolkit components, informed by medication reconciliation best practices, designed to help hospitals improve the quality of their medication reconciliation processes
•Preview the preliminary results of the MARQUIS study in order to understand the effects of a mentored quality improvement intervention on medication reconciliation errors
•Discuss lessons learned from study sites that have implemented the MARQUIS program and how they might be applied to Canadian hospitals, including an exploration of barriers to implementation and how to overcome them
•Make the case for provinces, health systems, and hospitals to invest in medication reconciliation quality improvement efforts, and why physicians need to play a major role in these efforts.
Watch the webinar: http://bit.ly/1ji1voq
Adding Value to the EMR: A Clinical PerspectiveHealth Catalyst
Known for leading large-scale healthcare improvement using data and analytics to drive positive change, Dr. Charles Macias speaks to creating greater value in the EMR through analytics. This approach has done more to increase value than many other cost-reduction efforts.
In this webinar you will 1) Explore each component of the value equation, 2) learn how TCH has increased the value of its healthcare using data to drive quality an ever more important need of those facing capitated or value–based care reimbursements and 3) consider a new ROI equation for systems who have invested heavily in their EMRs
The document discusses how health systems can achieve standardized patient-centric care through clinician-led transformation. It highlights the success of Trinity Health in saving $20,000 per day and improving outcomes by empowering clinicians to lead collaborative efforts to develop and implement evidence-based standardized care protocols and monitor their impact. Key aspects that contributed to Trinity Health's success include creating an open forum for clinicians to develop solutions, proving rather than just stating that clinicians are decision-makers, using data to prioritize opportunities, and establishing rigorous project management and measurement of results.
WeCareTLC Risk Management White Paper 2015_1452008903358Kevin Cooksey
The document discusses how employer-sponsored on-site clinics can help manage healthcare costs if they implement a comprehensive medical risk management approach. It provides details on WeCare TLC, a company that operates on-site clinics using the patient-centered medical home model and analyzes data to identify savings opportunities and improve population health. WeCare TLC clinics have achieved high employee usage rates, reduced costs 15-25% for employers within 3 years, and improved health outcomes for conditions like diabetes and hypertension. Medical risk management is presented as the key to making on-site clinics successful in both improving health and reducing costs long-term.
This document discusses outcomes-based contracts between pharmaceutical companies and payers. It provides background on rising healthcare costs, describes the benefits of outcomes-based contracts for stakeholders, and gives examples of existing contracts linked to outcomes like reduced hospitalizations or reaching clinical targets. The document also outlines challenges, keys to success, and potential future applications in areas like specialty medications.
The document discusses how employer-sponsored on-site health clinics can help manage healthcare costs if run as patient-centered medical homes (PCMHs) using a team-based care and medical risk management approach, as done by WeCare TLC. It describes WeCare TLC's model of comprehensive primary care clinics that use data analytics to customize care and drive down costs. Research shows the PCMH model improves outcomes and satisfaction while reducing emergency visits, costs, and medical trend growth for employers who have their employees use the on-site clinic as their primary care provider. WeCare TLC clients have seen healthcare cost reductions of 15-25% within three years of implementing this approach.
This document describes the implementation and results of establishing an independent breast care clinic directed by an advanced practice clinician (APC) at a university hospital. The goals were to decrease wait times for appointments, improve financial viability, and increase patient, APC, and physician satisfaction. After applying "lean" principles to redesign clinic workflows, the APC began independently evaluating and treating patients under physician supervision. Results showed trends of decreased median wait times for new appointments, increased monthly charges billed by the APC from $388 to $30,800, and high patient satisfaction scores for both the APC and surgeon of over 95%. The study demonstrated how utilizing an APC can help meet goals of improved access, value, and satisfaction
At the Heart of the Matter: Medical NecessityPYA, P.C.
PYA Principal Denise Hall and Michael Spake, Vice President of External Affairs and Chief Compliance & Integrity Officer at Lakeland Regional Health System, co-presented “At the Heart of the Matter: Medical Necessity,” at the AHLA Institute on Medicare and Medicaid Payment Issues. They discussed:
Recent cases and legal actions
Impact of medical necessity when interpreting the regulations and guidelines for:
-Stents
-Pacemakers
-Automatic Implantable Cardiac Defibrillators (AICD)
-Electrophysiology Studies (EPS) and Ablations
Common areas of risk in applying local coverage determination (LCD)/national coverage determination (NCD) guidance to cardiac procedures: how to identify your risks and avoid vulnerability
Best practices for ensuring compliance with regulations
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.
Purpose of the Call:
By the end of this webinar you will: •Hear about the changes to the MedRec in Home Care GSK
•Hear about the broader home care concepts as it relates to MedRec
•Receive practical tips and insights from the field
5 Reasons the Practice of Evidence-Based Medicine Is a Hot TopicHealth Catalyst
Evidence-based medicine is an important model of care because it offers health systems a way to achieve the goals of the Triple Aim. It also offers health systems an opportunity to thrive in this era of value-based care. In specific, there are five reasons the industry is interested in the practice of evidence-based medicine: (1) With the explosion of scientific knowledge being published, it’s difficult for clinicians to stay current on the latest best practices. (2) Improved technology enables healthcare workers to have better access to data and knowledge. (3) Payers, employers, and patients are driving the need for the industry to show transparency, accountability, and value. (4) There is broad evidence that Americans often do not get the care they need. (5) Evidence-based medicine works. While the practice of evidence-based medicine is growing in popularity, moving an entire organization to a new model of care presents challenges. First, clinicians need to change how they were taught to practice. Second, providers are already busy with increasingly larger and larger workloads. Using a five-step framework, though, enables clinicians to begin to incorporate evidence-based medicine into their practices. The five steps include (1) Asking a clinical question to identify a key problem. (2) Acquiring the best evidence possible. (3) Appraising the evidence and making sure it’s applicable to the population and the question being asked. (4) Applying the evidence to daily clinical practice. (5) Assessing performance.
WHITEPAPER HURLEY LAUNCH OF HOMEWARD HEALTHTim Barrett
The document describes a 10-month pilot program conducted at Hurley Medical Center that used Homeward Health's Digital Discharge platform to help reduce potentially avoidable hospital readmissions. The program was administered to 324 patients on an iPad and provided personalized education and a risk score to help prioritize resources. Preliminary results found a promising reduction in readmissions of up to 47% for heart failure patients compared to the previous year's baseline rates.
Purpose of the Call:
Women's College Hospital is an academic ambulatory hospital. The speaker will share their hospital’s journey as they sought to implement best practices for medication reconciliation from other settings customized for the ambulatory environment.
Read more and watch the webinar recording: http://bit.ly/1sxHIUP
Observation medicine nursing considerationsmflitcraft
This document provides an overview and outline of topics related to observation medicine and nursing considerations at Ronald Reagan UCLA Medical Center. It discusses UCLA Health System and patient satisfaction scores. The outline covers observation review settings and examples, the business case for observation including data analysis and cost considerations, staffing mix and characteristics, daily operations, and quality metrics. It provides details on Medicare rules and coverage for observation, examples of retrospective data reviews for observation opportunities, and considerations for staffing and managing observation patients.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
Objectives:
By the end of this call, you will be able to:
•Describe the processes of Root-Cause Analysis (RCA) and Multi-Incident Analysis (MIA) and their role in quality improvement
•Compare and contrast the different approaches to collecting hospital-acquired VTE data
•Identify an approach suitable for improving patient safety at your institution
The document discusses inefficiency in emergency rooms. It identifies several contributing factors to overcrowding including non-emergency patients, uninsured patients, and patients using the ER for prescription refills or pain management. This inefficiency impacts quality of care, access to care, and wait times, negatively affecting patient satisfaction. An action plan is proposed to improve patient flow, maximize resources, implement education programs, and establish performance metrics to monitor goals. Facilitating change may require addressing challenges like culture shifts or staff resistance through reinforcement, education, and adjustments based on feedback. Both productivity and quality must be balanced for optimal patient treatment and satisfaction.
The document describes Always Events, which are practices that should always occur to improve the patient experience. It then summarizes initiatives from 20 organizations to address common healthcare challenges through Always Events. One area is care transitions, where several grantees developed Always Events focusing on hospital discharge, handoffs between providers, and reducing readmissions. For example, one organization implemented a "SMART Discharge Protocol" to ensure key information is discussed at discharge. Another developed a "Patient-Centered Bedside Shift-to-Shift Handoff" process to include patients in shift changes. The document provides contact information for each program to allow other organizations to learn from their work.
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 discusses the patient-centered medical home (PCMH) model and its benefits. It provides 3 key points:
1) The PCMH model emphasizes primary care-led, coordinated, and comprehensive care centered around the patient. It aims to improve access, outcomes and reduce costs through care coordination and an emphasis on prevention.
2) Studies show PCMH interventions can reduce hospital and ER use by over 30% each and lower total costs by 9% while maintaining or improving outcomes.
3) Successful PCMH models require health IT and data sharing to facilitate care coordination, population health management, and quality improvement. They also rely on payment reforms that appropriately recognize the added value of the medical
Write a 3 page evidence-based health care delivery plan for one .docxowenhall46084
Write a 3 page evidence-based health care delivery plan for one component of a heart failure clinic.
Nursing within an organization is a critical component of health care delivery and is an essential ingredient in patient outcomes (Kelly & Tazbir, 2014). The concern for quality care that flows from evidence-based practice generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 2: Explain the accountability of the nurse leader for decisions that affect health care delivery and patient outcomes.
Describe accountability tools and procedures used to measure effectiveness.
Competency 3: Apply management strategies and best practices for health care finance, human resources, and materials allocation decisions to improve health care delivery and patient outcomes.
Develop an evidence-based plan for health care delivery.
Competency 4: Apply professional standards of moral, ethical, and legal conduct in professional practice.
Apply professional and legal standards in support of a care plan.
Competency 5: Communicate in manner that is consistent with the expectations of a nursing professional.
Write content clearly and logically, with correct use of grammar, punctuation, mechanics, and current APA style.
In an effort to improve the patients' health literacy concerning heart failure, it is important that the clinic staff and the hospital staff present a consistent, evidence-based message on self-care to these patients and their families in order to decrease acute exacerbation and re-admissions. Review current evidence for clinical practice guides or protocols when developing your patient teaching plans and materials. Consider the following:
What does the patient know about the disease process as a baseline?
What does the patient need to do understand as far as the best self-care processes?
Can the patient identify proper medication compliance?
Is there a financial issue that affects compliance?
Who buys and prepares the food in the home?
Can the patient verbalize when to seek medical assistance?
Instructions
Deliverable:
Develop an evidence-based plan for health care delivery.
Scenario:
The hospital where you work has an issue with increased readmissions within 30 days of discharge. After examining the core measures, it was found that heart failure was the most common core measure disease process experiencing the highest rate of readmissions. The leadership team has given your team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of this clinic is to ensure that discharge education is presented to the patient in an orderly, consistent manner and complies with evidence-based practice protocol.
Patient engagement is evolving to include a composite of practices that impact patient behaviors and health. Contemporary models of patient engagement include the HIMSS 5 phases of patient engagement and the Regional Primary Care Coalition's 6 dimensions of patient engagement. Meaningful Use Phase 3 identifies key priorities around patient access to health records and secure messaging. Barriers to patient engagement include defining engagement and integrating diverse engagement tools and technologies.
This document discusses how to develop a PICO question to help determine the most relevant information for deciding on an evidence-based intervention for a client. It provides examples of factors to consider for the patient/client population (P), intervention/treatment (I), comparison intervention (C), and outcomes (O). It also introduces some key resources for finding evidence-based guidelines and systematic reviews, such as those from SAMHSA and Cochrane, to help answer PICO questions and identify best practices. Stakeholder involvement is emphasized when implementing a new evidence-based practice.
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Designing Winning "Transitions of Care" Processes!
1. Designing Winning “Transitions of Care” Processes!
Lee Radosh, MD, FAAFP
Faculty, PAFP Residency Collaborative (RPC)
Director, Family Medicine Residency
Reading Hospital of Reading Health System, Reading, PA
Lee.Radosh@readinghealth.org
October 9, 2013
2. DISCLOSURE
Neither I nor any immediate family member (parent, sibling,
spouse or child) has a financial relationship with or interest
in any commercial entity that may have a direct interest in
the subject matter of this session.
3. Objectives
By the end of this presentation, participants will
be able to:
List key recent external forces related to transitional
care
Identify “priority tasks” in transitional care
Utilize tools and processes to augment your planning
Identify new CPT codes
4. Agenda
Define TOC
Make a cogent argument
for four main areas to
“attack”
Present tools to assist
Review newer CPT
codes
5. What is a Winning
Transitions of Care Process?
One that is MEANINGFUL, to
You, the practice (efficient)
Patients (clinically important)
Insurers (financially sound)
Hospital/practice administrators (all of the
above!)
6. For Our Purposes, Transitional Care Is . . .
“ . . . the actions of healthcare providers designed
to ensure the coordination and continuity of health
care during the movement, called care transition,
between health care practitioners and settings as
their condition and care needs change during the
course of a chronic or acute illness.
Older adults who suffer from a variety of health
conditions often need health care services in
different settings to meet their many needs.”
Wikipedia
7. For a Different Time . .
(But Two Minutes Please . . . )
Transitional care is also for young people
Moving successfully from child to adult health
services
http://www.medicalhomeinfo.org/how/care_deliv
ery/transitions.aspx
AAP medical home/transitions website
http://www.pafp.com/pafpcom.aspx?id=785
PAFP / AAP partnership
13. Ann Intern Med. 2009 Feb 3;150(3):178-87.
“A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.”
INTERVENTION: A nurse discharge advocate worked with patients during their hospital stay to arrange
follow-up appointments, confirm medication reconciliation, and conduct patient education with an
individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist
called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications.
Participants and providers were not blinded to treatment assignment.
CONCLUSION: A package of discharge services reduced hospital utilization within 30 days of discharge.
Pharmacotherapy. 2008 Apr;28(4):444-52.
“Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled
nursing facility.”
INTERVENTION: Patients were assigned to the medication reconciliation program (113 patients) or to
the usual care control group (408 patients) after discharge to home from an SNF. Assignment to the
medication reconciliation group or to the control group was based on provider submission of a
discharge summary within 0-48 hours of discharge or more than 48 hours after discharge,
respectively.
CONCLUSION: Our data support the hypothesis that a formal medication reconciliation process, with
its increased coordination of information between health care providers and patients, can decrease
mortality after discharge from an SNF. Our findings support the role of medication reconciliation as
an integral step in the transitional care process and interests of health care accrediting agencies, such
as the Joint Commission, that have included medication reconciliation as an important initiative.
14. Multidisciplinary team
approach
Clinical protocols and
regional guidelines
Enhanced palliative care
consultation and support
Education (of patients and
caregivers)
Coaching
Personal health record
Community supports
Evidence-Based Care Transitions
Strategies
Enhanced information
transfer at discharge
Follow-up care established
at discharge
Improved medication
management
Post-discharge plan of care
Telephone follow-up
Telemedicine
Electronic health record
(EHR)
Ventura, T et al. (2010). Improving Care Transitions and Reducing Hospital Readmissions: Establishing the Evidence for
Community-Based Implementation Strategies through the Care Transitions Theme. The Remington Report, 18(1), 24;
26-30.
15. Which is NOT one of the programs for
bundled payments for care improvement
initiative by Medicare?
1. Acute care hospital
stay only
2. Acute care stay +
post-acute care
3. Just post-acute care
4. All care for a patient
prospectively paid
for a 180 day period
16.
17. In the final ACO rules by Medicare, providers will
have to meet how many quality metrics to qualify
for performance bonuses?
1. 3
2. 33
3. 100
4. 309
18.
19. What Does This Mean Now?
Here are the measures
33 quality metrics
Several domains
20.
21.
22.
23.
24. Nice Summary of ACO Rule
http://www.aafp.org/online/etc/medialib/aafp_org/
documents/policy/fed/background/medicare-aco-
summary.Par.0001.File.tmp/AAFP-Final-
Medicare-ACO-Summary.pdf
Only 19 pages!
25. Goal
Be ready for the requirements!
Kudos to the PAFP (and others) for having the
vision to prepare us all for what’s to come
26. Operationalize This:
How to Quantify (metrics) - What To
DO To Prevent Re-admissions
Have appointment made prior to discharge
Medication reconciliation (by phone/in person)
Discharged patient should be seen within __ days
High-risk patients (“frequent flyers”)
Develop a registry of some sort
Frequent contact
Maybe weekly after discharge
All on the list, at least monthly
27. Communicate with Hospitals
Identify 1-3 main
hospitals where your
patients go
Communicate
Develop transition plans
31. PatientName(Last,First):_______________________________________ DOB:_______________
Date/TimeofCall(s)attemptedbutnotcompletedwithcallerinitials:
1)______________________________ 2)______________________________ 3)_______________________________
Messagescript:“Hellothisis_________. I‟mcallingfrom_________asafollowupfromyourhospitalization.Someonefrom
ourofficewilltrytoreachyouagaintomorrow,butpleasefeelfreetocallbacktodayat(officenumber)andaskfor_________.”
Ifunabletoreachpatientafterthreeattempts,datecertifiedlettersentwithmailerinitials:________________________
Date/Timecallcompletedwithcallerinitials:______________________________
With Discharge Instructions and Medication Reconciliation Forms in front of caller:
“Hello this is _________, may I speak with _________(patient, caregiver, or parent of minor patient)? I‟m
calling from _________as a follow up from your hospitalization. How you are doing today?”
“If you have your discharge instructions and medication list handy, could you go get them so we can review
them together?” (If patient does not have available, proceed without them.)
If significant clinical issues arise or there are discrepancies with medications, action is required:
immediate office visit, involve homecare or family, notify physician, or send to Emergency Department.
Script Patient Response Action taken
“I understand you were in the hospital for___.”
(SeeDischargeInstructionsheet,sectionReasonfor
Admission/DiagnosisandProblems)
“Is this correct?”
Yes / No.
If no, explain:
“How is your condition since you got home?” Comments:
“Now that you‟re home, do you have any questions
about your discharge instructions?”
Yes / No.
If yes, explain:
If applicable, “Have you completed or
scheduled your blood work for _______?” (list
LAB TESTS on discharge instruction sheet)
Yes / No.
If no, explain:
If applicable, “Have you completed or
scheduled your ________ ? “ (listADDITIONAL
TESTSondischargeinstructionsheet)
Yes / No.
If no, explain:
„Let‟s review your medications”. Then go
through each one on the Medication
Reconciliation form.
Confirm that if medication on the
Medication reconciliation form is
marked CONTINUE, that patient is
taking as directed.
Note discrepancies:
Confirm that if medication on the
Medication reconciliation form is
marked NOT CONTINUE, that patient
is not taking.
Note discrepancies:
“Are there any other medications that
you are taking that are not on the list?”
List:
Do you have a scheduled appointment with your
Family doctor?
Yes / No.
If no, schedule.
If yes, remind about date/time.
“Thank you for your time. We look forward to
seeing you on (restate appointment date and time).
Please bring all your medications and discharge
instructions to your appointment.”
5.26.10(2)
Glass G, Roehl B:
UMH Hospital f/u
phone script (available
at fmdrl.org)
32. IHI (Institute for Healthcare Improvement):
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoR
educeAvoidableRehospitalizations.aspx
33.
34.
35. Some Examples (From FHCC)
FHCC = Family Health Care Center (clinical site of
our residency)
Residents used to do EMR “Chart Note” at
discharge
Now, Epic – “One patient, one chart”
F/u visits (if appropriate) made
All most discharges get phone call (or secure
message from EMR) within 24 hrs from care
manager/team nurse/physician
Placed on registry?
36. Transition Care by FHCC Care
Manager and/or Team Nurse
Receives/reviews lists (daily, monthly) of patients
seen in ER and hospital discharges
Currently RH only
Calls all patients within 24 hours (business day)
Ensures follow-up appointments
Answers questions
Admittedly: low yield
Focuses upon high-utilizers (maintains registry)
Communicates with physicians about their
patients (via EMR system)
37. Name DOB MR#
Date of
D/C ER?
Hosp
discharge? TRHMC?
Other
(which?)
Phone call
made?
Date of
contact Contacted by
FHCC
F/U App't
Made?
Date of
FHCC f/u
In CM
Registry
prior to
d/c?
Responsible
Provider
Resp
prov
notified? Asthma CHF COPD
Bronchitis/URI/
Pneumonia
Ortho/MS
Pain HA
Hypergly
cemia/La
b issue
Depression/
anxiety
Other (list main
dx)
Was pt on
FHCC service
(adm only)?
Non-FHCC
referrals
Action
plan
Safety
issues Comments
11/30/1932 5/1/2011 X X had appt 5/9/2011 Cunningham X
6/19/1990 5/1/2011 X X X LM 5/2/2011 NMK Patel Pain all over Y
4/11/1978 5/1/2011 X X X 5/2/2011 NMK Peterson vomiting
8/17/1984 5/1/2011 X X X 5/2/2011 NMK not needed Shanmugam boil/mole change
10/19/1964 5/1/2011 X X appt tomorrow 5/2/2011 NMK 5/3/2011 Raff Diarrhea, Vomiting
11/30/1986 5/1/2011 X X X LM 5/2/2011 NMK Allergies
6/13/1971 5/1/2011 X X pt called X 5/2/2011 Dr Radosh Radosh CP
5/14/2012 5/2/2011 X X X Radosh 5/16/2011 difficulty breathing, bronchitis
9/30/1963 5/2/2011 X X X LM 5/3/2011 NMK Migraine
12/2/1993 5/2/2011 X X X 5/3/2011 NMK 5/11/2011 Baxter Chest tightness
2/18/1933 5/3/2011 X X X LM 5/4/2011 NMK Baxter Weakness, falls
1/9/1983 5/3/2011 X X appt 5/18/2011 Martin anxiety, MH eval
8/23/1932 5/3/2011 X X X 5/4/2011 NMK 5/4/2011 Tilich SIRS Y
11/12/1958 5/4/2011 X X X 5/5/2011 NMK 5/26/2011 Mancano Finger pain
3/20/1964 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Peterson Itchy all over
3/30/1961 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Peterson Change in mental status
12/24/1971 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Patel difficulty breathing
10/19/1992 5/5/2011 X Obs X Martin Chest Pain
7/8/1967 5/5/2011 X X X 5/6/2011 NMK 5/9/2011 Abou Saab Allergic RXN Can't swallow
12/31/1979 5/5/2011 X X X 5/6/2011 NMK not needed Raff Constipation, rectal pain
9/4/1955 5/6/2011 X X X 5/10/2011 NMK Abou Saab X
4/24/1980 5/6/2011 X X X 5/10/2011 NMK Peterson Sore throat
4/20/1947 5/7/2011 X X X 5/9/2011 5/9/2011 Hanafi Leg pain numbness
5/6/1973 5/7/2011 X X X LM 5/10/2010 NMK Weida Side back pain Nausea
4/23/1938 5/7/2011 X X appt today 5/10/2010 NMK 5/10/2010 Mancano Fall
7/11/1963 5/7/2011 X X pt called 5/10/2011 Baxter abdominal pain
9/29/1968 5/7/2001 X X appt today 5/9/2011 NMK 5/9/2011 Cunningham Cough, congestion
2/9/2007 5/7/2011 X X X 5/10/2011 NMK 5/20/2011 Peterson viral syndrome, chills
12/4/1933 5/8/2011 X X X 5/10/2011 NMK F/u cardiology Abn CV study Cardiology
4/3/1996 5/8/2011 X X pt called 5/10/2011 NMK F/u hershey Warfel Migraine Hershey
11/1/2008 5/8/2011 X X X 5/10/2011 NMK not needed Weida eye complaint, cough
10/19/1964 5/9/2011 X X appt NMK 5/17/2011 Raff X Diarrhea, Vomiting Y
2/9/1950 5/9/2011 X X pt scheduled 5/23/2011 Raff Poss HTN, HA
12/30/1971 5/10/2011 X X had appt 5/23/2011 Raff CP, Abn Stress Test Cardiology
1/1/1983 5/10/2011 X X pt called 5/10/2011 5/18/2011 Radosh Pain in shoulder
10/14/1975 5/10/2011 X X X 5/11/2011 NMK 5/12/2011 Shanmugam Shakey, multiple complaints
1/22/2008 5/10/2011 X X X 5/11/2011 NMK 5/13/2011 Murphy Vomiting
4/22/2011 5/10/2011 X X X LM 5/11/2011 NMK Lavrik Crying
7/1/1964 5/11/2011 X X had appt 5/19/2011 Martin MVC
7/8/1967 5/11/2011 X X X 5/12/2011 NMK 5/18/2011 Wang Anxiety Lt sided weakness
4/19/1969 5/11/2011 X X had appt 5/24/2011 Patel mouth pain
2/16/1976 5/11/2011 X X had appt 5/13/2011 Peterson MVA
9/10/1992 5/11/2011 X X had appt 6/2/2011 Lavrik abdominal pain
6/23/1991 5/11/2011 X X X LM 5/12/2011 NMK Martin shoulder injury
3/17/1972 5/12/2011 X X X LM 5/13/2011 NMK Peterson Chest Pain
10/9/1938 5/18/2011 transfer to SNF X Nsg home Radosh SVT hypotensive episode
7/2/1968 5/12/2011 X X X LM 5/13/2011 NMK Peterson injured toe
10/26/1979 5/12/2011 X X X NA 5/13/2011 NMK Patel abdominal pain
9/17/1995 5/12/2011 X X X NA 5/13/2011 NMK Shanmugam Burning with urination
4/10/1996 5/12/2011 X X X LM 5/13/2011 NMK Baxter Shoulder Pain
1/5/1938 5/12/2011 X X X LM 5/13/2011 NMK Patel Open Choley
1/11/1973 5/13/2011 X X pt called 5/13/2011 5/16/2011 Tucker abdominal pain
8/26/1953 5/13/2011 X X had appt 5/31/2011 Wang Finger Laceration
12/30/1991 5/13/2011 X X X LM 5/16/2011 NMK Abou Saab Ear Pain
9/17/2009 5/13/2011 X X pt called 5/13/2011 5/18/2011 Martin accidental ingestion
9/7/1963 5/14/2011 X X had appt 6/9/2011 Ekmark CP, SOB
12/1/1963 5/14/2011 X Obs X had appt 5/24/2011 Warfel CP, Asthma
7/27/1974 5/14/2011 X X X 5/16/2011 NMK 5/25/2011 Lavrik Bronchitis
12/30/1966 5/14/2011 X X X 5/16/2011 NMK not needed Radosh Chest tightness
5/5/1931 5/15/2011 X X X 5/16/2011 NMK 5/23/2011 Warfel Pneumonia
3/14/1966 5/15/2011 X X Baxter CP, High BP/cardiac cath cardiologist
9/30/1988 5/15/2011 X X X 5/16/2011 NMK 5/23/2011 Malik head laceration
3/24/1977 5/15/2011 X X X 5/16/2011 NMK 5/26/2011 Peterson HA, N & V
4/22/1984 5/15/2001 X X had appt 5/17/2011 Arzomand Dizzy, side numbness
1/2/2004 5/15/2011 X X had appt 6/2/2011 Peterson Dog bite
5/29/1970 5/16/2011 X X had appt 6/15/2011 Brigandi MVC
4/24/1969 5/16/2011 X X X 5/17/2011 NMK not needed Weida Back pain, sinusitis/Bronchitis
6/18/1950 5/16/2011 X X X 5/17/2011 NMK May-11 Wang Finger injury
11/5/1986 5/16/2011 X X 5/17/2011 NMK not needed Ekmark Back pain
11/8/1977 5/16/2011 X X had appt 5/20/2011 Tucker Coughing
4/18/1940 5/18/2011 X X x Deloris yes 5/24/2011 Weida CA
12/1/1963 5/19/2011 X X appt yes 5/24/2011 Warfel Asthma
3/10/1950 5/19/2011 X X appt Deloris yes 5/25/2011 Doshi fever/ chst pain
1/25/1962 5/21/2011 X X appt 6/2/2011 Radosh X
2/4/1939 5/20/2011 X X appt yes 5/24/2011 Arzamand cellulitus cancelled appoint
12/26/1927 5/25/2011 X X appt Deloris yes 6/2/2011 Mancano presyncope
5/20/1933 5/26/2011 transfer to SNF X Nsg Home Baxter CHF/ Pneumonia Deceased
8/30/1952 5/26/2011 X X Warfel Pneumonia Threshold Client
3/15/2029 5/27/2011 X X appt 6/15/2011 Lavrik Diarrhea/ Cervical Osteomylitis
4/5/1977 5/27/2011 X X appt 5/31/2011 Raff Pancreatitis
2/1/1947 5/28/2011 X X appt 6/1/2011 Campa Anemia
3/18/1960 5/27/2011 X X X LM 5/31/2011 NMK Patel Coughing blood
4/24/1980 5/27/2011 X X X 5/31/2011 NMK 6/9/2011 Peterson Abdominal pain
9/28/1951 5/27/2011 X X X LM 5/31/2011 NMK Baxter Toe injury
4/23/1976 5/27/2011 X X X 5/31/2011 NMK Brigandi Knee Injury
12/9/1964 5/28/2011 X X chart note 5/31/2011 6/8/2011 Weida Alcohol withdrawl Outpt detox
10/23/1978 5/28/2011 X X X 6/1/2011 NMK 6/6/2011 Lavrik Pelvic pain
12/22/1976 5/29/2011 X X had appt 6/1/2011 Weida Rash
7/19/1964 5/29/2011 X X X 6/1/2011 NMK not needed Lavrik HA, Nausea, Diarrhea
5/17/1995 5/29/2011 X X X LM 6/1/2011 NMK Warfel dizziness & vomiting
9/4/1932 5/30/2011 X X X LM 6/1/2011 NMK Brigandi Constipation
9/5/2001 5/30/2011 X X X 6/1/2011 NMK 6/7/2011 Baxter nosebleed, dizzy
3/28/2008 5/30/2011 X X had appt 6/3/2011 Doshi side face swollen
5/6/1951 5/31/2011 transfer to SNF chart note 5/31/2011 Malik Cunningham Osteomylitis RLE
7/10/1955 5/31/2011 X had appt 6/10/2011 Peterson spinal cord tumor
8/23/1957 5/31/2011 X X X LM 6/1/2011 NMK Warfel Leg Pain
4/24/1948 5/31/2011 X X X 6/1/2011 NMK 6/2/2011 Lavrik X
11/17/1942 5/31/2011 X X had appt 6/10/2011 Peterson Abdominal Pain
2/10/1987 5/31/2011 X X had appt 6/3/2011 Warfel Lump on neck
6/22/1998 5/31/2011 X X X 6/1/2011 Martin 6/3/2011 Murphy X Pneumonia
7/24/1963 5/31/2011 X X had appt 6/2/2011 Peterson Leg pain & swelling
11/3/2025 5/31/2011 X X X 6/1/2011 NMK 6/13/2011 Baxter Difficulty speaking
FHCC follow-up? CM/PCP Notification? MAIN reason for ER visit/hospitilzationDemographic Information Setting Facility Contacted?
38. Name DOB MR#
Date of
D/C ER?
Hosp
discharge? TRHMC?
Other
(which?)
Phone call
made?
Date of
contact Contacted by
FHCC
F/U App't
Made?
Date of
FHCC f/u
11/30/1932 5/1/2011 X X had appt 5/9/2011
6/19/1990 5/1/2011 X X X LM 5/2/2011 NMK
4/11/1978 5/1/2011 X X X 5/2/2011 NMK
8/17/1984 5/1/2011 X X X 5/2/2011 NMK not needed
10/19/1964 5/1/2011 X X appt tomorrow 5/2/2011 NMK 5/3/2011
11/30/1986 5/1/2011 X X X LM 5/2/2011 NMK
6/13/1971 5/1/2011 X X pt called X 5/2/2011 Dr Radosh
5/14/2012 5/2/2011 X X X Radosh 5/16/2011
9/30/1963 5/2/2011 X X X LM 5/3/2011 NMK
12/2/1993 5/2/2011 X X X 5/3/2011 NMK 5/11/2011
2/18/1933 5/3/2011 X X X LM 5/4/2011 NMK
1/9/1983 5/3/2011 X X appt 5/18/2011
8/23/1932 5/3/2011 X X X 5/4/2011 NMK 5/4/2011
11/12/1958 5/4/2011 X X X 5/5/2011 NMK 5/26/2011
3/20/1964 5/4/2011 X X X 5/5/2011 NMK 5/6/2011
3/30/1961 5/4/2011 X X X 5/5/2011 NMK 5/6/2011
12/24/1971 5/4/2011 X X X 5/5/2011 NMK 5/6/2011
FHCC follow-up?Demographic Information Setting Facility Contacted?
39. In CM
Registry
prior to
d/c?
Responsible
Provider
Resp
prov
notified? Asthma CHF COPD
Bronchitis/URI/
Pneumonia
Ortho/MS
Pain HA
Hypergly
cemia/La
b issue
Depression/
anxiety
Other (list main
dx)
Waspt on
FHCC service
(adm only)?
Non-FHCC
referrals
Action
plan
Safety
issues Comments
Cunningham X
Patel Pain all over Y
Peterson vomiting
Shanmugam boil/mole change
Raff Diarrhea, Vomiting
Allergies
Radosh CP
difficulty breathing, bronchitis
Migraine
Baxter Chest tightness
Baxter Weakness, falls
Martin anxiety, MH eval
Tilich SIRS Y
Mancano Finger pain
Peterson Itchy all over
Peterson Change in mental status
Patel difficulty breathing
CM/PCP Notification? MAIN reason for ER visit/hospitilzation
45. RRC “Plug”
ACGME competencies require this kind of
work
Transitional care counts!
Residents can:
Design plans/assist with development of
policies
Do med rec, home visits
Residents + transitional care =
“system-based practice” competency
46. $$$
Improved office efficiency?
More volume for 99214’s?
Piece of the pie?
Get money or assistance (care managers, etc.)
via hospital bundled payments
Pay for performance?
TOC metrics part of clinical integration bonuses
New CPT codes?
47. 99495 and 99496
• Cover transitional care management (TCM)
services as the patient is transitioning from
inpatient hospital care to his or her home or
another community setting
Moderate decision-making: 99495
High-complexity medical decision-making: 99496
Approved by CMS last fall; became available to
physician practices in January 2013
48. Tools for New Codes
http://www.aafp.org/dam/AAFP/documents/practice_
management/payment/TCMFAQ.pdf
Great two-page PDF summary by AAFP
http://www.aafp.org/dam/AAFP/documents/practice_
management/payment/TCM30day.pdf
Great two-page PDF worksheet by AAFP
http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/Transitional-Care-
Management-Services-Fact-Sheet-ICN908628.pdf
Eight-page PDF by CMS delineating details
49.
50.
51. Worth It?
Are the new codes worth the time and
effort?
We’ll see . . .
52.
53. “This is way too complicated. I cannot track
these charges and make sure they get billed out
30 days after discharge. We send claims same
day or next day. Holding work for later is just
asking for missed charges. Also I don't get DC
info until 4-5 days after discharge, if ever. I have
one staff member so saying staff can do this is
ridiculous since she is already doing a lot and
she is not a clinical person. What if send the
charge out and find out later they were
readmitted on day 28? This is not practical or
feasible. I will not use this code. The increased
pay is not worth the hassle.”
From FPM Blog
“. . .. I agree. It seems easier to
continue to bill the usual E and M code
rather than remember to bill the 30 th
day. Seeing the patient is important
after discharge so I wouldn't want to
discourage that visit. Unless the
coordination code pays a lot more
than the usual 99214 it seems
worthless. We will continue to do
uncompensated work.”
54. “How much are these new services worth?”
(from AAFP link)
“Payment allowances will vary by payer, and Medicare’s allowance will
vary geographically. Also, Medicare’s allowance will depend on the
conversion factor in force at the time claims are paid.
Based on these RVUs and the current (2012) conversion factor, the
Medicare allowance for code 99495 performed in a non-facility
setting (e.g., a physician’s office) would be approximately $164; in
a facility setting, the corresponding allowance would be approximately
$135. For code 99496 performed in a non-facility setting, the
Medicare payment allowance would be approximately $231.12;
when performed in a facility setting, it would be approximately
$197.76.”
55. Finally . . .
Be an advocate!
This is where Family Medicine should shine
And get paid more . . .
Get involved
Clinically integrated entities – committees
Health system task forces
Medical societies
56. Objectives (Met?)
By the end of this presentation, participants
will be able to:
List external forces related to transitional care
Identify “priority tasks” in transitional care
Have appointment made prior to discharge
Medication reconciliation (by phone or in person)
Discharged patient should be seen within __ days
Develop a registry of some sort (high-risk patients)
Utilize tools to augment your planning
Identify new CPT codes
57. To Do Tomorrow:
Inventory: what hospital(s) do your patients go to?
Complete the transitional tool
Call the contact – how can you get daily ED/discharge lists?
Have a meeting at your practice
How can hospital patients get app’t prior to d/c?
Meet with inpatient care managers?
Take inventory: what medication reconciliation
processes do you have, if any?
Who can/should do it, when, how (phone?)
Are you seeing dc’d patients for hospital f/u soon?
Do you have some type of registry for high-risk
patients (frequent flyers)?
Do patients get contacted?
When/how often/by whom?
58. Take Home Messages
Transitional care is gaining press, importance,
and soon - reimbursement
Choose key areas
Discharges, med rec, f/u visit, high-risk registry
Prevent re-admissions!
Start with specific tasks
Small, concrete steps
Do NOT re-invent the wheel
There is a lot of material out there
Be an advocate for this – don’t do it for free!
59. THANK YOU FOR YOUR ATTENTION!
Questions/comments?
Experiences/ideas to share?