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  • Solving a Puzzle: Invoicing for Patient Encounters with the San Diego CCTP – MediCaring.org
    be meaningful for us as well That s how our Manual Invoicing Process was born I ll be completely honest this invoicing baby is less than attractive Alright it s downright ugly Picture this an Excel worksheet 41 columns long With no margins and at a scale of 75 the worksheet still prints out on six 6 legal size pages And that s just to capture the data we need for managing and tracking our List Bills It doesn t include the additional 32 columns that we use for capturing other data elements such as Reason for Non Enrollment or Reason for Withdrawal Now factor in the fact that at full capacity we ll be maintaining these data for 13 hospitals and roughly 21 000 patients year What fun the manual process will be then Like I said it isn t pretty But it does work and it seems to work well We may even be sad to see the manual process go not likely when it s replaced by our web based invoicing and data collection system ALEX I ll share more about ALEX in a later post The format of the List Bill led to our second invoicing challenge Considering our size there s no way we can manage all of our List Bills by entering them one by one using the List Bill template Aside from increasing the risk for data entry errors entering all of the List Bills manually would be a more than full time job for several people Since that isn t an option it was back to the drawing board Here we had some help Reaching out to our Project Officer and other CCTP sites we asked if anyone had successfully submitted a List Bill in a format other than the List Bill template Our call was answered by the Southwestern Ohio CCTP They had figured out the Excel formulas needed to convert data into the format s that would meet Gentran s requirements Gentran is the online application for submitting List Bills to CMS With a little tweaking we ve tailored those formulas and added a few of our own to convert the information collected on our Manual Invoicing worksheet With just a little copy and paste action of data and formulas we re now able to create a List Bill for all of our patients in 10 15 minutes It doesn t matter if we have 1 or 1 000 the timeframe is the same Around here we call that a success Ms Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership This is part of our regular series on San Diego s experiences launching its CCTP work Key words CCTP CMS Medicare care transitions quality improvement hospital readmissions frail elders San Diego County Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em

    Original URL path: http://medicaring.org/2013/05/29/solving-a-puzzle-invoicing-for-patient-encounters-with-the-san-diego-cctp/ (2016-04-30)
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  • San Diego County – MediCaring.org
    formulas needed to convert data into the format s that would meet Gentran s requirements Gentran is the online application for submitting List Bills to CMS With a little tweaking we ve tailored those formulas and added a few of our own to convert the information collected on our Manual Invoicing worksheet With just a little copy and paste action of data and formulas we re now able to create a List Bill for all of our patients in 10 15 minutes It doesn t matter if we have 1 or 1 000 the timeframe is the same Around here we call that a success Ms Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership This is part of our regular series on San Diego s experiences launching its CCTP work Key words CCTP CMS Medicare care transitions quality improvement hospital readmissions frail elders San Diego County A Shift Happens Care Transitions Lessons from San Diego County Posted by Janice Lynch Schuster on May 8 2013 2 Responses Tagged with care transitions CCTP CMS frail elders readmissions San Diego County May 08 2013 Today we introduce a new series of posts that will describe the experiences of San Diego County as it rolls out its Community based Care Transitions Project CCTP funded by the Centers for Medicare and Medicaid Services CMS Carol Castillon who manages the project will share stories about the work its successes and challenges and what the team learns along the way The project is one of the largest in the program We hope this series encourages and inspires others and that you will share your stories too Look for the posts on the 1st and 3rd Wednesday of each month Thank you Carol for sharing your insights By Carol Castillon The County of San Diego s Health and Human Services Agency Aging Independence Services AIS in partnership with Palomar Health Scripps Health Sharp HealthCare and the University of California San Diego Health System has received CCTP funding from the Centers for Medicare and Medicaid Services CMS The project which launched in January will use those funds to provide innovative care transitions services countywide to up to 21 000 high risk Medicare patients in 13 hospitals All partners will test an intervention called Care Enhancement To appreciate the scope of this endeavor keep in mind that each Care Enhancement worker is assigned to a specific hospital but must also provide coverage to various other hospitals across the different systems As the project s common intervention we ve learned to adapt our approach to each hospital culture to ensure consistency across the services provided The Care Enhancement intervention offers patients and their caregivers critical social support services either by referral or direct provision of support services that can reduce the risk of an avoidable readmission A Care Transitions coach a nurse completes a risk assessment which can trigger the referral to the Care Enhancement team The Care Enhancement worker is then required to make

    Original URL path: http://medicaring.org/tag/san-diego-county/ (2016-04-30)
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  • No Disrespect: How Family Caregivers Can Improve Care Transitions – MediCaring.org
    with certain tasks notably wound care assisting with the use of incontinence equipment and preparation of special diets Helping a family member or friend cope with a colostomy is not a traditional ADL Activity of Daily Living Reinhard said The ADL assessment instrument which focuses on basic non medical assistance with eating dressing toileting bathing and transferring was originally developed in the 1950 s as a way of measuring the help that patients recovering from hip fractures needed Mary Naylor a professor and researcher at the University of Pennsylvania School of Nursing argued that in the era of the age wave providers should reframe their professional perspective to see themselves in part as enablers of patients and family caregivers Both Eric Coleman professor of medicine at the University of Colorado and Luke Hansen professor of medicine at Chicago s Northwestern University noted that it is still uncommon for physicians and hospitals to collect any data on family caregivers and even rarer to train them This presents problems they acknowledged in making various improvements in the care system stick Feminist author and caregiver Alix Shulman suggested that it is precisely the lack of anticipatory guidance or training which individuals who choose to make major changes to their lives in order to assist a seriously ill or disabled loved one find most difficult of all Specific conversations are needed she said Not just a list of websites or a stack of brochures UHF s David Gould and Carol Levine urged researchers and policymakers to join together to support caregiver assessments that include documentation of both the needs and limitations of caregivers as part of the routine delivery of health and long term care services Also needed they said are regular surveys of both the patient and the family caregiver s experience with services as well as a more sophisticated and systematic approach to identifying the networks of family friends and neighbors who come together to form a caregiver corps or circle of support that can be assembled to collectively provide the right level of help at the right time Making the necessary adaptations to our rapidly evolving health and long term care services systems in order to cost effectively train large numbers of people who may be willing to volunteer some of their time to assist those who wish to age in place is not a simple matter Perhaps one way to move a conversation forward is to consider whether the Center for Elder Care and Advanced Illness concept of a Caregiver Corps of trained volunteers can be created to help teams of health care practitioners and direct care workers deliver a more seamless array of services and supports while also giving families the confidence that they will be able to sustain assistance for the millions of frail elders and individuals with disabilities who want to remain a vital part of the community right up until the ends of their lives Such a Corps which would recruit volunteers young and old would

    Original URL path: http://medicaring.org/2013/05/23/no-disrespect-how-family-caregivers-can-improve-care-transitions/ (2016-04-30)
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  • Eric Coleman – MediCaring.org
    require serious work In a call to action Feder declared The support of caregivers should not be merely assumed but rather it must be thoughtfully considered We need to turn this around and get past the lip service Others at the UHF conference titled Transitions in Care 2 0 which culminated in the release of a ten step action agenda were in full agreement Susan Reinhard Senior Vice President of AARP s Public Policy Institute observed that the recent AARP UHF survey documents that more than two thirds of respondents report significant difficulty with certain tasks notably wound care assisting with the use of incontinence equipment and preparation of special diets Helping a family member or friend cope with a colostomy is not a traditional ADL Activity of Daily Living Reinhard said The ADL assessment instrument which focuses on basic non medical assistance with eating dressing toileting bathing and transferring was originally developed in the 1950 s as a way of measuring the help that patients recovering from hip fractures needed Mary Naylor a professor and researcher at the University of Pennsylvania School of Nursing argued that in the era of the age wave providers should reframe their professional perspective to see themselves in part as enablers of patients and family caregivers Both Eric Coleman professor of medicine at the University of Colorado and Luke Hansen professor of medicine at Chicago s Northwestern University noted that it is still uncommon for physicians and hospitals to collect any data on family caregivers and even rarer to train them This presents problems they acknowledged in making various improvements in the care system stick Feminist author and caregiver Alix Shulman suggested that it is precisely the lack of anticipatory guidance or training which individuals who choose to make major changes to their lives in order to assist a seriously ill or disabled loved one find most difficult of all Specific conversations are needed she said Not just a list of websites or a stack of brochures UHF s David Gould and Carol Levine urged researchers and policymakers to join together to support caregiver assessments that include documentation of both the needs and limitations of caregivers as part of the routine delivery of health and long term care services Also needed they said are regular surveys of both the patient and the family caregiver s experience with services as well as a more sophisticated and systematic approach to identifying the networks of family friends and neighbors who come together to form a caregiver corps or circle of support that can be assembled to collectively provide the right level of help at the right time Making the necessary adaptations to our rapidly evolving health and long term care services systems in order to cost effectively train large numbers of people who may be willing to volunteer some of their time to assist those who wish to age in place is not a simple matter Perhaps one way to move a conversation forward is to consider

    Original URL path: http://medicaring.org/tag/eric-coleman/ (2016-04-30)
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  • care transitions – Page 2 – MediCaring.org
    15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm These calls are open to all please invite anyone who wants to learn along with us As a reminder these sessions are recorded and all previous Learning Sessions are available at http www cfmc org integratingcare learning sessions htm key words QIOs CFMC care transitions community coalition CCTP CMS Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions Posted by Janice Lynch Schuster on April 23 2013 No Responses Tagged with care transitions CCTP coalition building Coleman Model community based discharge planning eldercare hospital readmissions Naylor Model rehospitalization Apr 23 2013 by Benjamin Kuder Every Community based Care Transitions Program CCTP in the country of which there are now 102 funded by the U S Centers for Medicare and Medicaid CMS aims to balance targeted evidence based interventions to patient needs CCTP teams know that every avoidable readmission has a story behind it The Area Agency on Aging 1 B AAA 1 B seeks to meet care transitions needs for elders in two of their counties Oakland and Macomb with an innovative multilayer strategy CMS directed communities applying to participate in the CCTP to conduct a root cause analysis so that they could build a CCTP that meets community needs The AAA 1 B found that it could deliver the highest priority services by dividing the population based on five clinical needs 1 Care Transitions Intervention CTI Coaching Following the self activation model developed by Dr Eric Coleman this strategy empowers participants with coaching that helps them find the strategies that enable the patient to take charge of recovery and achieve personal goals Through increased health literacy and greater confidence individuals with chronic conditions are better able to make decisions about their care and recovery and insist that clinicians provide appropriate help 2 CTI Coaching with Behavioral Intervention Many patients experience mental health issues such as depression anxiety and serious mental illnesses which contribute to frequent readmissions In this strategy a behavioral health coach works with patients to provide support and mitigate some of the problems that can hinder recovery 3 CTI Coaching with In Home Services This strategy provides coaching and referrals to in home services such as meal delivery or transportation to the doctor which help reduce risk of readmission 4 Coaching with Multiple Interventions Hospice Coaches connect with patients who have little family support and who do not want home care or hospice and try to reconnect them with supportive services and initiate longer term care planning 5 Skilled Nursing Facility SNF Transitions Coaching Skilled nursing facilities in the area had especially high readmission rates so this strategy provides coaching for better transitions from the hospital to the SNF and from SNF to home Coaches meet with participants and their caregivers before hospital discharge again shortly after nursing home admission and then shortly before discharge from the SNF In addition the coach also discusses differences between the nursing home and hospital how to pursue personal goals and how to find help to achieve these goals at the nursing home The coach also works with the participant and caregiver to complete the personal health record modified for the SNF and encourages them to participate in the care plan meeting The coach also engages hospital and nursing facility partners to increase communication and improve shared processes Tailoring these strategies to the five distinctive categories of patients allows AAA 1 B to provide high value transitions coaching to virtually everyone Many of the coaches say people have been dealing with chronic conditions so long and no one has asked them their opinion on their plan of care says Barbra Link director of care transitions for AAA 1 B Coaches help them to get tools to self activate That s the most powerful thing That s the foundation of the program Participants in the program must be referred from AAA 1 B s partner hospitals have traditional Medicare and either have one of the targeted conditions chronic obstructive pulmonary disease heart attack pneumonia or congestive heart failure or any condition with a readmission within the last 90 days The AAA 1 B Care Transitions Coach assigns each beneficiary to a category using a risk assessment completed by the hospital s care management team The program also allows Strategy 1 Coaches to refer the participant to a Specialty Coach Strategy 2 Strategy 4 and Strategy 5 when appropriate All coaches provide Strategy 1 and Strategy 3 Coaching but may consult with Specialty Coaches whenever needed The AAA 1 B project is about 10 months into its initial two years with the possibility of renewal for the following three years All five strategies are operating and 650 beneficiaries have enrolled Although the first strategy has the highest volume of people 67 percent the other strategies are proving to be just as important for elders who need more support The CCTP team quickly recognized that project leaders and staff must watch for problems that call for different remedies For example when AAA 1 B leaders observed that many of the program s vulnerable elders did not understand their nutrition needs they reached out to a nutritionist at a partner hospital to develop simple accessible one page flyers for patients regarding nutrition One flyer explained how

    Original URL path: http://medicaring.org/tag/care-transitions-2/page/2/ (2016-04-30)
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  • evaluation – MediCaring.org
    costs For example if one program reduces hospital utilization by 1 000 hospitalizations per year in an area where Medicare s average hospitalization cost is 15 000 then it saves 15 000 000 per year CMS pays community based organizations a modest fee around 300 per intervention patient The CCTP program would have to be serving 30 people to prevent one readmission in order to break even Clearly the ratio is likely to be more like 10 or 15 people to save one readmission and get a return on investment of 2 1 This suggests that the return on investment with even modest success is wildly favorable and would be so at virtually any revised estimate of cost and effectiveness which an evaluation could provide So why does the evaluation not address these central issues Further there is no reason why a 20 reduction in the now thoroughly discredited readmissions discharges ratio is the best target A more informative target would clearly focus on providing a reliable well characterized set of services that work to the advantage of patients and families and that also reduces total costs The CCTP program and other efforts to improve care transitions have already met that criterion so the question now needs to be What are the next prudent steps for health care managers and policymakers To answer that question it makes sense to look to the other recently released evaluation of readmissions work developed for the Partnership for Patients http innovation cms gov Files reports PFPEvalProgRpt pdf This report claims that readmissions reductions may have saved Medicare 2 8 billion out of 3 1 billion saved by all of the hospital acquired conditions reductions Table 3 in the report but this presentation only attributes improvement to the Partnership for Patients PfP and its Hospital Engagement Networks HENs The CCTP the hospital penalties under the Hospital Readmissions Reduction Program and the QIO s extensive work in supporting community efforts are not mentioned let alone cited as possible parts of the causal chain The metrics supporting the claim of gains pages 3 2 and 3 3 are similarly inconsistent One figure uses 30 day readmissions discharges in Medicare one uses the QIOs readmissions 1 000 beneficiaries per quarter but does not report any statistical tests and one uses the hospital reported 30 day all cause all payer readmissions discharges The report aims to have the reader believe that the PfP and the HENS generated a number of positive results including saving money On closer inspection however it becomes clear that the authors are counting the reductions in admissions as well as the reductions in readmissions in estimating the savings a tacit admission that at least some people at CMS recognize that good practices in transitions and in longer term community support reduce both the numerator and the denominator in the readmissions discharges metric There are other evaluations to come with some presumably already in the works Many site visits have been made and much data are

    Original URL path: http://medicaring.org/tag/evaluation/ (2016-04-30)
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  • IMPACT’s Impact on Quality Measurement for Frail Elders – MediCaring.org
    of us become more aware with age that we are working with a truncated timeline and long term outcomes are no longer relevant For that and other reasons many additional considerations start crowding the stage Some want to be sure that a disabled adult son has assets to live on others have no dependents Some want to honor their faith traditions others want to solidify their departure from those beliefs The endless variations make it impossible to have one care plan that fits all people So why do we now measure quality for frail elderly people as if everyone wanted mainly just to live longer with better health Often our metrics just comply with professional mostly physician guidelines on how to take care of somewhat younger bodies People become more and more individualized with their particular family finances dreams and fears as they age We really must learn to measure the quality of health care by the degree to which it serves the individual s priorities We must learn to ask What matters to you and what matters most to you and to judge quality by how well the services actually deliver on what matters most Could we do that Sure First we need to document what matters most to the frail elderly person and family and what strategies will most likely accomplish the feat commonly termed an assessment and care plan Then we need to measure whether the elderly person and family as appropriate feels that the services help to achieve what matters most We could start with a simple scale Working against my interests Not clear or not particularly helpful and Completely or mostly aligned with what matters to me We would learn how to do it better but the important thing is to start caring about what matters to the individual person Of course some things are important to so many people that we might learn to measure them across the frail elder population Metrics of what really matters to me could include for example the rate at which the care system spends down my financial assets the likelihood that I can stay in my home as long as I want to my confidence in having adequate preparation for adverse events and adequate backup for challenges and the stress that my family and friends feel as they try to ensure that I have what I need Most people care about avoiding falls and injuries and living where they want to live While we are at it let s start measuring important things about family caregivers availability skills stresses and challenges These are what most often really matter when you are living your last years with disabilities and limitations How different this is from the usual percentage with diabetes under control or percentage with colon cancer screenings Let s do what we can to help CMS commit to building the metrics that we need Here are some suggestions Contact the organizations to which you belong and encourage them

    Original URL path: http://medicaring.org/2014/10/28/impacts-impact/ (2016-04-30)
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  • CMS – Page 2 – MediCaring.org
    for the functional decline that is often associated with a hospital admission often not fully appreciating how depleted they are until they actually get home To respond to this CCTP has engineered a merging of the hospital and home perspectives My organization AIS is a real partner in this process we have had the opportunity to collaborate closely with each hospital One of our approaches has been to participate in bi weekly internal meetings or huddles We use these meetings to debrief one another about patients smooth work flow processes review data to ensure that we are on target to meet performance targets present success stories and conduct a root cause analysis whenever a patient is readmitted These meetings are truly multidisciplinary and include all members of the partnership assigned to a particular hospital As we go around the table and discuss our pre and post discharge interventions we have found that our feedback circle is gaining a presence of its own The feedback circle enables us to bridge the clinical to home environment in ways we have not experienced before We are able to immediately feed information back to hospitals about successes accomplishments and challenges In some cases the feedback circle has even enabled hospitals to change internal processes The home assessments conducted by our CTI Coaches and Care Enhancement Social Workers are beginning to be incorporated into the patient s hospital medical records and even into primary care physician s records We ve had physicians contact our coaches to commend the CCTP team on a job well done One particular physician was amazed in how much a patient had changed and even commented You guys have done more for this patient with your interventions than I could ever do Such feedback is almost music to our ears Carol Castillon works with AIS to manage the San Diego CCTP key words CCTP care transitions evaluation feedback loops quality improvement community partnerships San Diego A Shift Happens Care Transitions Lessons from San Diego County Posted by Janice Lynch Schuster on May 8 2013 2 Responses Tagged with care transitions CCTP CMS frail elders readmissions San Diego County May 08 2013 Today we introduce a new series of posts that will describe the experiences of San Diego County as it rolls out its Community based Care Transitions Project CCTP funded by the Centers for Medicare and Medicaid Services CMS Carol Castillon who manages the project will share stories about the work its successes and challenges and what the team learns along the way The project is one of the largest in the program We hope this series encourages and inspires others and that you will share your stories too Look for the posts on the 1st and 3rd Wednesday of each month Thank you Carol for sharing your insights By Carol Castillon The County of San Diego s Health and Human Services Agency Aging Independence Services AIS in partnership with Palomar Health Scripps Health Sharp HealthCare and the University of California San Diego Health System has received CCTP funding from the Centers for Medicare and Medicaid Services CMS The project which launched in January will use those funds to provide innovative care transitions services countywide to up to 21 000 high risk Medicare patients in 13 hospitals All partners will test an intervention called Care Enhancement To appreciate the scope of this endeavor keep in mind that each Care Enhancement worker is assigned to a specific hospital but must also provide coverage to various other hospitals across the different systems As the project s common intervention we ve learned to adapt our approach to each hospital culture to ensure consistency across the services provided The Care Enhancement intervention offers patients and their caregivers critical social support services either by referral or direct provision of support services that can reduce the risk of an avoidable readmission A Care Transitions coach a nurse completes a risk assessment which can trigger the referral to the Care Enhancement team The Care Enhancement worker is then required to make a hospital visit prior to discharge as well as a home visit within 72 hours of discharge The Care Enhancement position is brand new Even so all of the Care Enhancement workers had had years of experience in various programs throughout AIS prior to this role The manner in which they had provided services was engrained in handbooks and shifting to new roles and procedures required a huge shift in what they were doing Yes shift does happen But never did we realize that it would take so much work to shift As we further engulfed ourselves in developing the CCTP we realized that this was going to be a process not something that would happen overnight The new world of CCTP totally changed our work A world that was once filled with 23 page assessments and all the makings of what is typically long term case management by community based organizations CBOs was brought to a sudden halt That model shifted into an intense short term patient centered care coordination Clients became patients partners became nurses and our assignments became tasks Shift is difficult and for many of us it has been laborious Along the way we have created a CCTP training module for Care Enhancement to assist staff in adjusting to their new roles We lovingly called the module CCTP 101 and even included a section about this shift We have found it essential to foster an environment in which over communication and input is maintained as a vital piece to our developing system However our old ways sneak up on us like those catchy songs that play in your head over and over again Nevertheless we are confident that we will adapt to this shift and soon enough we will be asking what was that song we kept singing Want to know more Community based Care Transitions Program Overview http innovation cms gov initiatives CCTP key words San Diego County CCTP care transitions readmissions frail elders Learn from Successful Outliers or Shut them Down Posted by Janice Lynch Schuster on May 2 2013 No Responses Tagged with CMS coordinated care demonstration programs frail elders home visits house calls May 02 2013 Last Sunday s Washington Post April 28 featured a long thoughtful article by Ezra Klein describing an effective house visits program Health Quality Partners that is about to lose its CMS funding The article If This Was a Pill You d Do Anything to Get It http www washingtonpost com blogs wonkblog wp 2013 04 28 if this was a pill youd do anything to get it generated several hundred comments and lots of social media activity Klein describes CMS plan to end funding for a home health visit program developed by Pennsylvania s Health Quality Partners First developed as part of a demonstration created in the wake of the 1997 Balanced Budget Act this little program has achieved great successes An independent evaluation found that Partners one of 15 in that demonstration project reduced hospitalizations by one third and cut Medicare costs by one fifth Despite that track record CMS has notified Health Quality Partners that CMS funding will end in June Over the years it seems CMS has learned something from the ongoing demonstration but its attention has now turned to other projects ones that it hopes will prove to be scalable and in which it will invest tens of millions of dollars via the Center for Medicare and Medicaid Innovation CMMI This seems to Klein to me and to many people who commented on the article a little counter intuitive If a new treatment or procedure had led to this kind of result investors and patients would line up to support it and demand it But CMS appears to be stymied by good reports from one particular community about its own particular situation To be sure learning from the one gem in a demonstration program with more than a dozen that did not make the grade is difficult perhaps more difficult to pull off than interpreting a clinical trial or testing an investigational new drug There are risks to be sure in assuming that what works in Doylestown PA will be equally effective in St Louis Missouri or in thinking that the concerns and solutions experienced in one community can be addressed by solutions devised by another Communities are so varied in how they operate and no one solution is likely to work for each Even so many communities find that their frailest residents benefit from the kind of one on one attention to care that house calls can provide Each clinical service program must address real risks to effectiveness and efficiency here an obvious issue is how to target people for whom such a service is a necessity one that helps them to remain independent and out of the hospital rather than those for whom it would mostly be a convenience Also how can incentives be structured so that profits are not a chief motivating factor and so that costs are contained while care and outcomes improve These issues require ongoing attention from communities from the health care industry and from CMS as they work to reshape the health care industry to a framework that includes better care and services for the oldest among us As the country s leaders and policymakers increasingly turn attention to the looming challenges created by aging Boomers many look to individual communities and their successes In fact it is likely that the solutions we need and find will hinge on what different communities are allowed to assemble What each identifies as priorities how each allocates resources and where each turns its energies Learning how other communities succeed at this hard work will be critical for others testing for inspiration and ideas Dismantling a successful program without even testing whether its principles can be adopted elsewhere or it can grow to scale hardly seems to make sense Continuing to learn from it and deliberately adapting it in ways that work elsewhere seems to be a more responsible response Throughout our history we ve turned to outliers to point the way and inspire others along the journey key words home health care house calls CMS coordinated care frail elders Shining Stars Webinar Highlights Care Transitions Work Posted by Janice Lynch Schuster on April 24 2013 No Responses Tagged with best practices care transitions CCTP CFMC CMS coalition building community based hospital readmissions QIO Apr 24 2013 Focused on improving care transitions A bimonthly webinar series called Shining Stars gives you a chance to hear from others working on the ground to do just the same Sponsored by The Colorado Foundation for Medical Care the next Integrating Care for Populations Communities Learning Session Webinar will air on Thursday April 25 2013 at 3 00 pm ET Participants have an opportunity to hear from local communities that have been successful in improving healthcare through reducing hospital readmissions The webinars feature communities from different initiatives those that are led by Quality Improvement Organizations QIOs as well as those that are part of Aligning Forces For Quality that have received state funding Robert Woods Johnson awardees CCTP awardees Beacon communities ACOs and more The sessions are held on the 2nd and 4th Thursdays of the month A full schedule is posted at http www cfmc org integratingcare learning sessions htm If you are interested in participating follow the steps below Call Information Shining Stars Healthy Columbia Campaign South Carolina ReThink Health Community funded by the Fannie E Ripple Foundation Presented by Kate Hilton JD MTS Director ReThink Health Richard Foster MD Senior Vice President for Quality Patient Safety South Carolina Hospital Association Event Care Transitions Learning Session webinar Date April 25 2013 Time 3 00 PM 4 00 PM ET Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join us 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm These calls are open to all please invite anyone who wants to learn along with us As a reminder these sessions are recorded and all previous Learning Sessions are available at http www cfmc org integratingcare learning sessions htm key words QIOs CFMC care transitions community coalition CCTP CMS JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations Posted by Janice Lynch Schuster on January 23 2013 1 Response Tagged with care transitions CFMC CMS coalition building Coleman Model community based eldercare hospital readmissions JAMA measurement Medicare Naylor Model Jan 23 2013 By Dr Joanne Lynn The latest issue of JAMA features our paper describing an exciting and successful initiative from the Centers for Medicare and Medicaid Services CMS and fourteen of its quality improvement organizations QIOs Grounded in quality improvement methodology plan do study act this unusual project offers many insights for those aiming to reduce avoidable readmissions And its raises a number of important question about how we measure progress in reducing readmissions For more on that topic see our earlier MediCaring blog http medicaring org 2013 01 07 readmissions count should cms revise its calculations A Medicare patient s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system Errors in information transfer care planning or community support can cause hospitalizations rehospitalizations and unnecessary costs to the Medicare program This project involved a three year community based effort to improve the care transition process for fee for service Medicare beneficiaries Participating QIOs facilitated cooperation among providers health care facilities and social services programs such as Area Agencies on Aging They centered their efforts around each community s unique needs QIOs worked with communities to understand their own particular causes of readmissions and to implement appropriate evidence based models to address them Communities analyzed results of the intervention along the way and changed course to stick with interventions most likely to work The results when compared to 50 comparison communities showed significant reductions in hospitalizations and rehospitalizations both by an almost 6 average saving Medicare 3 million in hospitalization costs per average community per year This correlation has already led to new national efforts such as Partnership for Patients and the Community based Care Transitions Program In addition in the 10 th Scope of Work all 53 QIOs are leading community projects nationwide so far in more than 400 communities This paper may be the first time one of America s leading medical journals has published a report based on QI methods Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient but works for the delivery system too To learn more about this complex project you can visit www altarum org QIOpaper a special website developed by Altarum Institute in cooperation with the Colorado Foundation for Medical Care CFMC which led the work The site features background material links to print and online materials from JAMA including control charts from the 14 communities a top ten list a clever infographic and videos of the lead authors discussing major findings and lessons learned key words quality improvement care transitions CMS CFMC Joanne Lynn readmissions community coalitions JAMA Readmissions Count Should CMS Revise Its Calculations Posted by Janice Lynch Schuster on January 7 2013 2 Responses Tagged with care transitions CCTP CMS hospital readmissions Jan 07 2013 by Dr Joanne Lynn When community coalitions apply for funding from the Community Based Care Transitions program of the Centers for Medicare and Medicaid CMS they have to show that they will reduce hospital readmissions by 20 and will save money for Medicare Funding recipients will be held to those two outcomes in evaluating the contract In general CMS intends to evaluate these programs by applying the 20 reduction to the rate of rehospitalization that is rehospitalizations live discharges If a community s baseline rate in 2010 was 15 then 20 of 15 is 3 and they d have to reduce rehospitalizations to 12 If hospitalization itself remains stable these are the same goal numerically However much of what is done to reduce 30 day rehospitalization also reduces hospitalizations beyond 30 days and sometimes even hospitalizations without antecedent hospitalizations If patients learn more self care use more hospice obtain more support in the community and so forth then the use of hospitalization outside of that 30 day window may decline as well And it does not take a lot of decline in that rate to mimic the decline in 30 day rehospitalization making it a challenge to change the rate of rehospitalization hospitalization Suppose for example that a community had 10 000 hospitalizations and 1 500 30 day rehospitalizations in 2010 Suppose the CCTP work changed the rehospitalization number by a full 20 cutting it to 1200 per year by 2014 But that good work also cut down on hospitalization by 10 yielding 9000 for the denominator Then 1200 9000 would be just a 13 3 rate and the team would have missed the goal of 12 even though it had actually done a terrific job It is always risky to use a rate where the denominator is presumed to be stable but actually

    Original URL path: http://medicaring.org/tag/cms/page/2/ (2016-04-30)
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