To access 2007 – 2010 Learning Session audio or WebEx recordings, please contact the ICPC NCC at
- December 16, 2010 - Lessons Learned and Preliminary Results from the Care Transitions Theme. Presented by: Jane Brock, MD, MSPH and Alicia Goroski, MPH.
In this presentation, Dr. Brock and Alicia share an overview of the Care Transitions Theme: a CMS-funded subnational theme under the QIO 9thStatement of Work, including the importance of community recruitment, engagement, and collaboration in reducing hospital readmissions, preliminary results from 14 communities engaged in Transitional Care Improvement and the key successes and challenges of this work.
- November 18, 2010 - HHQI Campaign, Cross-setting BPIP and review of the HHQI Website. Presented by: Eve Esslinger Please see the new and updated BPIP learning session presented on October 13, 2011.
- October 28, 2010 - From Vision to Victory: Creating Safe, Smooth, and Sustained Transitions, Every Patient, Every Time. Presented by: Karen Zander, RN, MS, CMAC, FAAN
This presentation describes the components of Wrap-Around Case Management Services. This case management discharge model includes 4 phases of implementing 10 non-negotiable standards and practices.
- September 23, 2010 - PharmD/NP Model of Home-Based Primary Care: The Impact on Hospital Recidivism. Presented by: RevolutionCare, Inc: Jeannette Kates, MSN, APNC, PhD Candidate, Robert Alesiani, PharmD, and Ed Fleegler, MD, FACP
This presentation describes a Nurse Practitioner (NP)/Doctor of Pharmacy (PharmD) collaborative primary care model for medically isolated seniors. NP driven house call practice improves overall patient outcomes by integrating pharmacotherapy support into its daily practice. The approach has also been shown to improve disease‐related outcomes and quality of life, increase patient adherence to medications and improve chronic disease control, without higher costs, boost well‐being by reducing anxiety and depression, and promote patient access and self‐efficacy, address racial, ethnic, and socioeconomic disparities in care and outcomes, and reduce diagnostic‐testing costs in primary care and decrease lawsuits against clinicians.
- August 26, 2010 - The ReConnect Leadership Program presented by Brendan Bird at St. Anthony Hospital in Denver
This presentation describes the ReConnect Leadership Program at St. Anthony Hospital, a volunteer based model of improving care transitions and providing increased quality of life to their patients. Brendan describes how they establish communication with patients after they leave the hospital and a variety of the services they provide and assist with. He describes the funding as well as the improved hospital readmissions that have occurred as a result of this program.
- July 22, 2010 - "Chronic Care Management Pilots Show Early Promise" presented by Candace (Candy) Goehring MN RN, Unit Manager, WA Aging and Disability Services Administration, Home and Community Programs
This presentation details a tailored client coaching approach where the client is in charge of the care plan. The nurse’s role is to encourage client confidence, discuss and offer options and education that allow the client to increase their ability to manage their own healthcare to improve quality of life/health outcomes and to ask the client what ideas they have to better manage that care. Key findings are discussed as well as improved outcomes for those in the intervention.
- June 24, 2010 - "Getting Back to the Basics - What Drives My ACH Rate." Presented by Deb Perian, Bayada Nurses, Inc.
In this presentation, a home health agency discusses teamwork, best practices, and chart audits to develop interventions to reduce acute care hospital readmissions. As a result of their audits, this agency found that no specific physicians were responsible for transfers, some less experienced clinicians required more guidance and some clinicians required additional coaching related to documentation.
- May 27, 2010 - "Examining Complicated Transitions in Stroke Patients: Predictors, Outcomes and the Role of Race"
Presented by Amy Kind, MD, University of Wisconsin School of Medicine and Public Health
In this presentation, Dr. Kind discusses predictors of complicated transitions in stroke, role of race, one-year mortality and cost outcomes, reasons for 30-day rehospitalizations , post-hospital communication in stroke and future directions.
- April 15, 2010 -" Palliative Care: Facilitating Transitions Across Care settings, Care Providers and Goals of Care." Presented by Jean S. Kutner, MD, MSPH, University of Colorado Denver School of Medicine.
In this presentation, Dr. Kutner’s objective is for healthcare providers to understand how palliative care can facilitate care transitions. The benefits of palliative care include decreased pain and other distressing symptoms, increases in patient and family satisfaction, ease of transitions between care settings, promotion of more efficient use of hospital resources, decreased length of hospital and ICU stays, lower costs by increasing through-put and capacity for acute care admissions and improved staff retention.
- March 3, 2010 - H2H and the Medicare QIO Care Transitions Project Present the next H2H Webinar:
"339 Days in the Life of Mrs. B - A Medicare Beneficiary". Presented by Jane Brock, MD, MSPH.
Dr. Brock presents a thought provoking scenario using claims data to show the fragmented care of a typical Medicare patient with chronic illness and provides solutions that could improve care transitions in this population.
- February 25, 2010 - Achieving Improved Community Health Outcomes: Application of the Community Coalition Action Theory (CCAT). Presented by Teresa Titus-Howard, MSW, MHA , Centers for Medicare and Medicaid Services.
This presentation features information pertaining to a research project on the CCAT and invites QIOs to join in the effort.
- January 14, 2010 - "The Stroke Rehabilitation Journey" Staying on the Road to Recovery. Presented by Linda Doerflein and Barbara Rutkowski, HealthSouth Deaconess Rehab Hospital.
This presentation describes how one rehab hospital was able to reduce acute care readmissions and achieve maximal functional independence for their stroke patients.
- November 12, 2009 - Patient Screening Project - Information Sharing WebEx.
Presented by Diane Holland, PhD, RN, Mayo Clinic and Kathy Bowles, PhD, RN, FAAN, University of Pennsylvania
Kathy Bowles, PhD, RN, FAAN, University of Pennsylvania
This presentation describes a research study done to demonstrate that patient outcomes improve when decision support tools are introduced into discharge planning practice for elderly patients. The researchers suggested interventions to prevent these re-admissions include identifying high risk patients before discharge and devising new approaches to follow-up.
- October 22, 2009 - Partnering with the Continuum of Care to Create a Person-Centered Experience - Heidi Gil, Continuing Care Director, Planetree
Planetree was founded in 1978 with a vision of creating person-centered care and a holistic approach to long-term care. This presentation brings you through their journey and explains the philosophy and goals of this organization.
- October 8, 2009 - Ask Medicare - Presented by M. Cora Tracy, J.D., Centers for Medicare & Medicaid Services (CMS)
This presentation describes the “Ask Medicare” strategies which include establishing unifying messages around caregiving, amplified through integrated outreach including partnerships, advertising, and media outreach (social media and traditional media), bringing important information directly to caregivers through multiple communications channels including the Ask Medicare website and e-newsletter, and a variety of print publications and engaging partners as messengers and providing them with value added resources.
- September 24, 2009 - Pennsylvania Care Transitions Coaching: Our Journey
Presented by: Mary Harris, MSW; Care Management Unit Supervisor, Southwestern Pennsylvania Area Agency on Aging, Christine Baloh, MSW; Director of Social Services, Monongahela Valley Hospital and Beverly A Legath, RN, BSN, CCM; Manager, Clinical Resource Management Excela Health System, Westmoreland Hospital.
Learn how a Pennsylvania healthcare community partnered with the local AAA to achieve success in reducing hospital readmissions. You will learn how the AAAs work within the community and how they are willing to collaborate with QIOs to improve care transitions.
- September 10, 2009 - Care Transitions Performance Measures: Promoting Better Inpatient and Emergency Department Discharges. Presented by Mark Antman, DDS, MBA Senior Policy Analyst III, Clinical Performance Evaluation, American Medical Association.
In this presentation, Dr. Antman presents the care transitions performance measures from June 2009 by the Physician Consortium for Performance Improvement® (PCPI).
- August 27, 2009 - Daniel Johnson, MD, FAAHPM, Director, Life Quality Institute, Regional Department Chief, Palliative Care, Kaiser Permanente-Colorado - Palliative Care
In this presentation, Dr. Johnson explains what palliative care is and how successful Kaiser has been with this program in the care transitions process. The results have shown increased patient satisfaction, decreased hospital readmissions and decreased healthcare costs.
- July 23, 2009 - Legislative Updates related to Care Transitions. Rohini Ravindran, MA, Legislative Health Policy Advisor, Office of Senator Michael Bennet; David Schulke, Executive Vice President, American Health Quality Association; Jane Brock, Medical Officer, CFMC
In this discussion, the presenters give an up-to-date overview of the care transitions legislation that was occurring during this time frame.
- July 9, 2009 - Nicole McElveen, Program Director- NQF Care Coordination Project - Care Coordination Framework
In this presentation, you will learn about the NQF care coordination framework, how they endorse practices and measures, the purpose and scope of the project, identifying gaps and what the next steps will be.
- June 25, 2009 - W. June Simmons, CEO, Partners in Care Foundation - New Models of Care: Promoting Health and Managing Chronic Conditions
In this presentation, Ms. Simmons discusses new models for healthcare so that there can be reallocation of existing dollars from care to prevention and promoting health, strengthen community and home care to reduce use of institutions and reduce fragmentation.
- May 28, 2009 - Monique Parrish, DrPH, MPH, LCSW, LifeCourse Strategies - California Pilot Project - Implementation of the Care Transitions Intervention
Learn how a group of providers at 10 different sites implemented the Care Transitions Intervention, built a learning collaborative and how they evaluated the efficacy of the intervention as well as opportunities for sustainability and wider implementation.
- May 14, 2009 - Carol Levine, Director, Families and Health Care Project - Navigating Health Care Transitions as a Family Caregiver
Learn how the Next Step in Care provides easy-to-use guides to help family caregivers and health care providers work closely together to plan and implement safe and smooth transitions for chronically or seriously ill patients.
- April 23, 2009 - Chad Boult, MD - Guided Care Nurse Model
In this presentation, Dr. Boult describes the Guided Care Nurse Model which is initiated by specially trained RNs and based in primary physicians’ offices. These nurses collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs.
- February 26, 2009 - Judith Hibbard & Bill Mahoney - Patient Activation Measure and Care Transitions Study
Learn how the patient activation measure can have an impact in activating consumers to have the knowledge, skill and confidence to take on the role of managing their health and health care. The presenters discuss the PAM tool and how the application of the tool has an impact in care transitions.
- December 11, 2008 - Michael P. Silver, MPH - Keeping Patients at Home – A Home Health Performance Improvement Pilot
This pilot was initiated with a three year AHRQ grant to demonstrate reductions in risk-adjusted ACH rates and target identified causes of preventable hospitalizations. The presenter discusses key findings, root causes and benefits of participation for home health agencies.
- November 20, 2008 - Parish Nurse Ministries of New York Inc. & Stall Geriatrics, LLC - Niagara University Nursing Program
This learning session demonstrates that Parish Nurses, acting as transition coaches, can help maintain frail elderly in their homes following an acute hospital stay, subacute rehabilitation, or formal home care to reduce rehospitalizations and emergency room utilization.
- October 30, 2008: Joanne Lynn, MD - Using Population Segmentation to provide Better Health Care for All: The " Bridges to Health" Model
In this presentation, Dr. Lynn divides the population into eight groups: people in good health, in maternal/infant situations, with an acute illness, with stable chronic conditions, with a serious but stable disability, with failing health near death, with advanced organ system failure, and with long-term frailty. Each group has its own definitions of optimal health and its own priorities among services. Interpreting these population-focused priorities in the context of the Institute of Medicine’s six goals for quality yields a framework that could shape planning for resources, care arrangements, and service delivery, thus ensuring that each person’s health needs can be met effectively and efficiently. Since this framework would guide each population segment across the institute’s “Quality Chasm,” it is called the “Bridges to Health” model.
- September, 11, 2008: Mary Perloe, RN, MS, GNP - Improving Nursing Home Care by Reducing Avoidable Acute Care Hospitalizations.
In this presentation, Ms. Perloe describes the CMS special study with Georgia nursing homes using the Interact Toolkit to reduce acute care transfers and hospitalizations. You may also refer to the most recent learning session on this toolkit that was presented on September 22, 2011.
- July 24, 2008: Cheri Lattimer - Coordinating Transition As The Collaborative Team: Patient, Caregiver & Provider
In this presentation, you will learn about coordinating transitions across multiple provider settings and the barriers that healthcare workers and patients/families face during transitions of care. Ms. Lattimer is Project Director of the National Transitions of Care Coalition (NTOCC) and its multidisciplinary team of health care leaders that work to address complex issues like health literacy, patient safety and non-adherence.
- July 17, 2008: Vanessa Flint, MPH, MBA - Discharge Planning Checklist
In this presentation, Ms. Flint reviews the CMS developed discharge planning checklist. The checklist can be accessed at this site: http://www.medicare.gov/publications/pubs/pdf/11376.pdf
- July 10, 2008: W. Kline Bolton, M.D., FASN and Alvin H. Moss, MD - End-Stage Renal Disease
In this presentation you will learn about the incidence, prevalence, mortality and high healthcare utilization rates of CKD patients. Dr. Moss describes the relevance of palliative care for ESRD patients, identifies dialysis patients appropriate for palliative care using the “surprise” question and the Charlson Comorbidity Index and discusses the underutilization of hospice for dialysis patients, reasons for the low referral rate and potential cost savings. He also gives information on the national Kidney End-of-Life Coalition as a resource for hospice.
- June 26, 2008: Mary Fermazin, MD, MPA - Improving Care Transitions, Measuring Progress
In this presentation, you will learn how the NTOCC workgroup began to develop measures for improving care transitions. Dr. Fermazin will walk you through developing a framework for measurement, evaluating existing measures, assess gaps and develop recommendations to fill measure gaps.
- June 19, 2008: David Goodman, MD MS - Defining Populations and Providers for Measuring Health Care
In this presentation, Dr. Goodman defines how populations and providers are measured using Hospital Referral Regions, Hospital Service Areas and Primary Care Service Areas. He also discusses variation in per-capita Medicare spending across hospital referral regions. These data can be accessed at: www.dartmouthatlas.org
- June 12, 2008: Lori A. Gerhard, CASP, NHA - AAA’s and ADRC’s Role in Care Transitions
In this presentation, you will learn the goals, services and mission of the aging network as well as their role in the community to provide for safe transitions.
- June 5, 2008: Lori Nichols, Marc Pierson, MD - Explore the Shared Care Plan PHMS; Implementation in Your Community; How Does HealthVault Fit In?
HealthVault provides individuals to collect, store, and share their health information. It is a shared data platform that allows multiple applications to work with a person’s health data to improve health management and outcomes. In this presentation you will learn how this platform could work for consumers.
- May 29, 2008: Michael P. Silver, MPH - Causes of Avoidable Hospitalization in Home Health Preliminary Results from a Field Study
In this presentation, Mr. Silver introduces probabilistic risk assessment (PRA) as a systems and process analysis tool, describes the application of PRA in a clinical setting and reviews preliminary findings from system-based review of unplanned hospitalizations from the home health setting.
- May 22, 2008: Maulik S. Joshi, Dr.P.H. - Local Action for National Transformation and Harold D. Miller - Reducing Hospital Admissions by Transforming Chronic Care
Dr. Joshi discusses the role of the Network for Regional Healthcare Improvement--to accelerate improvement in the value (quality and cost) of healthcare delivery in the United States, by building and strengthening regional, multi-stakeholder coalitions and influencing national policy for regional coalitions. He talks about regional collaboratives that are making progress in making transformational improvement in healthcare. One of those collaboratives is the Pittsburgh Regional Health Initiative to reduce hospital readmissions for patients with chronic disease. Dr. Miller details the work that that was done in the Pittsburgh community.
- May 15, 2008: Judith Tobin, PT, MBA - CARE (Continuity Assessment Record & Evaluation) Overview
In this presentation you will learn about the evolution and purpose of the CARE tool.
- May 8, 2008: Stephen F. Jencks, MD, MPH - Rehospitalization: The Scope of the Problem
The presentation features Dr. Jencks and the research he has done about hospital readmissions.
- May 1, 2008: Marc Pierson, MD, Bill Mahoney, PhD, Lori Nichols - Transitional Care Whatcom County Perspectives
- April 24, 2008:Gail A. Nielson, BSHCA - Creating an Ideal Transition Home for Patients with Heart Failure
- April 17, 2008: Patricia Sodomka, FACHE - Sharing the Patient- and Family-Centered Care Experience at the Medical College of Georgia
- April 10, 2008: Brian Jack, MD, Testing the Re-Engineered Discharge
- April 3, 2008: Jennifer L. Wolff, MHS, PhD, Family Involvement in Transitional Care Among Medicare Beneficiaries
- March 27, 2008: VALUE Project Final Results (CO and NM)
- March 20, 2008: VALUE Project Final Results (CA and NJ)
- March 13, 2008: Chad Boult, MD, MPH, MBA, The Guided Care “Medical Home” for High-Risk Beneficiaries
- March 6, 2008: Joseph G. Ouslander, MD, Improving Nursing Home Care by Reducing Avoidable Acute Care Hospitalizations and Mary Jane Koren, MD, MPH, Safely Preventing Hospitalization of NH Residents
- February 28, 2008:Nan Holland, PGP Demonstration Project - Factors Influencing Performance Year 1 Quality & Efficiency Results
- February 21, 2008: Richard D. Brumley, MD, Palliative Care Across the Continuum Kaiser Permanente
- February 14, 2008: Re-Designing Health Care for Quality: The Case for Investing in System-wide Quality Improvement, Continued
Handouts are the same as the previous call
- February 7, 2008: Bonnie Brossart, Chief Executive Officer, Health Quality Council in Saskatchewan, Canada - Re-Designing Health Care for Quality: The Case for Investing in System-wide Quality Improvement
- January 31, 2008: Dr. Jane Brock (CFMC) and Mark Gottlieb, PhD (NMMRA) - Developing Metrics for VALUE
- January 24, 2008: Donald E. Casey Jr., MD, MPH, MBA, FACP - Findings from the CHP "HF GAP" initiative and Atlantic Health's Approach to Palliative Care
- January 17, 2008: Donald M. Berwick, MD, MPP, FRCP - Eating Soup with a Fork
- January 10, 2008: Joseph Lau - “Non-pharmacological Peri Discharge Interventions and Outcomes in Heart Failure (HF)"
- January 3, 2008: Thomas Edes, MD, MS - VA Home Based Primary Care
- December 20, 2007: Eric Coleman MD, MPH - Care Transitions Intervention
- December 13, 2007: Shannon Brownlee - "Overtreated"
- December 6, 2007: Mary Naylor PhD, RN - Transitional Care Model