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  • data sources – MediCaring.org
    greatly misunderstood what they were to do I recall the patient who told me about having to eat fresh vegetables for his heart whereupon he opened a fresh can of peas every day Those stories will greatly help you galvanize the will to move ahead And you ll have a process and form that you can persuade the quality improvement team at each hospital to do Perhaps at large hospitals five each week for four weeks and at small hospitals five in the month Within a month you d have enough data and stories to build the endeavor and continuing to collect the data provides rapid feedback about progress Pick a lead intervention or two and get it tested and underway You are likely to find a certain sense of chaos that there is a lot of catch as catch can processing with thorough unreliability on all sides If this is the case your coalition might well work on standardizing the process simply so that it is reliable You may find that the issues affecting the frail elders are different from those affecting younger populations more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger Whatever you find this is the root cause analysis that you ll need to decide priorities and to apply for CCTP funds Key words root cause analysis reviewing readmissions discharge record review quality improvement tools CCTP funding Care Transitions Workbook Now Online Posted by Janice Lynch Schuster on July 22 2011 No Responses Tagged with care transitions coalition building data sources measurement quality improvement rehospitalization Jul 22 2011 Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good Shortcomings in transitions today reflect larger systemic problems that can best be addressed by community organizations working together Indeed no single organization will be able to resolve the broader issues or work on its own to improve care transitions It will truly take a village to make transitions safe effective and routine Many organizations around the country are looking to build coalitions that focus on care transitions For many similar experiences building community connections will enable them to establish and lead such coalitions But many others will need guidance and support for learning the basics of coalition building and for understanding issues specific to care transitions The Center for Eldercare and Advanced Illness has just posted a workbook It Takes a Village that offers community leaders ideas and pointers for how to get started and how to get going It can be read in its entirety on the MediCaring org website at http medicaring org it takes a village The guide provides an overview of coalition building ranging from recruiting partners to resolving governance It describes what to consider when setting priorities for the work Much of

    Original URL path: http://medicaring.org/tag/data-sources/ (2016-04-30)
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  • Care Transitions Workbook Now Online – MediCaring.org
    consider when setting priorities for the work Much of the text is devoted to issues of measurement how will coalitions know that their work is improving patient care and experience The guide explains how to usemeasurement to advance the coalition s goals how to find good data sources and how to decide on what to measure It provides very specific information on fixing care transitions including how to fix the hospital discharge process and how to target rehospitalizations Because care transitions have a major effect on very sick and vulnerable patients and families the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services Community coalitions have proven effective at addressing diverse public health issues from improving maternal and child health to creating healthier environments Coalitions are defined by their focus on a particular issue by their willingness to collaborate and by their ability to bring a range of resources and perspectives to problem solving The guide offers a starting point we hope you find it compelling and useful We d like to hear about your experiences what works for you and what doesn t where are your successes and what have been your challenges Please join the dialogue by offering comments here or emailing us at email protected We look forward to hearing from you Key Words care transitions rehospitalization readmission quality improvement coalition building data sources measurement 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 i q cite s strike strong Name required E mail required URI The Price is Right Suggestions from current 3026 applicants Details of LTQA Innovative Communities National Summit MediCaring is a

    Original URL path: http://medicaring.org/2011/07/22/care-transitions-workbook-now-online/ (2016-04-30)
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  • measurement – Page 2 – MediCaring.org
    as ongoing supervision monitoring administrative costs and so on Most important however it does not include initial training Sites must have some previous experience with care transitions so they must have paid for initial training CMS payment also cannot directly support travel expenses for attending the required meetings in Baltimore the cost of this must come from some other source Applicants are required to use the worksheet provided by CMS for a link to the worksheet see http www cms gov DemoProjectsEvalRpts downloads CCTP ApplicationBudgetWorksheet zip No payments will be made more than once in 6 months for each beneficiary In other words CMS will not pay for re treatment of patients for whom first efforts to prevent rehospitalization failed Keep in mind that although the program will run for 5 years the initial award is only for 2 years with possibility of renewal annually thereafter Intervention CCTP interventions must target Medicare beneficiaries who are at high risk for readmissions based on criteria provided by HHS or for substandard care post hospitalization Interventions cannot duplicate already required services You must be willing to participate in collaborative learning and redesign including data collection Finally and not surprisingly your intervention must save money overall and show savings within two years You can find a list of evidenced based interventions at http www amda com advocacy Attachment j 16 pdf CMS s measures so far include Outcome measures 30 d Risk adjusted all cause readmission rate currently under development 30 d unadjusted all cause readmission rate 30 d risk adjusted AMI HF and Pneu readmissions Process measures PCP follow up within 7 days of hospital discharge PCP follow up within 30 days of hospital discharge HCAHP items note includes more than HCAHPS HCAHPS on medication info HCAHPS on discharge info Care Transitions Measure 3 item see http www caretransitions org documents CTM3Specs0807 pdf Patient Activation Measure 13 item see http www ncbi nlm nih gov pmc articles PMC1361231 table tbl1 Note There are some areas where the solicitation is unclear or internally inconsistent You should stay abreast of updated FAQs by subscribing to the email list at https service govdelivery com service subscribe html code USCMS 626 Key words hospital readmission care transitions 3026 funding evidence based intervenitons patient activation measure budget worksheet financing medicare beneficiaries payment rate CMS Care Transitions Measurement 101 Posted by Dr Joanne Lynn on May 17 2011 No Responses Tagged with Beacon communities best practices care plans care transitions discharge planning ESRD frail elders measurement Medicare rehospitalization SNF May 17 2011 Many improvement teams have real problems with measuring their progress some never get around to measuring and some never do anything else This presentation was set for the communities funded under the Beacon initiatives that are working to bring information exchange to care transitions but you ll find the pointers applicable to any intervention that your community might try You can download a PowerPoint presentation by clicking the following link caretransitionsmeasuresprimer PowerPoint presentation Keywords Beacon communities care

    Original URL path: http://medicaring.org/tag/measurement/page/2/ (2016-04-30)
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  • MediCaring book – Page 2 – MediCaring.org
    rock or jump and hope to make it We simply cannot keep on this way If we do we will force one another from the rock of current social arrangements And for as long as the rest of us insist on clinging to that rock hoping for a miracle rescue millions of our fellow travelers will experience devastating consequences as services shrink and costs explode And we will not sink alone but will take the fabric of society with us as essential and important investments in healthy children and a healthy economy become impossible Even worse if we fail to tackle the challenges of right sizing services for a much larger population of very old people we are likely to be forced to pick and choose who to pull from the river and who to leave behind We could attempt to sustain the illusion of helping some by providing the existing supports and services to an ever shrinking percentage of those in need while learning to accept that others will not have adequate housing food and health care That path is unacceptable Who among us wants to be saved from suffering and destitution while our friends and loved ones are swept away Tradition and culture guarantee that we are all in this together We will have to take our chances jump in and swim to a safer but unknown shore despite our fears and uncertainty about what we might encounter We did not of course plan for this journey with the idea that we would wind up stuck on a rock in an increasingly threatening environment Decades ago we designed a health care system that was well suited to the needs and realities of those times But circumstances have changed and our systems must now change too The first jump is to understand a new set of facts and develop a new set of understandings We can build our future in a way that treats us all fairly as we age and achievesreliability and efficiency Success is possible We can get through the next fifty years of a rapidly aging society having cared well for one another and having avoided slowing our overall economic development However the journey will entail some risks and failing to get underway will only make it harder to succeed When I plunged into the rapids I had some strengths to build on I could swim I wore a helmet and my loved ones were cheering me on I successful re emerged on shore And so too our society will improve our chances of navigating to the other side if we build on our strengths marshall our resources deliberately plan for what s ahead and encourage and support one another along the way We may occasionally wash up in a spot that turns out not to be the best but we can learn from that and move on Doing nothing we can continue to tread water and keep afloat a while longer But eventually even that

    Original URL path: http://medicaring.org/tag/medicaring-book-2/page/2/ (2016-04-30)
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  • CCTP Project in Delaware County, PA,Testing a Modified Transitional Care Model – MediCaring.org
    care physician PCP in a previous hospital discharge or hospital readmissions within the previous 180 days Once the nurse has identified an eligible patient the nurse will meet with him or her at the bedside to discuss enrolling in the program Patients who agree to participate will receive a visit from the project s social worker Together the nurse and social worker will provide the patient with user friendly transfer and discharge forms and teach the patient how to use AHRQ s Taking Care of Myself That booklet which is customized to the patient s needs includes information about medications diagnosis nutrition and activity follow up appointments and so on Patients will be encouraged to take the booklet with them to follow up appointments and to have physicians update it as needed The CCTP nurse is scheduled to make two home visits to the patient as the first visit will be with in 72 hours of the hospital discharge and another at week 4 before the completion of the program The COSA CCTP social worker will meet with patients weekly and also follow up by phone The nurse and social worker will follow the patient for 30 days The COSA social worker will work with the patient according to his or her needs and preferences If the patient would like the social worker will accompany him or her to the first post discharge PCP visit If additional COSA services are needed the patient can be assessed at bedside or in the community by a COSA Assessor and then assigned to a COSA Care Manager who would follow the patient much longer if needed In addition social workers have over sized business cards that will feature their photographs and contact information The cards give social workers a face patients can share the cards with family members at home so that they can see who will be visiting the patient For patients who have people in and out of the home daily the card is a visual reminder about the social worker The CCTP is an initiative of the Partnership for Patients a nationwide public private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three year period CCTP s goals are to reduce hospital readmissions test sustainable funding streams for care transitions services maintain or improve quality of care and document measurable savings to the Medicare program The CCTP project which received funding late this spring is ready to hit the ground running Two hospitals will launch the work on August 6 and three others will join in by October According to the COSA CCTP Project Director Terry Levine the project s success hinges on the relationships among COSA and all the participating hospitals In planning it he said it was important to communicate with the hospitals and to let them know that the CCTP work is not meant to replace their discharge planning

    Original URL path: http://medicaring.org/2012/08/02/cctp-project-in-delaware-county-patesting-a-modified-transitional-care-model/ (2016-04-30)
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  • Dr. Joanne Lynn on the Naylor Model: How the Transitional Care Model Works – MediCaring.org
    Care Model developed and tested by Dr Mary Naylor and her colleagues at the University of Pennsylvania You can learn more about TCM from its website http www transitionalcare info and by watching the video below Keywords Transitional Care Model Care Transitions Joanne Lynn Advanced Practice Nurses 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 i q cite s strike strong Name required E mail required URI CFMC Bimonthly Care Transitions Program Airs Thursday 10 13 New AARP Factsheet Summarizes Health Care Reform Opportunities that Support Family Caregivers MediCaring is a service of the Center for Elder Care and Advanced Illness at Altarum Institute Follow Us To receive our email newsletter send a request to email protected Tweets by medicaring Care Transitions News Ringling Bros circus elephants set for final act Sunday USA TODAY April 29 2016 PMH announces Annette Schnabel as president CEO Bureau County Republican April 29 2016 College baseball Weekend Preview April 29 May 1 NCAA com April 29 2016 AbbVie Doubles Down on M A Bloomberg April 29 2016 Aspen Valley Hospital reaps awards for patient experience Aspen Times April 29 2016 Optimizing care transitions the role of the community pharmacist Dove Medical Press April 26 2016 3 lessons to improve patient care transitions FierceHealthcare April 21 2016 Dave Alfano Launches Caring Transitions of Central Connecticut PR Web press release April 19 2016 Older adults with dementia face increased mortality risk due to care transitions Bel Marra Health April 14 2016 Central Wyoming Caring Transitions Owners Recognized for Pioneer Spirit PR Web press release April 4 2016 Tags advance care planning Affordable Care Act aging Altarum Institute best practices caregivers caregiving

    Original URL path: http://medicaring.org/2011/10/17/dr-joanne-lynn-on-the-naylor-model-how-the-transitional-care-model-works/ (2016-04-30)
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  • Transitional Care Model – MediCaring.org
    www transitionalcare info and by watching the video below Keywords Transitional Care Model Care Transitions Joanne Lynn Advanced Practice Nurses MediCaring is a service of the Center for Elder Care and Advanced Illness at Altarum Institute Follow Us To receive our email newsletter send a request to email protected Tweets by medicaring Care Transitions News Ringling Bros circus elephants set for final act Sunday USA TODAY April 29 2016 PMH announces Annette Schnabel as president CEO Bureau County Republican April 29 2016 College baseball Weekend Preview April 29 May 1 NCAA com April 29 2016 AbbVie Doubles Down on M A Bloomberg April 29 2016 Aspen Valley Hospital reaps awards for patient experience Aspen Times April 29 2016 Optimizing care transitions the role of the community pharmacist Dove Medical Press April 26 2016 3 lessons to improve patient care transitions FierceHealthcare April 21 2016 Dave Alfano Launches Caring Transitions of Central Connecticut PR Web press release April 19 2016 Older adults with dementia face increased mortality risk due to care transitions Bel Marra Health April 14 2016 Central Wyoming Caring Transitions Owners Recognized for Pioneer Spirit PR Web press release April 4 2016 Tags advance care planning Affordable Care Act

    Original URL path: http://medicaring.org/tag/transitional-care-model/ (2016-04-30)
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  • ONC Backs $40K App Challenge for Improving Cancer Care Transitions – MediCaring.org
    contest In the second part the competitors are judged and the winner gets 25 000 Here are some of the areas the challenge seeks to address according to the ONC s website Optimizing patient provider communication and customizing management of survivor care Follow up care needs like medication tracking and adherence health promotion appointment and symptom tracking Improving communication across survivor care networks using tools to improve health data and interoperability standards such as Blue Button Submissions will also be assessed on their ability to adapt to the evolving care needs of survivors including the potential for integration with electronic care platforms and between family friends and healthcare providers The deadline for the competition is May 28 at 11 59 pm Pacific time To apply click this link The winners will be announced over the summer Read more http medcitynews com 2013 05 onc backs 30k app challenge for improving cancer care transitions ixzz2TxPeFe00 This article is used with permission from www medcitynews com where it originally ran on May 15 2013 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 i q cite s strike strong Name required E mail required URI A Shift Happens Care Transitions Lessons from San Diego County Shining Stars Program Thursday May 23 MediCaring is a service of the Center for Elder Care and Advanced Illness at Altarum Institute Follow Us To receive our email newsletter send a request to email protected Tweets by medicaring Care Transitions News Ringling Bros circus elephants set for final act Sunday USA TODAY April 29 2016 PMH announces Annette Schnabel as president CEO Bureau County Republican April 29 2016 College baseball Weekend Preview April

    Original URL path: http://medicaring.org/2013/05/21/onc-backs-40k-app-challenge-for-improving-cancer-care-transitions/ (2016-04-30)
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