Podcasts about care transitions

KMOX Health Editor Fred Bodimer talked with Dr. Ann Elizabeth Mohart, Mercy Vice President and Medical Director of Care Transitions about Mercy launching its first Hospital-at-Home program in the St. Louis area.

The newest episode of Mary Free Bed's Advisory Group podcast, Be Advised, spotlights physical medicine and rehabilitation residency programs and how they bring value to an organization.This episode's featured guest is Dr. Adam Lamm, assistant medical director for Mary Free Bed's Physical Medicine and Rehabilitation Residency (PM&R) program.Dr. Lamm specializes in the care of adults with brain injuries and strokes. He works with patients in our inpatient and outpatient Brain Injury programs as well as our post-concussion program.A graduate of Case Western Reserve University School of Medicine, Dr. Lamm earned his medical degree as well as a master's degree in bioethics. He completed a physical medicine and rehabilitation residency at Spaulding Rehabilitation Hospital/Harvard Medical School, where he served as chief resident. Following his residency, Dr. Lamm completed a brain injury medicine fellowship at Spaulding.Be Advised is hosted by Joyal Pavey, vice president of the Mary Free Bed Advisory Group. The podcast hosts experts who shine a spotlight on the field of medical rehabilitation as a critical component of health care.This conversation covers a wide range of topics, including:Dr. Lamm's background and journey to the field of PM&RThe history of Mary Free Bed's residency programWhat value does a residency program add to an organization?What can incoming residents expect from Mary Free Bed's program?Where do graduating residents go onto in their careers?The comprehensive PM&R Residency at Mary Free Bed includes clinical, educational and research opportunities in all areas of physical medicine and rehabilitation. Resident physicians gain experience working with brain injury, spinal cord injury, stroke, multiple trauma, amputation, cancer, COVID-19 rehabilitation and other diagnoses.For questions about this or other “Be Advised” podcasts email us at: advisorygroup@maryfreebed.comFind out more about the Advisory Group.

The ‘Be Advised' Podcast is back with a new episode exploring the topic of medical leadership and what that looks like now and into the future of rehabilitation programs. This episode's guest is Dr. Michael Jakubowski, the Chief Medical Officer of Mary Free Bed Rehabilitation Hospital. Over the last several years, the inpatient rehabilitation industry has seen a rise in the complexity of persons served. Patients now often have multiple co-morbidities, a higher case mix index and require a well-coordinated team of specialty providers. Through Dr. Jakubowski's leadership, Mary Free Bed has been able to ensure patients with complex needs receive critically-important medical coordination, to help facilitate sustainable functional outcomes, as well as decrease complications of care. On this episode of Be Advised, Dr. Jakubowski discusses the role medical leadership plays in a progressive, forward-focused rehabilitation program. He is joined by host, Joyal Pavey, vice president of the Mary Free Bed Advisory Group. Co-advisors, and co-hosts are J'nise Ramsey and Sherry Mullins who serve as regional directors of care transitions and Dr. Robert Krug.For questions about this or other “Be Advised” podcasts email us at: advisorygroup@maryfreebed.comFind out more about the Advisory Group.

Family caregivers play a crucial role in the successful healthcare transitions of the loved ones. They are uniquely capable of monitoring their loved one's progress and spotting red-flags early on; they can also provide valuable information to physician regarding disease progression, environmental changes, and other key details. Caregivers should be treated as partners in the medical care of their loved ones. Sadly, this is not always the case. Caregivers are often not involved in discharge and care transition planning processes, and they may not be adequately educated on their loved one's diagnosis, risk factors, or other essential information. And that failure to involve caregivers has high costs for everybody. Today, Terri Stacy and Joy Wallsten, our producer, are joined by Regenstrief Institute Research Scientist, Dr. Kristin Levoy, who led a meta-analysis of findings from 54 studies (involving more than 31,000 individuals) confirming that caregiver engagement across healthcare transitions of chronically ill adults is instrumental in preventing rehospitalizations and holds potential for enhancing other patient outcomes. Connor Prairie Memory Cafes: https://www.connerprairie.org/explore/things-to-do/memory-cafe/ Sensory Friendly Hours: https://www.connerprairie.org/event/sensory-friendly-hours-3/2022-08-14/ Email Tina: tina@joyshouse.org Learn more about Joy's House: www.joyshouse.org See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Family caregivers play a crucial role in the successful healthcare transitions of the loved ones. They are uniquely capable of monitoring their loved one's progress and spotting red-flags early on; they can also provide valuable information to physician regarding disease progression, environmental changes, and other key details. Caregivers should be treated as partners in the medical care of their loved ones. Sadly, this is not always the case. Caregivers are often not involved in discharge and care transition planning processes, and they may not be adequately educated on their loved one's diagnosis, risk factors, or other essential information. And that failure to involve caregivers has high costs for everybody. Today, Terri Stacy and Joy Wallsten, our producer, are joined by Regenstrief Institute Research Scientist, Dr. Kristin Levoy, who led a meta-analysis of findings from 54 studies (involving more than 31,000 individuals) confirming that caregiver engagement across healthcare transitions of chronically ill adults is instrumental in preventing rehospitalizations and holds potential for enhancing other patient outcomes. Email Tina: tina@joyshouse.org Learn more about Joy's House: www.joyshouse.org See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

In this podcast, Editor-in-Chief Dr. Jeanette Hasse, interviews Stephen Adams and Dr. Joseph Boullata, two of the authors of the ASPEN Consensus Statement “Safe care transitions for patients receiving parenteral nutrition” published in the June 2022 issue of NCP. June 2022 Business Corporate by Alex Menco | alexmenco.net Music promoted by www.free-stock-music.com Creative Commons Attribution 3.0 Unported License creativecommons.org/licenses/by/3.0/deed.en_US

HealthIMPACT Live Presents: Patients as Partners - Ensuring Your Health System is a Partner Throughout the Patient Journey from Prevention to Recovery at HomeOriginally Published:  Apr 7, 2022YouTube Video: https://www.youtube.com/watch?v=l2qxDdZfV8sThe shift to virtual care during the pandemic has created a whole new set of patient experience and engagement challenges.  Managing the health of vulnerable patients with chronic illnesses like diabetes virtually was of particular concern.  The need for engaging accessible tools has never been greater.  In this session a healthcare leader will discuss what works and what doesn't when it comes to supporting, engaging, activating, coaching, and ultimately partnering with patients:Empowering patients at key decision points for a better experience and outcomesThe power of trustworthy content with behavior-based delivery and tracking tools to enable everyone to understand health care decisionsLeveraging analytics to provide key insights as patients struggle with decisions during the care process Emily Dumas, Manager of Care Transitions, University of Alabama Birmingham Medical Center

The Mary Free Bed Advisory Group's podcast, “Be Advised,” is back with its eighth episode. Special guest is Dr. Ralph Wang, a Mary Free Bed physician, who discusses his role at the hospital, including involvement with its COVID-19 ReCOVery Program, and offers input on the importance of transitions of care.Dr. Wang is a physiatrist – a physician who specializes in physical medicine and rehabilitation. An employee since 2019, he cares for adult inpatients with a variety of diagnoses at Mary Free Bed's main campus in Grand Rapids, Michigan. He earned his medical degree at Northwestern University and completed his residency at the Baylor College of Medicine and TIRR Memorial Hermann. He served as Illinois medical director for U.S. Physiatry prior to joining Mary Free Bed.“Be Advised” is hosted by Joyal Pavey, vice president of the Advisory Group. The podcast spotlights the field of medical rehabilitation and why it's a critical component of health care. 

In our latest episode of “Be Advised,” we discuss home health and skilled nursing facilities and how they partner with inpatient rehabilitation programs.Home care, sub-acute, and skilled nursing facilities play a vital role in the post-acute continuum of care, and when that care is well coordinated, patients can sustain better outcomes.But, how do you actually help patients and staff with the changing reimbursement models and the current health care environments? Our guests on this episode of “Be Advised,” the Mary Free Bed Advisory Group Podcast, will help us answer that!  For this episode you'll meet Kiersten Cudney, LNHA, MPA, Administrator for Mary Free Bed Sub-Acute Rehabilitation, and Trey Kubizna, Regional Director and Administrator for Mary Free Bed at Home.For questions about this or other “Be Advised” podcasts email us at: advisorygroup@maryfreebed.com Advisory Group: https://www.maryfreebed.com/about-us/mary-free-bed-advisory-group/ Mary Free Bed Sub-Acute Rehabilitation: https://www.maryfreebed.com/conditions/sub-acute/ Mary Free Bed at Home: https://www.maryfreebed.com/mary-free-bed-at-home/ 

The community “arm” of our center, Ms. Boston discusses the outreach relationships she has with providers, to ensure a seamless transition to our center.

Jason Peoples joins the Be Advised podcast to discuss virtual care, telemedicine and how to accelerate the meaningful use of these mediums in acute care and rehabilitation.Jason is the Director of Technology and Innovation at Mary Free Bed. He has 12 years of experience in health care, with his last five years at Mary Free Bed. Jason was instrumental in the development of Mary Free Bed's virtual care programs leading up to and during the pandemic. In this episode, Jason shares his experience and insight on health care organizations can best utilize virtual services to help patients have the best experience. 

Dr. Allan J. Kozlowski joins the Be Advised podcast to discuss how outcomes research aligns with care transitions. Allan J. Kozlowski, Ph.D., serves as the Director of Outcomes Research at the John F. Butzer Center for Research & Innovation and Assistant Professor in the Department of Epidemiology and Biostatistics at Michigan State University College of Human Medicine. He's been instrumental in the development of many of the Advisory Group care transitions services and many other research based initiatives at Mary Free Bed and Michigan State University. 

This week on Sg2 Perspectives, Sg2 Senior Director Justin Cassidy, PhD, joins Trevor DaRin to interview FHN Chief Operating Officer/Chief Nursing Officer Kathryn Martinez, MSNRN, FACHE, on the health system's integrated approach to care transitions—including making the case for ROI and setting up community liaison programs to assist with culturally competent care—and its success with remote patient monitoring technology, from data management and involvement of complex care managers to partnering with public agencies for help in rural areas.   We are always excited to get ideas and feedback from our listeners. You can reach us at sg2perspectives@sg2.com, find us on Twitter as @Sg2HealthCare, or visit the Sg2 company page on LinkedIn.

The second episode of Be Advised features Dr. W. Christian VandenBerg,  who joins us to discuss aligning Care Transitions and Patient Access. Dr. VandenBerg is medical director of Access at Mary Free Bed Rehabilitation Hospital. He specializes in cancer rehabilitation, traumatic and non-traumatic neurological impairments (spinal cord injury, brain injury, stroke and multiple sclerosis) and spasticity/dystonia. He has been a staff member since 1989.Dr. VandenBerg is a graduate of the Michigan State College of Human Medicine and completed his PM&R residency through Northwestern University at the Rehabilitation Institute of Chicago.

This course will cover components of successful discharge planning and early aftercare in the engagement of recently hospitalized individuals. Participants will better understand the role of hospitalization and continuity of care post-discharge.

A simple text-based patient monitoring and outreach solution deployed in just 8 days by New York City Health + Hospitals (NYCHH) at the start of the COVID-19 pandemic continues to benefit patients, staff, and the people of New York City a year later. Hear Dr. David Silvestri, Emergency Physician and Senior Director of Care Transitions and Access at NYCHH talk about the importance of inclusive design to ensure equal access to care. Learn more about New York City Health + Hospitals: https://www.nychealthandhospitals.org/ Learn more about Lumeon: https://www.lumeon.com/ Find more great Health IT content: https://www.healthcareittoday.com/

Most medical mistakes happen during care transitions. Helen and Jerry have some tips on improving those crucial moves between care providers and settings.  Care transitions are changes in a patient's care setting or care provider.  Patients may move from living at home to residing in a facility, or make a transition from home health to hospice care.  Maybe the care transition is from one hospice team to another, or from the outpatient hospice staff to the inpatient hospice unit for crisis management.  Communication is key!  If you're a patient or a caregiver, make sure to ask your questions and repeat them if you need to.  Write down the answers and keep those written instructions close by for easy access.  Don't be afraid to make a follow up phone call after a care transition has happened.  If you're a healthcare provider, it's your responsibility to make those transitions successful by providing full support and education to patients and their caregivers.  Repeat instructions patiently, and provide written medication lists and instructions that are easy to read and understand. You can find more support and education about end of life care at theheartofhospice.com.  We're here 24/7 to help you with information about hospice philosophy, self care, and advance care planning.  Your organization can have Jerry or Helen to speak at your next event or conference by sending an email to host@theheartofhospice.com. Stay connected with us - you are The Heart of Hospice! 

Hello everyone, This week I have a hamster community member, Lauren, from @_bearthehamster_ on to talk about how her hamsters and her a=history with hamster care!! We discussed the struggles of U.K vs. U.S proper hamster care items and stories about our hamsters!! Write in collaborations from @woody_hamster_ and @beathesyrianhamster!! If any of you have noticed the difference between male and Syrian hamster behavior let me know!! This will be a future topic discussed on the podcast. Thank you so much Hamster Community, you are the best! I appreciate you all and enjoy hearing from you, meeting you, as well as hearing feedback from you! Send me a message on Instagram if you would like to be featured or come on the podcast with me! I truly love you all in the Hamster Community and am extremely grateful for every single one of you! Have a wonderful week, and I will see you all again next Friday for another episode!! For more info on how to be featured, adorable hamster content, and podcast updates follow @Petra_the_hamster on Instagram! --- Support this podcast: https://anchor.fm/holly-hernandez9/support

With us today is Maureen McCarthy. Maureen is president of Celtic Consulting, LLC, and CEO and founder of Care Transitions, LLP, a care coordination service provider. We chat about the proposed FY 2022 payment rule for SNFs.

With us today is Maureen McCarthy. Maureen is president of Celtic Consulting, LLC, and CEO and founder of Care Transitions, LLP, a care coordination service provider. We discuss how reimbursement avenues have changed in the past year, and how SNFs need to consider what might change as the pandemic hopefully improves.

Dr. Peter Chang, Vice President of Care Transitions at Tampa General Hospital, joined the podcast to outline where he sees virtual care technology headed and innovations in enterprise imaging and radiology. He also offered 3 words of wisdom for clinical leaders on the rise.

Jon, Kari, and Julie talk about how to care for our seniors and their care transitions. Kari DeCarlo, BSW, Vice-President of Creative Eldercare Consultants, has her Bachelor’s Degree in Social Work with over 20 years in health care. Kari possesses excellent assessment skills and can identify one’s needs for appropriate placement. At Creative Eldercare Consultants, Kari aims to provide professional and compassionate guidance during the challenging process of finding the best care and housing match. Her unbiased viewpoint for families will help reduce any unforeseen placement concerns during this often delicate time. Julie Haskins-White, CSA, CDP: President/Owner of Creative Eldercare Consultants, has her Bachelor’s Degree in Marketing, with over 30 years of professional senior health care experience in Southeastern Michigan. In addition to her strong background in geriatric health care management and marketing, she has worked with thousands of families to help review their loved one’s needs and to find the best resources for care and housing. Julie served as the Executive Director of Trinity Health’s Private Duty Home Care Division for the State of Michigan, overseeing care at 7 offices and 4 assisted living communities., and worked for over 25 years in the home care field. She started the company in 2012, along with earning her Certified Senior Advisor’s Designation, and has since added the Certified Dementia Practitioner Designation as well, to enhance her skills and stay abreast of current trends in the senior industry. She serves as a very compassionate, knowledgeable voice for families and seniors in transition and personally connects them to the resources to assist them in find their optimal senior living match. Mission: The mission of Creative Eldercare Consultants is to provide kind, personal and knowledgeable assistance to the elderly and their families during the often stressful and time sensitive process of making care and housing changes. Connect with Jon Dwoskin: Twitter: @jdwoskin Facebook: https://www.facebook.com/jonathan.dwoskin Instagram: https://www.instagram.com/thejondwoskinexperience/ Website: https://jondwoskin.com/LinkedIn: https://www.linkedin.com/in/jondwoskin/ Email: jon@jondwoskin.com Get Jon’s Book: The Think Big Movement: Grow your business big. Very Big!   Connect with Kari DeCarlo and Julie Haskins-White: Website: www.creativeeldercare.com

Dr. Peter Chang, Vice President of Care Transitions at Tampa General Hospital, joined the podcast to outline where he sees virtual care technology headed and innovations in enterprise imaging and radiology. He also offered 3 words of wisdom for clinical leaders on the rise.

Transitioning elderly patients from acute care facilities continues to be inefficient, inconvenient and fraught with risk.. It shouldn’t be this way. naviHealth is a company that makes a technology platform that uses evidence-based protocols along with dedicated staff to track patient recoveries, manage hospital discharges and improving support clinical decision making. Their goal is to help build a future with more senior-centered care. We sat down with Jay LaBine MD, Chief Medical Officer at naviHealth. We discussed how decisions are made when transitioning patients to post-acute care, the future of homecare, and the overall lack of investment in this area. Watch this video to learn more about: * Transition of care pre- and post-COVID-19 * The role Medicare plays in transition of care * How increasing transparency can lead to faster senior care improvement * The two most important things for a hospital CEO when it comes to transition of care * Why it’s important to invest in the care model and not just the technology Learn more at: https://www.navihealth.com/

Expert Maureen McCarthy, president of Celtic Consulting, LLC, and CEO and founder of Care Transitions, LLP, a care coordination service provider, joins us to talk about what SNF audits may look like after the pandemic.

UAB's Associate Vice President for Care Transitions Alison Garretson, MBA, RN, NEA-BC, discusses effective care transitions, including preventing medical errors, identifying issues for early intervention, preventing unnecessary hospitalizations and readmissions, supporting consumer preferences and choices, and avoiding duplication of processes and efforts to more effectively utilize resources. This podcast is also available in video format at https://youtu.be/BwSKDw1yqAY.

Expert Maureen McCarthy, president of Celtic Consulting, LLC, and CEO and founder of Care Transitions, LLP, a care coordination service provider, joins us to talk about billing telehealth in SNFs amid COVID, and the future of telehealth in SNFs.

Certified Elder Law Attorney Barbara McGinnis and Elder Care Coordinator Debra King, LCSW talk about what families need to consider when an elderly loved one needs to move to a different level of care.

On this episode, Jt Thomas sits down with Ronda Paulson, founder of Isaiah 117 House, and talks about her vision for creating a safe home for foster children in transit. --------------------- Thank you for listening to Bristol Radio! Please like, share and subscribe to our Podcast channel on your favorite podcast network. For More Bristol News and Information, go to: http://bit.ly/BristolRadioPodcast Also, for more Bristol news, please like and subscribe to all of our Social Media accounts: Facebook: https://www.facebook.com/bristolmotorspeedway/ Twitter: https://twitter.com/bmsupdates Instagram: https://www.instagram.com/bmsupdates/ YouTube: https://www.youtube.com/user/ThunderValley Twitch: https://www.twitch.tv/bristolmotorspeedway/videos

Join Jennifer N. Clements, Pharm.D., FCCP, BCPS, CDE, BCACP, of Spartanburg Regional and Zach Weber, Pharm.D., BCPS, BCACP, CDE, of Purdue University College of Pharmacy as they discuss care transitions for patients with diabetes.

On this episode of the podcast, we had on Dr. Peter Chang, VP of Care Transitions at Tampa General Hospital and the driving force behind Tampa General Hospital's new CareComm Center. The CareComm Center was created to harness predictive analytics to help improve patient experience, operations, and outcomes. On this episode, we focused on the following: - The challenges of implementing such a transformative initiative. - The biggest hurdles in building the command center. - How the command center may evolve over the next year or five years. - Other key metrics TGH hopes to achieve with CareComm. To learn more about the CareComm Center, Tampa General Hospital, and Dr. Peter Chang, please use the links below. Our sponsor for this podcast is our parent company, BlocHealth. BlocHealth is the credential sharing platform for healthcare professionals and organizations, powered by blockchain technology and their smart, universal common application. They make it easy for healthcare professionals to request, upload and share important credentialing items with various stakeholders, saving time for everyone involved. Healthcare organizations can leverage BlocHealth's credential verification and provider enrollment services as well. For more information, please go to www.blochealth.com and follow BlocHealth on social media - @blochealth Be sure to check out the social channels of our guest: -Website - Facebook - Twitter - LinkedIn - Video Also, be sure to follow Slice of Healthcare on our social channels: - Website - Facebook - LinkedIn - Instagram

Topic: Care Transitions What are care transitions? -Acute to home or chronic care/step down -Example: Hospital to home Concern -Don’t want patient to return to the hospital within 30 days for same problem - Medicare refusal to pay for certain conditions to promote prevention Issues -Understand discharge orders -Comply with discharge orders -Drug coordination from pre-hospital, to in hospital, or post-hospital regimen -Labs and services to follow up Examples -Pneumonia & Serious infections – injectable to oral antibiotic, antibiotics compliance, monitor for symptoms (temperature, swelling, pain, GI symptoms, dizzy/confused, etc.) -Heart Failure – monitor weight everyday, comply with medicines -COPD/Emphysema – arrange for O2, use FiO2 to expand vital capacity, correct use of inhalers -Asthma – correct use of inhalers -Heart Attack – BP, lipid, ACEI regimen of medications – promote compliance -DVT – transition from injectable-to-oral anticoagulants – promote compliance, alert notification if bleed -Pain management – CDC recommendations Support -Nurse case managers -Pharmacists -Home – rest, anabolic diet, hydration ______ Make sure to subscribe to get the latest episode. Contact Us: Pharmacy Benefit News: http://www.propharmaconsultants.com/pbn.html Email: info@propharmaconsultants.com Website: http://www.propharmaconsultants.com/ Facebook: https://www.facebook.com/propharmainc Twitter: https://twitter.com/ProPharma/ Instagram: https://www.instagram.com/propharmainc/ LinkedIn: https://www.linkedin.com/company/pro-pharma-pharmaceutical-consultants-inc/ Podcast: https://anchor.fm/pro-pharma-talks

In this episode of Help Choose Home, we'll hear from Jamie Summerfelt, M.Ed, MSPT, president and CEO of Visiting Nurse Association (VNA) in Omaha, Nebraska. With more than 28 years of healthcare at home experience, Summerfelt is passionate about home care. Harnessing the power of community relationships is something that he sees as integral to the success of extending the capacity to provide health care at home. In establishing partnerships with hospitals, physicians and others in the community, home care agencies are integral to help ensure success in transitional and chronic care.

In the health care industry, communication is vitally important, not only in providing specifics about a patient’s condition, but also in detailing the type of care needed after a stay in the hospital. Dr. Christine D. Jones is an Assistant Professor of Medicine at the University of Colorado, Denver, where she is the Director of Care Transitions for the Hospital Medicine Group.   Over time, Dr. Jones has seen an evolution in the role hospitalists – internal medicine-trained physicians who care for general medical patients in hospitals – play in the care and communication on behalf of patients. Where it was once common for a patient to be given a discharge summary with instructions to follow up with his/her primary care physician, now hospitalists are routinely working to make the follow-up appointments prior to the patient being discharged.

Capturing Emergency Department Discharge Quality With the Care Transitions Measure by SAEM

Capturing Emergency Department Discharge Quality With the Care Transitions Measure: A Pilot Study  Dr. Chana Rich interviews Dr. Amber Sabbatini about this pilot study in the June issue of Academic Emergency Medicine.

Understanding What Drives Health Information Exchange Use During Postacute Care Transitions by Managed Care Cast

Most large hospitals have targeted resources to help older adults with severe acute illness. Dr. Candace Kim, UCSF Geriatric Medicine, talks about potential stressors and specialized services. Knowing about the options and how the system works will help prepare you to navigate the hospital and care transitions more effectively. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 33746]

Most large hospitals have targeted resources to help older adults with severe acute illness. Dr. Candace Kim, UCSF Geriatric Medicine, talks about potential stressors and specialized services. Knowing about the options and how the system works will help prepare you to navigate the hospital and care transitions more effectively. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 33746]

Most large hospitals have targeted resources to help older adults with severe acute illness. Dr. Candace Kim, UCSF Geriatric Medicine, talks about potential stressors and specialized services. Knowing about the options and how the system works will help prepare you to navigate the hospital and care transitions more effectively. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 33746]

Most large hospitals have targeted resources to help older adults with severe acute illness. Dr. Candace Kim, UCSF Geriatric Medicine, talks about potential stressors and specialized services. Knowing about the options and how the system works will help prepare you to navigate the hospital and care transitions more effectively. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 33746]

As patients move out of an acute care setting (e.g., an ICU) into a post-acute setting (skilled nursing facility, rehabilitation facility, or even home), there is a challenging handoff that must occur to ensure their safe transition and ongoing recovery. Caregivers must be able to take all of the patient's information and complex medical situation and build a care plan that will allow them to regain their health and hopefully avoid future problems. This handoff is one of the areas of healthcare that can represent a chokepoint. Clay Richards is CEO of NaviHealth, a Cardinal Health company that helps healthcare organizations create and manage those care transitions. They help “manage patients, improve clinical and financial outcomes, and share risk with payors and providers.” Richards joined us on The Future of Health to explain the problem of care transitions and NaviHealth's solution.

Today Jessie is joined by her good friend and colleague, Jodi Smith, the Regional Administrator of Hospital Operations and Post-Acute Care for Kaiser Permanente. Jodi is one of Kaiser’s greatest and brightest. She was Eric Coleman’s research assistant; he is the national leader and founder of much of today’s care transition work. She is a true thought leader, a Nurse Practitioner, and full of heart for the patients, members, and people Kaiser serves. In this episode, they discuss: What kind of help people actually need after they’ve been in the hospital. What value-based care means, and specifically what it means to patients in our healthcare system. And, how connecting people with one another is the true secret to reforming healthcare. We hope to leave you feeling connected with renewed ambition to support the people through their wellness / illness journey. Thanks for listening!

Date: October 29, 2015 Featuring: Kimberlydawn Wisdom, MD, MS, Senior Vice President of Community Health & Equity and Chief Wellness and Diversity Officer, Henry Ford Health System John Whittington, MD, Lead Faculty, IHI Triple Aim; Senior Fellow, Institute for Healthcare Improvement Sandra Bailey, Vice President for Care Transitions, Methodist Le Bonheur Healthcare Joy Sharp, Manager, Community Navigators, Methodist Le Bonheur Healthcare Mara Laderman, MSPH, Senior Research Associate, IHI Health and health care improvement communities in the US are focusing on equity and racial disparities in some important new ways. Frustrated by the slow progress of closing gaps (despite decades of research and documentation of the problems), many are forging ahead to create more equitable access to care and better outcomes wherever and whenever they can. The new learning is coming from the “doing,” often making use of existing data that already tell a powerful story of persistent inequities (e.g., in cancer diagnosis and treatment, heart disease, and diabetes care) and highlight where there are opportunities to intervene.  On this episode of WIHI, we explored the opportunities health systems have to reduce inequities by virtue of their role as employers and purchasers, as well as their overall stature in the community. Health systems can promote equity with better hiring practices; by using a diverse pool of contractors and suppliers for goods and services; by offering living wages; and by engaging in initiatives in low-income — and often adjacent — neighborhoods. There are also many ways to use the influence and the resources of a health system to develop more community-friendly spaces and places for outdoor activities and physical exercise. These aren’t just pie-in-the-sky ideas. They’re being spearheaded by organizations such as Methodist Le Bonheur Healthcare in Memphis and the Henry Ford Health System in Detroit. There are numerous other examples — but still, not nearly enough.

In this podcast, Susan Craft of the Henry Ford Health System (HFHS), one of four collaborative founders, outlines a few SNF participation and reporting mandates that run the gamut from meeting attendance to LACE readmission risk scores.

World Renowned Population Health and Care Transitions Program founder Dr. Eric Coleman joins PopHealth Podcast to share about his history, the formation of the Care Transitions Program, and the launch of a new program with the Care Transitions Program’s first Non-Medical Partner

Among the myths surrounding care transitions management is the belief the intervention can be effectively executed pre-discharge or by phone only, explains Jennifer Drago, executive vice president of population health for Sun Health. In this audio interview, Ms. Drago dispels this myth, outlining requirements for a professionally designed, evidence-based transitions of care program, and why inclusion of dedicated staff and home visits will enhance clinical outcomes and possibly save lives.

https://www.resourcesforintegratedcare.com/

https://www.resourcesforintegratedcare.com/

Community Care of North Carolina’s Transitional Care program was awarded the Hearst Health Prize this month not only for demonstrating how effective transitional care is for its 1.5 million Medicaid beneficiaries, but also for continually evaluating and modifying the intervention based on its findings. In this broadcast, Carlos Jackson, CCNC’s director of program evaluation, shares one of CCNC’s more interesting findings, identifying the priority population for the intervention, and explains why the care transition management mindset must expand beyond reducing hospital readmissions.

When Bon Secours adapted Geisinger's case management model six years ago and embedded nurse navigators within physician practices, there was reluctance and even resistance from some solo cowboy physician practitioners, recalls Robert Fortini, PNP, chief clinical officer for Bon Secours Medical Group. Today, providers are fiercely protective of the cadre of 70 nurse navigators, who do the heavy lifting of chronic care management. In this audio interview, Fortini offers some lessons learned for organizations considering the embedded case management approach, including budgetary planning, calculations, and icing-on-the-cake outcomes for patients and hospitals.

Nursing Grand Rounds

On the Wednesday, June 3rd 2015 broadcast at 9AM PT/12PM ET our special guest is Jennifer Drago, Executive Vice President, Population Health for Sun Health. Complete bio for Jennifer here: 'As executive vice president of population health, Drago has played a pivotal role in developing and launching several groundbreaking population health-style programs, including the Sun Health Center for Health & Wellbeing, Care Transitions, Community Education and Memory Care Navigator. Several of these programs have received national recognition for quality and innovation. Drago has worked in health care for more than 20 years, including stints as an associate administrator for Boswell Memorial Hospital and Del E. Webb Memorial Hospital. She also held the position of vice president of planning services for the former Sun Health hospital system.' More about Sun Health:  Sun Health is 501(c)(3) nonprofit organization in Arizona that is committed to building health programs that enhance the lives of everyone it serves – residents, patients, donors and volunteers. A leading-edge example is Sun Health’s population-based approach to chronic disease management. Join Fred Goldstein @fsgoldstein and me @2healthguru for a deeper dive into one long term and post acute care (including assisted living and memory care) health eco-system's grasp on and future plans for population health and their innovative CMS Community-based Care Transitions Program (CCTP).

This course is designed to help members of a multidisciplinary team in oncology care increase their knowledge of cultural competence; it will enhance care professional’s confidence when interacting with patients from diverse backgrounds of the concept of cultural competence through three case studies.

JJ Chen, MD, MPH, MBA

With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital's Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF's and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over. Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during "Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers," a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.

To rise to the challenge of non-compliant patients, providers should ask how they can work together to empower patients toward self-management rather than why patients are non-adherent in the first place, suggests Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC). CFMC coordinates the work of state-based Quality Improvement Organizations (QIOs), who have been working with hospitals and community providers to improve care transitions and reduce readmissions. In this interview, Ms. Goroski describes some of the interventions focused on patients, providers or both groups that have not only lowered key Medicare readmission rates but also reduced participants' overall admission stats. Ms. Goroski shared lessons learned from the 14 communities that participated in the CMS care transition demonstration project and details on program rollout to over 12 million Medicare beneficiaries in 400 communities during a May 22, 2013 webinar, now available for replay "Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions."

Interview with Joan M. Teno, MD, MS, author of Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009

Listen NowThis 35 minute interview begins with Dr. Lynn describing the work of her Center in addressing how to improve care for the frail elderly.  Dr. Lynn then explains in some detail a three-year quality improvement intervention undertaken by 14 QIOs (Medicare Quality Improvement Organizations) that reduced hospitalizations and re-hospitalizations by almost six percent, i.e., she summarizes today's JAMA-published article she co-authored, "Association Between Quality Improvement for Care Transitions in Communities and Re-hospitaliations Among Medicare Beneficiaries."  Dr. Lynn explains what is "quality improvement" research or moreover how/why it differs from more traditional clinical practice improvement research.  She addresses generalizability in context of QI research, how hospitals may reconcile reduced hospitalizations and rehospitalizations and how this improved care transitions work is being extended via several other federal programs.  Finally, Dr. Lynn discusses how and why we need  to re-engineer health care delivery to create reliable, supportive services, not necessarily medical services, to assist and support an ever increasing population of frail elderly that will experience lenghty periods of disability.  Dr. Joanne Lynn leads the Center on Elder Care and Advanced Illness for the Altarum Institute.   She previously has served as a consultant to the administrator of the Centers for Medicare and Medicaid Services, as a faculty member of the Institute for Healthcare Improvement, and a clinical expert in improvement for the Care Transitions project at the Colorado Foundation for Medical Care.  She has also been a senior researcher at RAND and a professor of medicine and community health at Dartmouth Medical School and at The George Washington University. Dr. Lynn has published more than 250 professional articles. Her dozen books include The Handbook for Mortals, a guide for the public; The Common Sense Guide to Improving Palliative Care, an instruction manual for clinicians and managers seeking to improve quality; and, Sick to Death and Not Going to Take it Any More!, an action guide for policymakers and advocates.  She is a member of the Institute of Medicine and of the National Academy of Social Insurance, a fellow of the American Geriatrics Society and The Hastings Center, and a master of the American College of Physicians.  She received her MD from Boston University. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

The contributions of an embedded case manager to the practice quickly become evident, explains Diane Littlewood, R.N., regional manager of case management for health services, Geisinger Health Plan, which in turn bolsters physician buy-in for the program. She describes the upfront basics that help to ensure that health plan and provider expectations for embedded case management are met. Ms. Littlewood examined an embedded case manager program, from the factors that will help determine if a program is right for an organization and deciding on the placement to defining roles and responsibilities for the program, during "Embedded Case Managers: Navigating Care Transitions, Gaps in Care and Patient Compliance," a 45-minute webinar on March 10, 2010.

Geisinger Health Plan's successful Transitions of Care program is the health plan's response to rising rehospitalization rates among Medicare patients, a major concern of both CMS and private payors. Geisinger Health Plan's Doreen Salek defines the transition teams' key area of focus when providing a "clean and clear handoff" of a patient from one care site to another, with the goal of avoiding readmission to the hospital. The health plan's director of business operations of health services also defines the plan's ideal home health partner, its blueprint for a universal plan of care to improve care coordination and its expectations of patients and their families and caregivers. Salek, along with Janet Tomcavage, R.N., M.S.N., vice president of health services for Geisinger Health Plan, explained how a focus on transitions of care across the continuum can enhance care quality and reduce readmissions during an August 26, 2009 webinar, Constructing Care Transitions to Reduce Hospital Admissions. The 45-minute session is part of HIN's continuing Medical Home Open House webinar series.