Join us for a free webinar series on “Shining Stars Across the Nation”.
We will hear from local communities that have been successful in improving healthcare through reducing hospital readmissions. We will feature communities from different initiatives— those communities that are lead by the QIOs, those that are part of Aligning Forces For Quality, those that have received state funding, Robert Woods Johnson awardees, CCTP awardees, Beacon communities, ACOs and more.
Intended Audience: Health & Human Services, QIOs, healthcare providers, partners, and consumers
Dates: 2nd and 4th Thursdays from 3 - 4 PM ET
June 27, 2013: Banner Health in Phoenix, AZ - An Accountable Care Organization
July 11, 2013: Lovelace Hospital, New Mexico - Aligning Forces for Quality Alliance Community
July 25, 2013: Western Pennsylvania Community-based Care Transitions Program - Community-Based Care Transitions Program (CCTP Awardee)
August 8, 2013: ARC-Avoiding Readmissions through Collaboration, California - Community-Based Care Transitions Program (CCTP) Awardee
Shining Stars Across the Nation: January 10, 2013 – December 2013
January 10, 2013: MI STAAR Community- Michigan - IHI STAAR Initiative
In this presentation, Nancy Vecchioni, RN, MSN, CPHQ, Vice President Medicare Operations MISTA*AR co-lead, Improvement Advisor, describes the history of the STAAR Initiative in Michigan. Peggy Segura RN, MSN, FNP-BC Nurse Practitioner, Quality & Safety - Clinical Effectiveness MI STA*AR Project Leader from Sinai-Grace Hospital in Detroit goes into great depth of how they implemented this project at Sinai-Grace .Peggy shares the key changes to improve transition from hospital to home, resources and lessons learned.
January 24, 2013: p2 Collaborative of Western New York - Community Based Care Transitions Program (CCTP) Awardee
In this presentation, Megan Havey, Manager of Care Transitions and Bonnie Saunders, Unit Supervisor, Cattaraugus County Department of the Aging describe the CBO role, the Care Transitions Intervention that was implemented and their community journey as a CCTP award recipient.
February 14, 2013: Eau Claire County Coalition - Wisconsin - State Funded Grant Awardee
In this presentation, Lisa Riley, APSW- Care Transition Coach, describes how the Eau Claire community came together, completed a root cause analysis and implemented the Care Transitions Intervention. She includes in her presentation barriers that were encountered, improvement in readmission rates since inception and where they are today.
February 28, 2013: National Program Updates: ADRC, CCTP, HEN, Medicaid, ONC and QIO
In this presentation, Marybeth Ribar, MS, RN, Technical Director, Division of Community Systems Transformation, Disabled and Elderly Health Programs Group, Juliana Tiongson, MPH, Community-based Care Transitions Program, Caroline Ryan, Center for Disability and Aging Policy, U.S. Administration for Community Living, Janhavi Kirtane Fritz, Director of Clinical Transformation, Beacon Community Program, Office of the National Coordinator for Health IT (ONC), Mary Andrawis, PharmD., M.P.H., Hospital Engagement Network and Shiree M. Southerland, PhD, RN, BSN, GTL, Centers for Medicare and Medicaid Services share the latest updates on these programs and how they link and are beneficial to the Integrating Care for Populations and Communities Aim.
For more information on the Medicaid Care Transitions Programs please find the recently posted FAQs on the TCM website.
March 14, 2013: Central Community Coalition - New Jersey - Robert Wood Johnson Foundation Grant Awardee
In this presentation, Alyce Brophy, President and Chief Executive Officer Community Visiting Nurse Association and Alyssa Kizun, Director of Care Management Somerset Medical Center share their community journey including the adaptation of the CTI model, accomplishments, challenges, outcomes and progress that has been made to date. They also share some tips on how to begin building a community and the assistance provided by the New Jersey Quality Improvement Organization (QIO).
March 28, 2013: Washington County Coalition, Rhode Island - A Quality Improvement Organization Community
In this presentation, Lynne Chase, Senior Program Administrator, Healthcentric Advisors Liaison, Lynne Driscoll, RN, CCM, Manager of Case Management, South County Hospital, Jeffrey Bandola, MD, Medical Director – South Bay, Scallop Shell, and South Kingstown, Jennifer Fairbank, RN, BSN, Executive Director, South County Nursing and Rehabilitation Center, Karen Hockhousen, RN, BSN, ICCS, Director of Clinical Services, VNS Home Health Services share their collaborative journey with improving med management, interventions that were implemented and recommendations that produced excellent results in improving care transitions and reducing hospital admissions and readmissions.
April 11, 2013: AAA 1-B Southeast Michigan Community-Based Care Transition Program - A Quality Improvement Organization Community
In this presentation, Barbra Link, Director of Care Transitions and Tina Berry, Manager of Care Transitions share five modified CTI interventions deployed within this new CCTP community including some innovative strategies including a “recovery specialist” as well as strategies targeting those patients with behavioral health issues. They share how tailoring these strategies to the five distinctive categories of patients allows AAA 1-B to provide high-value transitions coaching to virtually everyone They also share the challenges they have faced including implementing coaching in SNFs, data and plans going forward.
April 25, 2013: Healthy Columbia Campaign - South Carolina - ReThink Health Community funded by the Fannie E. Ripple Foundation
In this presentation, Kate Hilton and Dr. Rick Foster share their experiences in organizing an entire community within a specific zip code using community organizing strategies and tactics to improve healthcare outcomes.
May 9, 2013: American Academy of Family Physicians Bruce Bagley, M.D., Medical Director for Quality Improvement Rescheduled presentation from the Cultivating Partnerships Series
May 23, 2013: Rio Arriba County Community - New Mexico - A Quality Improvement Organization Community
June 13, 2013: Hickory House Nursing and Rehab Center- Pennsylvania - A Quality Improvement Organization Community
Cultivating Partnerships: June 14, 2012 – November 29 2012
June 14, 2012: Engaging Partners – 101
In this initial presentation for the Engaging Partners series, Traci Archibald, GTL and Laura Mankin, ICPC Program Manager, describe the importance of partnering with other providers in the community and across the state to build strong community leadership. You will also hear from 5 QIOs that have developed those partnerships within their communities.
June 28, 2012: National Association for Area Agencies on Aging (N4A) & Administraton for Community Living (ACL)
Sandy Markwood, CEO, N4A & Marisa Scala-Foley, Social Science Analyst
In this presentation Sandy describes the structure, value, services and current trends in the Aging Network and goes on to tell us how the AAA has implemented care transition activities on the local level. Marisa gives an overview of the new Administration of Community Living and how they are engaged in care transitions at the community level.
July 12, 2012: National Association for Home Care & Hospice (NAHC) & Visiting Nurse Associations of America (VNAA). Mary St. Pierre, Vice President, Regulatory Affairs, NAHC & Margaret (Peg) Terry, Vice President of Quality and Innovation.
In this presentation Mary describes the activities that NAHC is actively engaged in and promoting to keep home health agencies abreast of the latest legislation. She also gives an example of what one home health agency has implemented to reduce hospital readmissions. Peg describes how the VNAA is working with QIOs through the HHQI initiative and joining other community based efforts to reduce hospitalizations such as Pioneer ACOs and Bundling demonstrations.
July 26, 2012: Long Term Quality Alliance (LTQA), LeadingAge, & American Health Care Association (AHCA). Doug Pace, Executive Director, LTQA, Dr. Cheryl Phillips, Senior Vice President, Advocacy, LeadingAge, & Sandra Fitzler, Senior Director of Clinical Services, AHCA.
In this presentation, Doug shares the history and mission of LTQA and describes the White Paper on Preventable Hospitalizations among other papers that were designed to develop policy and measures in the long term care community. Dr. Phillips describes the Advancing Excellence program, updated goals and the AE Hospital Transfer Log. She also discusses the work with the QIOs. Sandy describes AHCA’s alignment with QIO work, efforts on reducing hospitalizations, antipsychotic drug use, and staff turnover, helpful interventions & resources and gives direction of how QIOs can support this work. As Dr. Phillips so eloquently stated, “Through the three associations, we have the ability to align with message and momentum.”
August 9, 2012: American College of Cardiology (ACC), Hospital to Home (H2H). Shilpa B. Patel, Program Manager, Quality Initiatives & Mary Anne Elma, Director, Science & Quality.
In her presentation, Shilpa describes the goals and core concepts of the H2H Initiative and how it aligns with other similar initiatives. She also shares the aggregated improvement data in readmissions from those providers that are a part of this quality improvement project. Nancy shares how Michigan has formed a Care Transitions Coordinating Team and Care Transitions Coalition to keep providers engaged and makes “sense” of all the projects that are working to reduce hospital readmissions. She also goes on to describe the “See you in 7” Southwest MI Collaborative.
August 23, 2012: Case Management Society of America (CMSA). Cheri A. Lattimer, Executive Director
In her presentation, Cheri describes the updates and overview of the National Transitions of Care Coalition, the compendium and new evaluation software tool.
September 13, 2012: American Pharmacists Association (APhA), National Alliance of State Pharmacy Associations (NASPA), & American Society of Health-System Pharmacists (ASHP). Anne L. Burns, Senior Vice President, Professional Affairs, APhA, Benjamin M. Bluml, Vice President, Research, APhA, Rebecca P. Snead, Executive Vice President & CEO, NASPA, Shekhar Mehta, Director, Clinical Guidelines and Quality Improvement.
In this presentation, each presenter shares the initiatives their organization is currently involved in to reduce hospital readmissions and how QIOs and providers can forge partnerships and access tools. Anne discusses medication reconciliation as being the foundational concept to improving care transitions and provides multiple resources to assist with this issue. Shek shares how ASHP is partnering with QIOs to reduce hospital readmissions by sharing resources and expertise in the medication use process, using member and state affiliate level coordination strategies to improve transitions to outpatient care and to educate providers and patients on the process and importance of safe medication use. Becky provides numerous examples of state pharmacy associations partnering with QIOs and other healthcare providers. You will also find useful tools that can be readily downloaded for your use.
September 27, 2012: National Association of Public Hospitals and Health Systems. Jane Hooker, Assistant Vice President for Quality & David G. Schulke, Vice President, Research Programs.
In this presentation, David introduces HRET and describes the work that the Hospital Engagement Network is currently engaged in with hospitals across the country including the patient experience of care (HCAHPS) measures. Jane describes the new quality initiative that was deployed within their association’s member hospitals and the partnership with the American Hospital Association.
October 11, 2012: National Council on Aging & National Hospice & Palliative Care Organization. Sue Lachenmayr, Program Director, Jon Keyserling, Senior Vice President and Counsel, Office of Health Policy, & Kathy Brandt, Senior Vice President, Office of Innovation
In this presentation, Sue describes the prevalence, impact and risks of chronic disease, why self-management is so vitally important and the program, resources and tools that are available through NCOA. Jon and Kathy, in their presentation, describe the hospice/palliative care continuum and the robust Medicare benefit available to beneficiaries.
October 25, 2012: American Academy of Family Physicians (Cancelled - to be rescheduled at a later date). Dr. Bruce Bagley, Medical Director of Quality Improvement
November 8, 2012: National Rural Health Association & Health Resources and Services Administration. Amy L. Elizondo, Vice President, Program Services & Paul Moore, Senior Health Policy Advisor
In this presentation, Amy describes the mission and vision of NRHA and how providers and QIOs can partner with this agency to improve rural health at a local level. Paul describes why focusing on critical access hospitals in care transitions is so important.
November 29, 2012: American Medical Directors Association Dr. James Lett, Chair, Transitions of Care Committee
In this presentation, Dr. Lett describes why it is so important to understand the perceptions, and accuracy of the insufficient quality and quantity of information received at the Emergency Department from skilled nursing facility (SNF) admissions. He goes on to explore strategies to reduce the number of residents transferred back to the Emergency Department/Hospital from the SNF and institute procedures to insure that those residents who must return to the Emergency Department/Hospital do so with appropriate information to augment patient safety.
Community Organizing: February 9, 2012 – May 24, 2012
February 9, 2012: Introduction to Leadership & Organizing
In this presentation, Kate Hilton presents an overview of leadership and the theory of organizing for health and the core principles of interdependent leadership. Organizing is a form of leadership that equips people with the resources they need to make change.
February 23, 2012: Public Narrative: Story of Self
In this presentation, Kate Hilton describes how to develop a story of self and why coaching individuals as they develop their stories is an important organizing practice. This session also features sample stories of self and how the public narrative can be used to generate interest, build relationships, and drive commitment to change.
March 8, 2012: Building Relationships in Organizing
In this presentation, Ella Auchincloss details how to develop intentional relationships in organizing using the 1:1 method. People are the essential resource in organizing and by developing relationships, communities can drive volunteer commitment and inspire creativity to engage diverse social networks and the broader community. This session also features an example of a 1:1.
March 22, 2012: Mapping Actors - Identifying & Recruiting Leadership
In this presentation, Ella Auchincloss describes how developing strategy can help identify available resources and turn them into the power needed to get the outcomes desired. This session also features a real life example of developing a “mapping actors” grid to identify leaders in a local community.
April 12, 2012: Structuring Effective Leadership TeamsIn this presentation, Ella Auchincloss describes why developing and sustaining effective teams is critical to creating change and shares insight into the elements of developing a “dream team”, including establishing a clear purpose, engaging the right people, and enabling team structure. She also shares some examples of why teams don’t work well together and how this can be detrimental to quality improvement.
April 26, 2012: Developing Motivating Vision & Goals
In this presentation, Ella Auchincloss describes how healthcare providers can apply the theory of change to develop a motivating vision and measureable goal(s) to organize a campaign to reduce hospital readmissions within communities.
May 10, 2012: Developing a Campaign Timeline & Tactics
In this presentation, Ella Auchincloss describes how to develop a set of tactics to meet our goals by using the resources we have and developing the capacity of the team. Ella gives us a real life example on how we can apply these ideas in the healthcare setting using a community in South Carolina.
May 24, 2012: Call to Action: Story of Self, Us & Now
In this presentation, Kate Hilton describes and illustrates public narrative and how this leadership practice motivates others to join us in action. A call to action is about changing the healthcare problems that we face, uniting people with a shared goal to work on together, committing to take specific actions and building energy to achieve change. The public narrative is a combined story of self, us and now so that by sharing our stories, we can inspire local communities to take action and make commitments that will drive our work to reduce hospital readmissions.
Intervention Opportunities: September 1, 2011 – January 26, 2012
September 1, 2011 at 3 PM ET: Interventions 101 - NCC Team Overview of Key Interventions
This presentation features a high-level overview of 9 interventions developed to reduce hospital readmissions. They include the Care Transitions Intervention, Transitional Care Model, Project BOOST (Better Outcomes for Older adults through Safe Transitions), Project RED (Re-engineered Discharge), Interact (Interventions to Reduce Acute Care Transfers), Home Health Quality Improvement National Campaign-BPIP (Best Practice Intervention Package), STAAR Initiative (State Action on Avoidable Rehospitalizations), GRACE Model (Geriatric Resources for Assessment and Care of Elders) and The Bridge Program (an adaptation of the Enhanced Discharge Planning Program, EDPP).
September 8, 2011: STAAR Initiative – Amy Boutwell, MD, MPP
In this presentation, Dr. Boutwell describes the STAAR Initiative and discusses why reducing rehospitalizations is a compelling quality improvement endeavor requiring systemic improvement. She lists numerous improvement opportunities that exist in every provider setting and cites strategies and recommendations that will reduce hospital readmissions.
September 22, 2011: INTERACT II - Joseph Ouslander, MD and Laurie Herndon, MSN, GNP-BC, ANP-BC
This presentation features Joseph Ouslander, MD and Laurie Herndon, MSN, GNP-BC, ANP-BC. Laurie presents on the purpose of the INTERACT II, reviews the key tools in the toolkit, implementation strategies and shares lessons learned. Dr. Ouslander discusses the pilot study of INTERACT, how it evolved and data associated with the intervention.
October 13, 2011: Home Health Quality Initiative Best Practice Intervention Packages - Eve Esslinger, RN, BSN, MS, COS-C
In this presentation, Eve Esslinger, RN, BSN, MS, COS-C, Lead HHQI RN Project Coordinator, describes how to access the Home Health Quality Improvement (HHQI) campaign Best Practice Intervention Packages (BPIPs) and data reports, how to identify HHQI campaign tools and resources that help home health agencies reduce avoidable hospitalizations and improve management of oral medications. She also discusses the impact of the campaign’s success and upcoming Phase III campaign.
October 27, 2011: Care Transitions Intervention℠ - Eric Coleman, MD, MPH
In this presentation, Dr. Coleman discusses the structure, key elements and findings of the Care Transitions Intervenion. He describes the coach roll in this intervention and how it differs from the traditional education role of healthcare providers.
November 3, 2011: Project Boost – Mark Williams, MD, FHM
In this presentation, Dr. Williams describes how we arrived at this point in our healthcare system, demonstrates variability in rates of rehospitalization, outlines key healthcare reform legislation components and reviews how Project BOOST can enhance the hospital discharge transition.
November 17, 2011: Transitional Care Model - Mary Naylor, PhD, RN
In this presentation, Dr. Naylor outlines the case for transitional care, discusses the gaps in care, root causes of poor outcomes and gives a detailed summary of the unique features and core components of the transitional care model.
December 8, 2011: Bridge model - Walter Rosenberg, LSW, Kristen Pavle, LSW and Ilana Shure, LSW
This presentation features the work of the Illinois Transitional Care Consortium in conjunction with numerous community-based organizations and hospitals in developing and testing the Bridge Model—a social-worker led transition care model. Mr. Rosenberg and Ms. Shure describe the framework and key components in detail.
January 12, 2012: Project RED - Brian Jack, MD
In this presentation, Dr. Jack outlines the various issues/errors that occur with hospital discharge, the value and data from Project RED, the RED checklist (eleven mutually reinforcing components) and barriers that he has encountered over the past 10 years of research with this project.
January 26, 2012: GRACE Model - Steven Counsell, MD
In this presentation, Dr. Counsell details the unique features, core components, keys to success and dissemination of this model. Dr. Counsell describes this model as an intensive medical home-type model that is initiated in the primary care office.
Rising to the Challenge: January 13, 2011 – July 28, 2011
January 13, 2011: Identification of Stage D Heart Failure; A Hospice’s Model of Compassion. Presented by Anthony Bolden, MSW, LSW and Donald C. Haas, MD, MPH
Dr. Donald Haas, a private heart failure physician in a New Jersey private practice setting, discusses the difficulty of identifying Stage D heart failure and why failure to recognize patients at this stage has a negative impact on hospital admissions, outcomes, resources and patient care. Anthony Bolden, MSW, discusses the creation of a specialized heart failure hospice program for Stage D heart failure patients. He shares why this specialized hospice model is special, what the benefits are and how it is managed and staffed with cardiac experts. The outcomes and cost savings of this hospice program are substantial.
January 27, 2011: The Use of Community-Based-Interventions to Reduce 30 Day Readmissions: The Good, the Bad, the Ugly. Presented by the Alabama Quality Assurance Foundation, Care Transitions Team.
• Dianne M. Richmond, RN, MSN, APN, Care Transitions Theme Lead
• Sherrie Smith, RHIA, CPHQ, Quality Resource Specialist
• Rashaan Anderson, PhD, MSPH, BS, Quality Resource Specialist
• Nikki Bell-Johnson, RN, BSN, Quality Resource Specialist
• Patricia M. Richetto, RN, BSN, MSN, Quality Resource Specialist
Learn how the Alabama QIO collaborated with their care transitions community in a variety of creative ways to achieve reduced hospital readmissions. You will also learn about their challenges, successes and lessons learned. The hospitals in this project used the Patient Activation Measure (PAM) and the Care Transitions Intervention (CTI) and were very successful in reducing hospital readmission rates.
February 10, 2011: Reducing HF Readmissions - The Creighton Journey Using Project Red Model. Presented by Dianne Hayko, RN, MS and Cathy Jesus, MSW, CSW.
Learn how CIMRO, the NE QIO, collaborated with the Creighton University Medical Center to significantly reduce hospital readmissions using Project Red, without the software component. The key initiative was to reduce HF readmissions and to improve care transitions points including discharge. Listen to how this community formed a team, made system changes and partnered with other providers to achieve their goals.
February 24, 2011: Care Transition Project Impact on SNFs in South Texas. Presented by Janice Toreki, RN, Quality Improvement Consultant, Tammy Lopez, QI Brownsville Nursing and Rehabilitation Center, Dr. Lorenzo Pelly, SNF Medical Director.
Presented by Janice Toreki, RN, Quality Improvement Consultant (TMF, the TX QIO), Tammy Lopez, QI Brownsville Nursing and Rehabilitation Center, Dr. Lorenzo Pelly, SNF Medical Director. Learn how a group of nursing homes in south Texas reduced their hospital readmission rates significantly by focusing on the readmission problem, improving cross-setting communication and collaboration, having access to performance improvement data, implementing best practice interventions to reduce avoidable hospitalizations and having a community Physician Champion that was essential to motivate physicians.
March 10, 2011: Social Network Analysis: How to Find Out What a Proportions of Transitions Table is Really Telling You Presented by Eldon (Bill) Mahoney, PhD
Learn from Bill Mahoney, PhD, Statistician, as he describes the application and value of the Proportions of Transitions Table which he introduced in the 9th SoW to assist the QIOs in the Care Transitions Theme.
March 24, 2011: Physician Necessity: The Mother of Successful Intervention. Presented by Juan Garcia, MD, FACC, FSCAI
Listen and learn from Juan C. Garcia, MD, FACC, FSCAI Diplomat, American Boards of Internal Medicine, Cardiovascular Disease, Interventional Cardiology & Certification Board of Nuclear Cardiology, Miami Heart Center, Miami, Florida as he describes lessons learned with physician engagement to prevent heart failure readmissions from the physician perspective.
April 14, 2011: Assessing a Patient’s Risk at Discharge; Using a Tool to Identify Appropriate Post Discharge Resources. Presented by Laurie Robinson, RN, CPE, CPUR, eQHealth Solutions (LA QIO)
Learn how EQ Health Solutions (LA QIO) collaborated with a healthcare community including hospitals, home health, physicians and a host of other provider settings to design a tool (Discharge Risk Assessment Tool) for early identification of high risk patients to identify appropriate post discharge resources and to improve communication of discharge recommendations with the physicians and the treatment team in their successful effort to reduce hospital readmissions.
April 28, 2011: The 'Rhode Map' - A Snapshot of Rhode Island Providers Approach to Care Transitions. Presented by Nelia Odom, RN, BSN, MBA, MHA; Maria Ducharme, RN, MS, NE – BC; Karen Joost, RN, MS; Susan E. Dugan MA, RN; Jeanne Brockway RN, MSN Ed; and Joan M. Woods, MS, LNHA, FACHCA
Learn how different provider settings in Rhode Island came together to design system changes to make seamless transitions and reduce avoidable hospital readmissions. Hear how a successful hospital connected patients with their community physician prior to discharge, how a home health and hospital partnered together to use technology to support congestive heart failure patients, and how a skilled nursing facility initiated discharge planning started from day one.
May 12, 2011: Collaboration - A Healthcare Imperative between the QIO and ESRD Network (PA QIO). Presented by Judy Stevenson , MSN, CPHQ/ESRD Assistant Executive Director The Renal Network, Inc. and Neil Bowser AIT Central Administration Quality Improvement Coordinator, J. Kane Regional Centers
Learn how the Pennsylvania QIO (Quality Insights) was able to reduce hospital readmissions through working with the End Stage Renal Disease Network 4. In this presentation you will learn how working together they were able to identify the complex care needs of the ESRD patient, identify barriers associated with transitioning ESRD patients across settings and discover the critical components of communication for seamless delivery of care during transitions.
May 26, 2011: Opportunities to Improve Transitional Care in the Atlanta Area. Presented by Nancy Morrison-Director 60+ Program-Piedmont Hospital, Cathy Berger-Director Area Agency on Aging, Sara Moseley RN, MSN-PI Coordinator-Gwinnett Medical Center, Lynne Sycamore, RN, BSN-Patient and Family Education Coordinator.
Learn how three community based intervention models have provided the foundation for expanded care transitions opportunities. Included in this presentation is the Atlanta Regional Commission’s Area Agency on Aging—Healthy Aging Task Force and the care transition services that they provide.
June 9, 2011: Northwest Denver Connected for Health -A Public Narrative: A Story of Self, Us and Now. Presented by Risa Hayes, Project Manger- CFMC, Tom Ventura, Health Data Analyst – CFMC; Breanna Gaetzi - Covenant Care at Home; Gay Delduca, Director of Care Management - Exempla Lutheran Medical Center./p>
Learn how a community of activated care providers came together, and how they were able to reduce hospital readmissions through patient activation using the patient activation measure and the Care Transitions Intervention.
June 23, 2011: Improving the Management of the Heart Failure Patient in the Greater Lansing Community (MI QIO)
Learn how one community in Michigan was able to reduce hospital readmissions by designing processes to appropriately refer for home health services, utilize remote monitoring, improve transition planning, empower patients and caregivers, manage medical co-morbidities and initiate appropriate patient-centered end of life/palliative care discussions.
July 14, 2011: Health Care Excel (IN QIO) Care Transitions: the St. Mary’s Experience, Reducing HF Readmissions. Presented by Dawn Worman, RN-BC, MSN, Sherry Aliotta, RN-BC, BSN, CCM, Don Julian, RPh, and Jan Ernest, RN, MSN, NEA-BC
Learn how one hospital in Indiana focused on heart failure using several different interventions including patient/family engagement, medications adherence using pharmacy students, discharge/case management and follow-up care with physicians, home health agencies, long term and skilled nursing providers to reduce hospital readmissions.
July 28, 2011: Improving Quality and Value Through Re-engineered Care Transitions: The New York Community Approach to Success. Presented by: Sara Butterfield, RN, BSN, CPHQ, CCM, Senior Director, Health Care Quality Improvement, Project Leader, Care Transitions Initiative; Stephen Wright, RN, BSN, MBA, Cardiology Program Director, Ellis Medicine; Theresa Roberts, RN, Quality Improvement Supervisor, Washington County Public Health and Hospice; Colleen Page, RN, CIC, QA, Quality Improvement, Vanrensselaer Manor; and Shawn Galbreath, Executive Director, High Peaks Hospice & Palliative Care.
Learn how multiple provider settings including a hospital CHF program, home health and hospice agency and a nursing home in a five county region in upper New York State were able to reduce avoidable hospital readmissions.
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