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  • Don’t Accept Medical Errors as the Standard of Care for Frail Elders – MediCaring.org
    for many elderly persons in need in most of the country the waiting lists are routinely more than 6 months long because we have not chosen to fund the Older Americans Act adequately What are we doing And how can we complain effectively Each family somehow believes that its situation is bad luck or how things are There is no benchmark by which to set expectations so the families accept the errors dysfunctions suffering and impoverishment that so often come with disabilities in old age Why are the errors of our system not being debated or even mentioned in political campaigns How can we change this We can start by changing our abysmal expectations of the services that we get Let s question why the care system is so deaf to the priorities of our loved ones everywhere we can in the newspapers in the candidate debates through social media Let s reengineer current services build highly reliable care systems in our communities and see what it really costs Projections for the costs of a community anchored care system that is person centered and flexible enough to bring most services into the home are not much different from current care arrangements Let s record stories good and bad Let s figure out how family caregivers can become politically powerful Why is it for example that Medicare has no standing advisory committee speaking for the interests of its millions of beneficiaries If we are lucky we will grow old So it s our future too not just our parents We ve started an initiative to get family caregiver issues on the party platforms in all states that generate party platforms You can join the Family Caregiver Platform Project initiative It takes very little time and gets leaders talking Go to http caregivercorps org to sign up now There are some bright spots on which we can build The Centers for Medicare Medicaid Services has introduced payment for advanced care planning discussions between Medicare beneficiaries and their physicians We agree that this is a good idea and strongly support it But care planning is not just an end of life matter it needs to be comprehensive and a standard practice All health care providers and social services agencies should pursue the goals that the elder and family actually most want We invite you to read our MediCaring blog for more of our comments on this proposal http medicaring org 2015 08 25 comments on payment for advance care planning What else can you think of We need other leverage points that would focus the pent up frustration of millions of family members who have already witnessed the misery of ordinary elder care What should have been available to Marcy as she helped her parents live their last years Hers is a story that we can all absorb and tell others then we can go out and insist that our care system change Eventually Marcy and her family found some exceptional paid caregivers

    Original URL path: http://medicaring.org/2015/09/28/dont-accept-medical-errors-as-the-standard-of-care/?pfstyle=wp (2016-04-30)
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  • MediCaring.org – Page 2 – Making It Safe to Grow Old
    system of the future To that end we are asking you to sign a public petition calling for the Center for Medicare Medicaid Innovation CMMI to launch a demonstration that would allow MediCaring Communities Webinar Posted by Elizabeth Rolf on June 2 2015 No Responses Tagged with communities Medicaring MediCaring model Jun 02 2015 Our efforts to move MediCaring Communities forward are underway Please click this link to view an informational webinar recording in which Joanne Lynn lays out the details of the MediCaring Communities plan describes next steps in the campaign and explains how to get involved http altarum adobeconnect com p1gikillyf8 Introducing the Family Caregiver Platform Project Posted by Elizabeth Blair on May 27 2015 6 Responses Tagged with caregivers Platform Project public policy May 27 2015 By Anne Montgomery Now and during the exciting months ahead people across the country will begin meeting to debate create and vote on ideas and proposals for possible inclusion in their state party platforms leading up to 2016 Wherever you live Altarum Institute s Center for Elder Care and Advanced Illness CECAI hopes that you will participate Just How Dysfunctional is Frail Elder Care in the U S Posted by Elizabeth Rolf on May 19 2015 No Responses Tagged with frail elders hospice Meals on Wheels Medicare older americans act May 19 2015 By Joanne Lynn Very very dysfunctional You need evidence Try these two tales First a remarkably illuminating piece of research was released on March 2 concerning the Meals on Wheels program http www mealsonwheelsamerica org docs default source News Assets mtam full report march 2 2015 pdf sfvrsn 6 The title was More than a Meal and it showed that people who got warm meals home delivered by volunteers 5 days per PBS Caring for Mom and Dad Posted by Elizabeth Rolf on May 6 2015 No Responses Tagged with caregiving eldercare family caregivers frail elders May 06 2015 By Elizabeth Rolf On May 7 2015 PBS will begin to air Caring for Mom and Dad The hour long special will cover the challenges adult children face caring for their aging parents including raising young children caring for dementia patients in their homes and the frustrations and challenges of caregiver support The episode calls for Identifying Communities with Potential for Pioneering MediCaring Suggest Yours Posted by Elizabeth Rolf on April 17 2015 5 Responses Tagged with caregiving CMS communities Medicare Medicaring Apr 17 2015 By Joanne Lynn The time has come to seek Medicare s cooperation so MediCaring Community programs can get underway in many parts of the country These programs are as necessary to an aging society as pediatrics and obstetrics are for children and maternal care Empowering communities to take care of their own residents who aim to Stop Taking Caregivers for Granted Posted by Elizabeth Rolf on March 24 2015 No Responses Tagged with ACT assisting caregivers today caregiving end of life care family and medical leave act family caregivers FMLA Mar 24 2015 By

    Original URL path: http://medicaring.org/page/2/ (2016-04-30)
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  • Email Protection | CloudFlare
    is protected by CloudFlare Email addresses on that page have been hidden in order to keep them from being accessed by malicious bots You must enable Javascript in your browser in order to decode the e mail address If you have a website and are interested in protecting it in a similar way you can sign up for CloudFlare How do spammers get email addresses How does CloudFlare protect email

    Original URL path: http://medicaring.org/cdn-cgi/l/email-protection (2016-04-30)
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  • Affordable Care Act – MediCaring.org
    happen overnight and a lot of different payment models will need to be tried The problem is that fee for service and delivery system changes do not line up Emanuel said For example marketing and advertising for costly procedures and treatments influence patient decision making More important he observed health care providers many of whom are not primarily focused on delivering the best possible care for the most efficient price follow entrenched patterns of practice The result is that rising health care costs are threatening wage growth and all of the other things we human beings care about Despite the large challenges inherent in bending the health care cost growth curve Emanuel does not advocate abandoning U S social insurance programs Instead he advocates serial systemic reforms For example he notes that although we don t have a good alternative to peer review which some critics call a bottleneck to rapid reform he believes it is feasible and imperative to develop new protocols for more rapid testing and dissemination of pilots demonstrations and other types of initiatives We need a frame shift to look at multiple factors at the same time he said We need to evaluate differently with different standards and perhaps larger numbers It is within this broader measurement context that Zeke Emanuel believes transparency will be an essential driver of change Doctors are highly competitive Emanuel told the crowd of Disruptive Women They are trained to want to be number one The current dilemma he says is that the driven nature inherent in training physicians goes out the window when they start practicing But as quality measures increasingly become public spotlighting how good processes of care and delivery are along with patient outcomes and patient experience the big push for change will come from providers he predicted Emanuel also acknowledged that the quest to coordinate services and drive down costs must involve and engage individual patients Right now patients are not focused on costs he said They are not going through websites to compare the costs of various procedures and treatments But if metrics of cost and quality can be arrayed in a simple way and if a selection among them can be developed to include price this could help to drive costs to a more reasonable level he said To that end Emanuel is currently writing a concept paper on shared savings that discusses the possibility of sharing savings not only between health care providers but also with patients If there is a choice between treatments that are clinically equivalent he reasoned why shouldn t patients get part of the savings Why not indeed Anne Montgomery is a Senior Policy Analyst for the Center for Elder Care and Advanced Illness at Altarum Institute The Price is Right Suggestions from current 3026 applicants Posted by Harshika Satyarthi on July 18 2011 No Responses Tagged with Affordable Care Act Beacon communities budget care transitions CBO CMS community based measurement Medicare rehospitalization Section 3026 Jul 18 2011 As coalitions around the country move towards completing their application for Community Based Care Transitions Program CCTP Section 3026 of the ACA many teams will encounter difficulties in completing the proposal see budget worksheet at http www cms gov DemoProjectsEvalRpts downloads CCTP ApplicationBudgetWorksheet zip Here are a few concerns and helpful suggestions raised during a recent meeting with potential 3026 applicants from the IHI Triple Aim and ONC Beacon participants Regarding finance the pricing is done on a per unit basis rather than a grant or contract basis that hospitals and community based organizations CBOs might expect Per unit pricing is just like any other Medicare service Your program will submit a list of patients served each month and payment will go to the CBO Some CBOs may find it helpful to confer with someone experienced in per unit pricing i e experience in small business You will need to estimate what fixed and variable costs the intervention incurs along with a reasonable estimation of the number of targeted beneficiaries eligible for your program Having as precise an estimate as possible of this anticipated volume is crucial in arriving at the correct rate per eligible discharge Keep in mind that having a lower than anticipated volume can lead to losses because you incur fixed costs that you did not cover The greater the volume the more spread out your costs will be One way of improving your volume estimate is getting a good approximation for the acceptance rate into the program which can be based on previous experience Many programs initially have very high refusal rates but usually you can decrease that over time Although the budget worksheet does not include a place for an acceptance rate you could modify your entry on Row B and then enter the explanation in an accompanying footnote Not to exceed budget is another aspect that might cause some confusion Basically your not to exceed budget is the money CMS will set aside for your entire program Remember that the budget you are proposing is for five years There might be changes in your program over this time period only some of which you could predict For example you might be able to streamline your intervention over the first two years or you might predict an increase in patient volume You could write in these predicted changes with a modification on Row M and then enter the explanation in an accompanying footnote The aim of the program is to be integrated as a permanent part of Medicare and to this end it allows and encourages learning throughout the program However the degree of flexibility is unknown Here is the link to the powerpoint presentation from the meeting on 7 12 11 http medicaring org wp content uploads 2011 07 CCTP Budget Proposal pptx This is a collaborative effort and the above suggestions would not have been available if not for care transitions teams sharing their experience So any comments questions or modifications to our suggestions are

    Original URL path: http://medicaring.org/tag/affordable-care-act/ (2016-04-30)
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  • Altarum Institute – MediCaring.org
    the Robert Wood Johnson Foundation moderated the three panels The first kicked off by U S Senator Johnny Isakson R GA and Elizabeth Falcone from the office of U S Senator Mark Warner D VA included an in depth look at The Care Planning Act of 2013 That bill would reimburse interdisciplinary teams to help Medicare and Medicaid beneficiaries map out options for living with advanced illness and document a care plan geared to their own values and preferences and guide the course of their treatment Other panelists included Shannon Brownlee a writer who shared her family s story of the fragmented care her mother received and how such experiences have become the norm for many aging Americans Jennie Chin Hansen CEO of the American Geriatrics Society described how we might affect the forces that influence the current system She suggested that we must address the space in between the years in late life that are often characterized by increasing dependency disability and frailty A second panel discussed economic trends as well as national strategies that could help to create a framework for improving care in advanced old age This session highlighted ideas by health economist Joseph Antos from the American Enterprise Institute and John Rother of the National Coalition on Health Care A third panel examined trends at the community level with remarks from Mimi Toomey of the Administration for Community Living Suzanne Burke of the Council on Aging of Southwestern Ohio John Feather CEO of Grantmakers in Aging and Joanne Lynn Director of the Center for Elder Care and Advanced Illness at Altarum Institute Roundtable cosponsors included Grantmakers In Aging Grantmakers In Health LeadingAge National Alliance for Caregiving National Coalition on Health Care National Consumer Voice for Quality Long Term Care and OWL The Voice of Midlife and Older Women key words Altarum Institute public policy aging elder care Joanne Lynn Advanced Old Age Roundtable Video Online Posted by Janice Lynch Schuster on October 3 2013 No Responses Tagged with advanced old age aged Altarum Institute frail elders Joanne Lynn Oct 03 2013 Video from an Altarum Roundtable on advanced aging which featured discussion of strategies to improve care for frail elders is now online The session was sponsored by Altarum Institute along with Grantmakers In Aging Grantmakers In Health LeadingAge National Alliance for Caregiving National Coalition on Health Care National Consumer Voice for Quality Long Term Care and OWL The Voice of Midlife and Older Women Moderated by Susan Dentzer the panels featured national leaders policymakers program organizers and strategists U S Senator Johnny Isakson kicked off a session that included staff from the office of U S Senator Mark Warner with whom Isakson has introduced The Care Planning Act of 2013 Other panelists included Shannon Brownlee Jennie Chin Hansen Joe Antos John Rother Mimi Toomey John Feather and Suzanne Burke The ideas and insights shared by panelists sparked an intriguing Q A session and the program offered a step toward galvanizing essential conversations for improving care

    Original URL path: http://medicaring.org/tag/altarum-institute/ (2016-04-30)
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  • best practices – MediCaring.org
    hospitalization rate They will recognize that if hospitals in areas with low hospitalization rates are protected then hospitals in areas with high hospitalization rates will be more vulnerable Some have hoped that traditional risk adjustment could solve this problem because the most likely scenario is that average risk of readmission increases as the number of discharges decreases That prospect is not promising because the most assiduous work on risk adjustment has produced tools of only moderate power The prospects for solving this problem with improved risk adjustment are not promising 4 5 When you find yourself in a hole you should stop digging It seems prudent for NQF to suspend endorsement of the pending discharge based readmission measures and for CMS to delay implementing discharge based measures if NQF endorses them until CMS has studied and reported the extent to which readmission penalties punish hospitals that are actually reducing both admissions and readmissions and has laid out an approach to any problems found Finally the problem identified here underlines the importance of placing a population based foundation under at least some measures of health care system performance Footnotes References 1 Centers for Medicare and Medicaid Services Readmission reduction program Retrieved from http www cms gov Medicare Medicare Fee for Service Payment AcuteInpatientPPS Readmissions Reduction Program html 2 Epstein A M Jha A K Orav J E 2011 December 15 The relationship between hospital admission rates and rehospitalizations New England Journal of Medicine 365 24 3 Kind A J H Jencks S Brock J Yu M Bartels C Ehlenbach W Smith M 2014 December 2 Neighborhood socioeconomic disadvantage and 30 day rehospitalization a retrospective cohort study Annals of Internal Medicine 161 11 765 775 4 Yale New Haven Health Services Corporation Center for Outcomes Research Evaluation 2014 July 2014 measure updates and specifications Hospital wide all cause unplanned readmission version 3 0 Retrieved from https staging qualitynet org dcs BlobServer blobkey id blobnocache true blobwhere 1228774408425 blobheader multipart 2Foctet stream blobheadername1 Content Disposition blobheadervalue1 attachment 3Bfilename 3DRdmsn Msr Updts HWR 0714 pdf blobcol urldata blobtable MungoBlobs 5 Kansagara D Englander H Salanitro A Kagen D Theobald C Freeman M Kripalani S 2011 October 19 Risk prediction models for hospital readmission A systematic review Journal of the American Medical Association 306 15 1688 1698 Innovation Requires Shedding Established Patterns Posted by Les Morgan on May 28 2014 No Responses Tagged with best practices eldercare frail elders innovation Joanne Lynn Medicare Medicaring May 28 2014 While diligently trying to improve care for frail elders often by filling gaps in the care system even our most innovative programs tend to work within the constraints that created those gaps in the first place Dr Joanne Lynn Director of the Center for Elder Care and Advanced Illness CECAI has been visiting and often coaching many innovative programs as they work to do a better job for their community s frail elders Dr Lynn reports being inspired and sometimes awed by the deep personal and professional commitments of their program staff Yet she finds more and more evidence that genuine reforms to create sustainable and reliable arrangements for the services that frail elders need will require breaking out of our increasingly archaic habits Even the most innovative leaders and programs continue to accept historic barriers and red tape that stymie enduring improvements Rules Changes as Game Changers Think about what you accept in your own work or what you feel that you are forced to accept because of rules and regulations that in your experience have simply always been there Remember the Centers for Medicare Medicaid Services Innovation Center can waive most regulations and even an act of Congress can be undone by later laws So why do we keep working with the assumptions that home care means being homebound that skilled nursing facility use means only rehabilitation and that hospice care requires refusing what the Medicare statute called curative treatment Think about other important changes that we have made in the health care system Would labor and delivery have changed if we had persisted in thinking that women should be unconscious during delivery Would hospice have emerged if we had adhered to the belief that randomized controlled trials aiming for small improvements in survival time were all that mattered to cancer patients Not likely Not Just a Body Shop Yet even our forward thinking programs continue to categorize people by disease or prognosis A prominent efficiency contractor a business working under contract with managed care bundled payment or accountable care organizations to reduce expenditures especially in the post hospital period said that its work in the 90 days after hospitalization did not extend to long term care Really A frail elder who needs long term care is likely to need that care during the first 90 days after hospitalization and planning for the time beyond that People needing long term supports need a service delivery system that works with a comprehensive care plan for a good life not just for a few months of rehabilitation services A modern folk song by David Mallet has the wonderful line We are made of dreams and bones Indeed each unique individual comes to old age not only with a medical history but often more importantly with a lifetime of connections to others personal and family histories and aspirations and an array of resources Our bodies are not like cars which can go to the repair shop just for tires Perhaps a person can sometimes see a doctor for preventive maintenance or repairs to just one body part But once someone is living with serious illnesses or disabilities the central challenge is how to live well with those conditions and their treatments Still whole sectors of the health care industry continue to operate like repair shops addressing one treatment diagnosis or setting and therefore regularly falling short in providing good care for frail elders Comprehensive Care for Frail Elders Imagine a service delivery system that really worked for frail elders A key member of a multidisciplinary team would know each person well and understand the particulars of each situation including strengths fears and priorities The frail elderly person his or her family and the care team would develop and agree to a plan of services that optimally helps attain important and achievable goals At the same time an organization representing the community would be continually working toward making available an optimal array of services Making such an arrangement a reality will require developing new rules and procedures that enable the community to improve service supply and quality We will have to learn how to evolve from the currently dysfunctional structure a legacy developed for a different time and a different population with a different set of challenges MediCaring Communities CECAI is now working with several communities whose visionary leaders are moving toward our comprehensive MediCaring model learning how to work within current limitations without accepting them MediCaring offers a strategy that spans settings and time through to the end of life and even beyond to support the bereaved This model goes beyond our traditional focus on medical services by including important services such as housing nutrition transportation social connections and caregiver support One idea behind MediCaring is to balance the resources available for medical services with those needed for social supports within each community We know that many other communities and organizations are working to similar ends and we would enjoy hearing more about just what you are doing Share some compelling stories of how you are using the flexibility of Center for Medicare Medicaid Innovation waivers or the adaptability granted by capitation or local funding to make a difference for frail elders now Write us comment or share on social media We are eager to learn from you Want to learn more The MediCaring reforms http medicaring org Building reliable and sustainable comprehensive care for frail elderly people http altarum org our work jama reliable and sustainable comprehensive care for frail elderly people Health Affairs blog on efficiency contractors by Dr Joanne Lynn http healthaffairs org blog 2014 04 24 only evidence based after hospital care where should the savings go Reducing Readmissions From the Experts Webinar Thursday August 8 3 pm ET Posted by Janice Lynch Schuster on August 7 2013 No Responses Tagged with best practices care transitions CCTP CMS community based discharge planning eldercare frail elders hospital readmissions Medicare quality improvement Aug 07 2013 As part of its ongoing series on reducing readmissions the Integrating Care for Communities project from the Colorado Foundation for Medical Care hosts a webinar on Thursday August 8 at 3 ET Details about the program can be found here with information provided by CFMC During this session we will hear from ARC Avoiding Readmissions through Collaboration California Community Based Care Transitions Program CCTP Awardee Learning Objectives Participants will Identify the structure and tactics used by the collaborative to drive readmission reduction in participating hospitals Trace the collaborative s efforts to develop a Patient Advisory Council Examine how to develop and deploy a successful relationship between a hospital and their SNFs to optimize care transitions Presented by Cheryl Reinking RN MS Interim Chief Nursing Officer El Camino Hospital Cheryl Reinking RN MS has served 25 years at El Camino Hospital in progressive nursing leadership roles her most recent being as Interim Chief Nursing Officer which she assumed in July 2013 Cheryl has led a number of hospital wide initiatives and was key to the hospital s implementation of the nationally recognized Nurses Improving Care for Healthsystem Elders NICHE program which was designed to create increased patient centric care for hospitalized older patients She developed the hospital s site specific program Pat Teske RN MHA Cynosure Health Pat Teske RN MHA is the implementation officer for Cynosure Health In her role she strives to implement the company s vision through strategic planning and execution of projects on time and within budget that yield successful outcomes Previously she held the position of vice president of Quality Improvement and Care Management for Catholic Healthcare West Pasadena CA where she lead the regions chief nursing officers quality directors case managers and medical staff directors to accomplish their annual goals As an independent contractor Pat supported BEACON the Bay Area Patient Safety Collaborative as well as other state and local collaboratives She is currently leading the Avoid Readmissions through Collaboration ARC effort in CA and working nationally with HRET on the Partnership for Patients HEN A requested public speaker at national state and local conferences including IHI NPSF and TJC Ms Teske has developed and offered numerous educational programs designed to support performance improvement and system reliability Pat received her MHA from the University of LaVern and her BS in Nursing from the University of Virginia Lisa Ehle MPH Program Manager Cynosure Health Lisa Ehle MPH is a Program Manager at Cynosure Health and currently oversees the Avoid Readmissions Through Collaboration ARC program and the ARC Patient Advisory Council Before joining Cynosure Health Lisa served as the State Director of Program Services with the March of Dimes Massachusetts Chapter where she co founded the MA Perinatal Quality Collaborative and directed a Program Services Committee charged with addressing the perinatal needs of the state She has been an advocate for maternal and child health issues including preterm birth prevention routine HIV screening smoking cessation and improving hospital discharge practices Lisa has worked at the state level for the MA Department for Public Health creating policies and guidelines for infectious disease prevention and screening programs Lisa received her Bachelor of Science in Physical and Psychiatric Rehabilitation Counseling from Boston University Sargent College and a Masters of Public Health from Boston University School of Public Health specializing in Social and Behavioral Sciences Event Care Transitions Learning Session webinar Date August 8 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 key words readmissions rehospitalizations care transitions quality improvement organizations CMS CFMC Shining Stars Webinar June 27 to Learn from Leaders in Improving Care Transitions Posted by Janice Lynch Schuster on June 25 2013 No Responses Tagged with best practices care transitions CMS Medicare QIO webinar Jun 25 2013 Integrating Care for Populations Communities hosts a Learning Session Webinar on Thursday June 27 2013 at 3 00 pm ET This webinar is the twelfth presentation in the Learning Session series Shining Stars Across the Nation During the series entitled Shining Stars Across the Nation we hear from local communities that have been successful in improving healthcare through reducing hospital readmissions The webinars feature communities from different initiatives those communities that are lead by CMS Quality Improvement Organizations QIOs those that are part of Aligning Forces For Quality those that have received state funding Robert Wood Johnson awardees CCTP awardees Beacon communities ACOs and more These sessions are held on the 2nd and 4th Thursdays of the month The complete schedule is posted at http www cfmc org integratingcare learning sessions htm Call Information Shining Stars Banner Health in Phoenix AZ An Accountable Care Organization Presented by Linda Stutz RN MBA Care Coordination Senior Director Banner Health Tricia Nguyen MD MBA Chief Medical Officer Banner Health Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join 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 If you are not already receiving notifications about upcoming Learning Sessions you may register or update your subscription preferences at http eepurl com jOFqb key words Integrating Care Shining Stars Care Transitions Banner Health webinar learning session 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

    Original URL path: http://medicaring.org/tag/best-practices/ (2016-04-30)
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  • CCTP – MediCaring.org
    http www nejm org doi full 10 1056 NEJMsa0803563 The Hospital Readmissions Reduction Program http www cms gov Medicare Medicare Fee for Service Payment AcuteInpatientPPS Readmissions Reduction Program html The Community based Care Transitions Program http innovation cms gov initiatives CCTP Reducing Readmissions From the Experts Webinar Thursday August 8 3 pm ET Posted by Janice Lynch Schuster on August 7 2013 No Responses Tagged with best practices care transitions CCTP CMS community based discharge planning eldercare frail elders hospital readmissions Medicare quality improvement Aug 07 2013 As part of its ongoing series on reducing readmissions the Integrating Care for Communities project from the Colorado Foundation for Medical Care hosts a webinar on Thursday August 8 at 3 ET Details about the program can be found here with information provided by CFMC During this session we will hear from ARC Avoiding Readmissions through Collaboration California Community Based Care Transitions Program CCTP Awardee Learning Objectives Participants will Identify the structure and tactics used by the collaborative to drive readmission reduction in participating hospitals Trace the collaborative s efforts to develop a Patient Advisory Council Examine how to develop and deploy a successful relationship between a hospital and their SNFs to optimize care transitions Presented by Cheryl Reinking RN MS Interim Chief Nursing Officer El Camino Hospital Cheryl Reinking RN MS has served 25 years at El Camino Hospital in progressive nursing leadership roles her most recent being as Interim Chief Nursing Officer which she assumed in July 2013 Cheryl has led a number of hospital wide initiatives and was key to the hospital s implementation of the nationally recognized Nurses Improving Care for Healthsystem Elders NICHE program which was designed to create increased patient centric care for hospitalized older patients She developed the hospital s site specific program Pat Teske RN MHA Cynosure Health Pat Teske RN MHA is the implementation officer for Cynosure Health In her role she strives to implement the company s vision through strategic planning and execution of projects on time and within budget that yield successful outcomes Previously she held the position of vice president of Quality Improvement and Care Management for Catholic Healthcare West Pasadena CA where she lead the regions chief nursing officers quality directors case managers and medical staff directors to accomplish their annual goals As an independent contractor Pat supported BEACON the Bay Area Patient Safety Collaborative as well as other state and local collaboratives She is currently leading the Avoid Readmissions through Collaboration ARC effort in CA and working nationally with HRET on the Partnership for Patients HEN A requested public speaker at national state and local conferences including IHI NPSF and TJC Ms Teske has developed and offered numerous educational programs designed to support performance improvement and system reliability Pat received her MHA from the University of LaVern and her BS in Nursing from the University of Virginia Lisa Ehle MPH Program Manager Cynosure Health Lisa Ehle MPH is a Program Manager at Cynosure Health and currently oversees the Avoid Readmissions Through Collaboration ARC program and the ARC Patient Advisory Council Before joining Cynosure Health Lisa served as the State Director of Program Services with the March of Dimes Massachusetts Chapter where she co founded the MA Perinatal Quality Collaborative and directed a Program Services Committee charged with addressing the perinatal needs of the state She has been an advocate for maternal and child health issues including preterm birth prevention routine HIV screening smoking cessation and improving hospital discharge practices Lisa has worked at the state level for the MA Department for Public Health creating policies and guidelines for infectious disease prevention and screening programs Lisa received her Bachelor of Science in Physical and Psychiatric Rehabilitation Counseling from Boston University Sargent College and a Masters of Public Health from Boston University School of Public Health specializing in Social and Behavioral Sciences Event Care Transitions Learning Session webinar Date August 8 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 key words readmissions rehospitalizations care transitions quality improvement organizations CMS CFMC CCTP Success Will We Know It When We See It Posted by Janice Lynch Schuster on July 3 2013 No Responses Tagged with care transitions CCTP CMS Coleman Model community based frail elders hospital readmissions Medicare quality improvement rehospitalization Section 3026 Jul 03 2013 By Carol Castillon Defining success in work that focuses on people who are very sick can be a challenge The usual metrics just aren t always applicable With that in mind how will we know success in our community based care transitions work CCTP Like everyone else involved in this endeavor San Diego faces the challenge of reaching a 20 reduction in Medicare fee for service readmissions We are avidly monitoring our progress But is that really success To some extent of course it is and it would be fabulous to get there If and when we do though I think there would still be a void Perhaps I m naïve or perhaps I have what we lovingly call a social worker s heart but my definition of success is something a little different The only way to convey this is by telling the story of patient X A day after admitting patient X to a partnering hospital our Inpatient Transition Coach assessed the patient for meeting our high risk criteria That same day the patient was assigned to the Care Transitions Intervention CTI coach The coach saw the patient and enrolled him into CTI as well as into our Care Enhancement program which could address the need for social services Throughout the hospital stay the partnering hospital provided the patient with assistance in communicating his needs to his healthcare team From this interaction the team learned that the patient could not afford his medication co pays Based on hospital regulatory charity guidelines we were able to have that fee waived After 3 days in the hospital the patient was discharged and the CCTP clock began to tick When the patient opened his apartment door our coach found herself in an all too familiar situation She found that the apartment had been hit by what looked like a tornado involving the patient s medications The patient filled with nervousness and relief at seeing the coach who is a nurse blurted I need to call 911 I need to get to the ER Every CTI coach fears hearing this Staying calm our coach assessed the patient and found that he had been suffering from a headache since the day of discharge The patient did not have any pain medications or transportation to obtain such medications Using her charismatic charm the coach was able to coach the patient to call his physician and discuss these symptoms She then helped him to identify some key issues that were quite evident with his medications The visit lasted for about 2 hours but even with that much time the coach could not complete the four pillars of the CTI model Instead she worked with the patient to set follow up medical appointment with his physician and connected him with some of our Care Enhancement services Through Care Enhancement we were able to provide a taxi prescription to get the patient to his doctor s office The Care Enhancement social worker then worked miracles The social worker connected the patient with a home health program which the patient had declined at discharge She assisted the patient in obtaining transportation through our Metropolitan Transit System Access which assists people with disabilities The long term needs assessment found that the patient had shown symptoms of depression and so the social worker addressed this problem with the patient and physician The patient was connected with in home counseling aide and attendance through the VA and housing In terms of housing she helped the patient to move from his second floor apartment floor and limited his ability to go out the patient uses a scooter to a living environment better suited to his needs Now that s success Because of our team s work and focus the patient doing better This was a direct result of our collective interventions Patient x has ongoing support from a team that is committed to improving the lives of each and every patient we meet Right now we are at 80 days post discharge and no readmission Carol Castillon works for Aging Independence services and manages the CCTP work in San Diego County key words CTI Coleman model care transitions San Diego County CMS readmissions quality improvement care enhancement The Feedback Circle San Diego CCTP Listens to All Perspectives to Improve Care Transitions Posted by Janice Lynch Schuster on June 21 2013 No Responses Tagged with care transitions CCTP CMS coalition building community partnerships discharge planning hospital readmissions Medicare quality improvement rehospitalization San Diego Section 3026 Jun 21 2013 By Carol Castillon By developing a feedback loop so that community based organizations and hospitals can communicate more effectively about shared patients San Diego s Community based Care Transitions Project CCTP has opened a door for improving patient health improvement Over the past few months I have witnessed first hand the development of this crucial piece of the program In the San Diego CCTP anchored by Aging Independence Services a community based organization we offer two CCTP approved interventions the Care Transitions Intervention CTI and Care Enhancement Our partnership includes four health systems and 13 hospital campuses When I think of hospitals and medicine I think of answers Individuals seek attention from hospitals and physicians for answers as to why they are ill or why their bodies are not reacting as they should Clinicians and other professional caregivers witness health problems within the clinical environment or only hear about them from a patient or caregiver For those individuals who are in a high crisis mode accuracy can become a problem And often as soon as a patient is admitted to the hospital he or she patient expresses the desire to go home and in order to get home they will say or agree to just about anything clinicians recommend I know this from my own experience as someone who believes quite sincerely that there s no place like home At the same time patients and their loved ones often are unprepared 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 Solving a Puzzle Invoicing for Patient Encounters with the San Diego CCTP Posted by Janice Lynch Schuster on May 29 2013 No Responses Tagged with care transitions CCTP community based discharge planning frail elders hospital readmissions Medicare rehospitalization San Diego County May 29 2013 By Deborah Marquette It was the classic conundrum how do you fit a square peg into a round hole The County of San Diego is widely known for doing things a little differently and our model for providing community based care transitions project CCTP services is no different The San Diego Care Transitions Partnership SDCTP CCTP model includes the Care Transitions Intervention CTI However in addition to CTI the SDCTP model includes a variety of interventions that are completed prior to discharge e g High Risk Health Care Coach Inpatient Navigator Bridges and Pharmacy The model also includes additional post discharge interventions such as CTI Care Enhancement and non CTI follow up phone calls These additional interventions posed our first challenge for invoicing We quickly realized that the List Bill design CMS method for billing Medicare for CCTP wouldn t meet our internal needs for gathering monitoring and tracking invoice and intervention data For some of our interventions there is no clear mapping between our intervention and the List Bill s Care Transition Services For others the List Bill was too ambiguous For example if we select Telephone follow up as the Patient Encounter how will we know whether that patient received CTI or our non CTI follow up phone call intervention Hmm thoughtful pause we needed to find a way to meet the List Bill requirements while capturing the data in a way that would 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 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

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    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 Getting There From Here CMS Advises Potential CCTP Applicants on What It Takes to Win Posted by Janice Lynch Schuster on July 16 2012 No Responses Tagged with care transitions CCTP CFMC CMS frail elders hospital readmissions Medicare rehospitalization Jul 16 2012 Eager to apply for Community Based Care Transitions Program CCTP funds from the Centers for Medicare and Medicaid CMS CMS is equally eager to make awards Aiming to encourage organizations to apply to the final round of the CCTP funding CMS sponsored a 90 minute webinar that featured tips from program administrators on how to write a winning application along with insights from communities that have recently been funded The webinar offered just about everything applicants need to know to be successful It highlighted insights on what to do and what to avoid as you pull together a team and submit your application CMS Chief Medical Officer Paul McGann MD introduced the session by stating that in terms of the Partnership for Patients PFP the 3026 program is critical to helping CMS achieve its goals to improve patient safety while reducing costs He noted that the program is the first time ever that communities have been invited to define and price a Medicare benefit The program represents an opportunity for organizations coordinate and collaborate to deliver services that help residents experience better health outcomes It is he said a new way of reaching out The webinar represented CMS effort to push out as much information as it can so that organizations can successfully apply to become CCTP communities A final round of funding decisions will be made in late September To be considered applications must be received no later than close of business on September 3 2012 Details about application requirements and parameters can be found on the CMS Innovations website at http www innovations cms gov initiatives Partnership for Patients CCTP index html In addition to providing an overview of the program the site includes links to the RFP the application package and the budget worksheet In general to be eligible programs must represent a partnership between an acute care hospital and a community based organization if it is the anchoring organization the acute care hospital must be on CMS list of high readmit hospitals Otherwise it need not be CBOs must provide care transitions services They must have a governing board that includes consumer representation they must be non profits they must be located in the community they aim to serve and they must have previous experience in care transitions work Closed systems those in which for example a hospital and a home care agency are part of the same organization are not eligible to apply Preference is given to applications that include organizations supported by the Administration for Community Living ACL formerly the Administration on Aging and that serve medically underserved and rural areas Successful applicants from around the country talked about various aspects of their applications and their work These groups included P2 collaborative from Western New York Carondolet in Arizona Age Options in Illinois and Delaware County Pennsylvania Potential applicants would do well to read the one page summaries written by each of these sites and posted at http www innovations cms gov initiatives Partnership for Patients CCTP partners html In the coming weeks MediCaring aims to interview staff at each of these sites to learn more about what made their applications stand out and what they plan to do in the coming years Ashley Ridlon of CMS described some of the lessons learned by organizations that have already successfully applied to the program These organizations have found that a number of factors contribute to readmission including those on the individual level as well as those on a systems level Individual problems include poor patient provider interactions medication mismanagement and avoidable returns to the emergency department Systems level problems include the absence of standardized forms and processes poor cross setting communication and a failure to activate patients to ensure that they are engaged and informed partners in their care The root cause analysis required by the CCTP application process is designed to help communities uncover their own problems and gaps in care transitions and to consider and implement relevant interventions This process is at the heart of a successful CCTP application Ridlon emphasized that applicants must conduct community specific root cause analyses and develop an implementation plan that is in line with those findings She also noted that those plans need to align with other care transitions activities currently available in a community In addition relevant documented experience providing care transitions services is essential to writing a successful application In describing that experience CMS urged applicants to be explicit with details describing not only reductions in readmissions but methodology evaluation characteristics of patients enrolled or not enrolled and outcomes They should also describe in detail any care transitions training their staff have received who participated when and where and how others will be trained Ridlon urged participants to engage their CMS Regional Quality Improvement Organizations QIOs an invaluable resource QIOs can help applicants to conduct their root cause analyses collect data identify partners arrange meetings and select interventions Juliana Tiongson also of CMS described issues surrounding the budget process It is essential that applicants read and understand what the RFP calls for To some extent the program can be defined

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