Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare

August 7, 2019

Promising Models of Care Coordination/care Management For Beneficiaries With Chronic Illnesses

Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare
Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare
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http://socialwork.nyam.org/mwg-internal/de5fs23hu73ds/progress?id=1/DIeJ7cnT

August 7, 2019

Effect of a Hospitalist-Care Coordinator Team on a Nonteaching Hospitalist Service.

O’Leary K, Lindquist L, Colone MA, et al. Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service. J Hosp Med. 2008 Mar;3(2):103-9.http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract. Accessed December 11, 2014. BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to […]
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O'Leary K, Lindquist L, Colone MA, et al. Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service. J Hosp Med. 2008 Mar;3(2):103-9.http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract. Accessed December 11, 2014. BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to evaluate the impact of a hospitalist-care coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency. DESIGN AND PARTICIPANTS: During each of 12 weeks, hospitalists on a nonteaching hospitalist service were randomly assigned to work with a hospitalist care coordinator (HCC) or to work independently. MEASUREMENTS: Each week hospitalists completed a survey to assess their satisfaction and perceived work efficiency. Patient satisfaction with hospital discharge was assessed by telephone interviews. Hospital efficiency was analyzed with multivariate linear regression using log-transformed length of stay (LOS) and cost as dependent variables. RESULTS: The 356 patients cared for by hospitalist-HCC teams were similar to 337 patients cared for by control hospitalists. Twenty-eight of 31 hospitalists (90%) who worked with an HCC responded that the HCC improved their efficiency and job satisfaction. Seventy-one of 196 eligible patients (36%) completed the postdischarge interview. The mean ratings of overall satisfaction with hospital discharge on a scale of 10 were similarly high in both groups (8.57 vs. 8.37; P = .94). In multivariate regression analyses, LOS was 0.28 days shorter and cost was $585.62 lower for patients cared for by hospitalist-HCC teams; however, these results were not statistically significant (P = .17 and .15, respectively). CONCLUSIONS: Hospitalists working in a team approach with an HCC reported improved efficiency and job satisfaction compared with hospitalists working independently. These findings are important in light of growing concerns about hospitalist workload and job satisfaction.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract

August 7, 2019

Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients

This special report is based on an in-depth analysis of responses from nearly 100 healthcare organizations to the 2009 Healthcare Intelligence Network Industry Survey, “Managing care Transitions,” as well as selected case studies of care transition management programs.
This special report is based on an in-depth analysis of responses from nearly 100 healthcare organizations to the 2009 Healthcare Intelligence Network Industry Survey, “Managing care Transitions,” as well as selected case studies of care transition management programs.
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http://hin.3dcartstores.com/Retooling-Care-Transitions-to-Reduce-Hospitalizations-in-Medicare-Patients_p_3925.html

August 7, 2019

Pharmacy Team Providing Enhanced Services to a Transitional Care Unit.

Boord A, Sanders S, Bass L, et al. Pharmacy Team Providing Enhanced Services to a Transitional Care Unit. Am J Health Syst Pharm. 2007;64(6):647-651. http://www.medscape.com/viewarticle/555610_1. Accessed December 11, 2014. The development of a pharmacy team to evaluate patients admitted to the TCU resulted in improved patient care and outcomes. One […]
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Boord A, Sanders S, Bass L, et al. Pharmacy Team Providing Enhanced Services to a Transitional Care Unit. Am J Health Syst Pharm. 2007;64(6):647-651. http://www.medscape.com/viewarticle/555610_1. Accessed December 11, 2014. The development of a pharmacy team to evaluate patients admitted to the TCU resulted in improved patient care and outcomes. One of the team's most important contributions is the virtual elimination of medication errors following the implementation of computerized transfer orders.
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http://www.medscape.com/viewarticle/555610_1

August 7, 2019

Quality Matters Newsletter: In Focus: Toward a System of Coordinated Care

Hostetter M. In Focus: Toward a System of Coordinated Care. Quality Matters. The Commonwealth Fund.http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june.Published May/June 2007. Accessed December 11, 2014. The care of many patients lacks necessary oversight and continuity, particularly during transitions among health care providers and settings. Current efforts to improve care coordination focus on patient coaching […]
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Hostetter M. In Focus: Toward a System of Coordinated Care. Quality Matters. The Commonwealth Fund.http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june.Published May/June 2007. Accessed December 11, 2014. The care of many patients lacks necessary oversight and continuity, particularly during transitions among health care providers and settings. Current efforts to improve care coordination focus on patient coaching and tracking of high-risk groups, but widespread reform will require changes to the financing of care delivery and other system-wide changes
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http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june

August 7, 2019

Home Health Telemedicine

Home Health Telemedicine is a remote technology-enabled model in which nurses manage the care of chronic patients in their homes using video units and diagnostic devices.
Home Health Telemedicine is a remote technology-enabled model in which nurses manage the care of chronic patients in their homes using video units and diagnostic devices.
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http://www.innovativecaremodels.com/care_models/18

August 7, 2019

Guided Care Patient-Centered Medical Home

Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is […]
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Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information technology to provide state-of-the-art care for 50-60 chronically ill Medicare beneficiaries. Following a comprehensive assessment and planning process, the Guided Care nurse educates and empowers patients and families, monitors their conditions monthly, and coordinates the efforts of health care professionals, hospitals and community agencies to be sure that no important health-related need slips through the cracks
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http://www.guidedcare.org/pdf/Guided%20Care%20summary%20and%20results.pdf

August 7, 2019

Care Cooperation and Continuity Across Clinicians, Facilities and Systems: Massachusetts Strategic Plan for Care Transitions

Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and […]
Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and HIT strategies
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http://www.iom.edu/~/media/Files/Activity%20Files/Quality/VSRT/16-Care%20cooperation%20and%20continuity.ashx

August 7, 2019

AARP: Advance Directives: Planning for the Future

AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one’s health care wishes are at the end of life? Find out how advance directives can help.
AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one's health care wishes are at the end of life? Find out how advance directives can help.
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http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html

August 7, 2019

AARP: Talking About Your Final Wishes

AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do […]
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AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do I want to die? Who will take care of me? What do I have to do to achieve a "good death?" These questions raise just a few of the issues to be considered in deciding your care at the end of life.
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http://www.aarp.org/relationships/grief-loss/info-2003/endoflife-finalwishes.html