JOINT COMMUNITY VENTURE SAVANNAH, GEORGIA CHATHAM COUNTY SHONDRA DAVIS RN AMEDISYS HOME HEALTH DEE DEE SEAGRAVES RN ST. JOSEPH’S/CANDLER HEALTH SYSTEM.

Slides:

Advertisements

Similar presentations

Planning for an Expected Death at Home

Advertisements

RARE Action Learning Day, November 2012 Park Nicollet Post Hospital Discharge Follow Up Calls Karen Loscheider, RN Kris Kopski, MD, PhD.

Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014.

FACE TO FACE ENCOUNTER. Group Effort Due to increased scrutiny by CMS regarding documentation of Face to Face, Homebound status and the justification.

Transitional Care Post Discharge; Tracking and Documentation.

Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Community Collaboration.

Inpatient Coding Strategies American College of Physicians March 1, 2013.

©2011 Walgreen Co. All rights reserved. Georgia Hospital Association Reducing Readmission Learning Collaborative November 7, 2012.

Collaboration Between a Health Plan and a Community Health System to Improve Care Coordination for a Medicaid Population Karen Michael, RN, MSN, MBA Vice.

Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities Sally Johnson Arkansas Foundation for Medical Care This material is.

Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.

Presented by Marti Coté, R.N. and Tiffany Lewis DHCFP.

Implementing “ER is for Emergencies” in Critical Access Hospitals RHQN Best Practices Call June 12, 2012 Facilitator: Bev McCullough, RN, MBA, CPHQ Director,

The Health Roundtable Implementation of Agency for Clinical Innovation (ACI) Orthogeriatric Model of Care Tracey Drabsch Orange Innovation Poster Session.

Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research.

5/24/20151 Fitting the Pieces Together Utilizing a Hospitalist in the ED to Reduce Admissions Presented by: Patty Williamson, CFO Isidoros Vardaros, M.D.

COMMUNITY BASED HOME HEALTH SERVICES Denise Looker, LSW, MHSM Director of Operations Visiting Nurse Assn. of Arkansas.

Best Practice Intervention Package: Transitional Care Coordination.

Healthy Homes Pilot Program with SSM Hospital. Healthy Homes The purpose of Healthy Homes is to give patients, recently returning home from the hospital,

Case Management Maintenance Galynn Thomas, RN, MSN Children’s Medical Services.

Presented to Florida Hospital Association Webinar February 18, 2010 By Wally Plosky, Program Director HERAP Duval County Health Department.

Safe Transitions Of Care STOC 2011 MHA Pilot- 4Q 2010 Transition responsibility belongs to the sending clinician/organization, until the receiving practitioners.

Reduction Of Hospital Readmissions Hany Salama, MD Diplomat ABIM IM Hospice and Palliative Care Sleep Medicine.

Priority Health Asthma Management Program Controlling Asthma in Michigan.

Community-Based Care Transitions Program

Integrated Health Associates (IHA) and Mercy PHO 9/19/2015.

Care Management Going Forward Connie Sixta, RN, PhD, MBA.

© Copyright, The Joint Commission Integration: Behavioral and Primary Physical Health Care FAADA/FCMHC August, 2013 Diana Murray, RN, MSN Regional Account.

INTERACT COLLABORATIVE ORIENTATION SESSION NYSHFA/IPRO PARTNERSHIP Sara Butterfield, RN, BSN, CPHQ, CCM Christine Stegel, RN, MS, CPHQ NYSHFA/IPRO INTERACT.

Partners in Palliative Care Program JAMES LEE, MD THE EVERETT CLINIC EVERETT, WASHINGTON VELDA FILZEN, RN, BSN, CHPN, PARTNERS PROGRAM COORDINATOR PROVIDENCE.

Care Transitions Program Sherrill Rhodes, MSN, HCAP Divisional Director Quality & Service Excellence Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population.

Chapter 17 Documenting, Reporting, and Conferring.

MAKING CARING CONNECTIONS CONTINUITY OF CARE TRANSFER PROJECT Staff Education Presentation Hospital Presenter’s Name Date.

{ Care Transitions Program Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health Medical Center Health System.

MAKING CARING CONNECTIONS: CONTINUITY OF CARE TRANSFER PROJECT Management Presentation Hospital Presenter’s Name Date.

MAKING CARING CONNECTIONS CONTINUITY OF CARE TRANSFER PROJECT Staff Education Presentation LTC Facility Presenter’s Name Date.

Effectiveness and Cost of a Transitional Care Program for Heart Failure Arch Intern Med. 2011;171(14): September 11, 2012 Brett Stauffer MD MHS.

Quality Improvement and Care Transitions in a Medical Home Maryland Learning Collaborative May 21, 2014 Stephanie Garrity, M.S., Cecil County Health Officer.

Home Health Face-to-Face Encounter Adapted from Presentations of National Association for Home Care & Hospice and Home Care Association of Washington by.

CareConnection’s PowerNote. Accessing PowerNote – Step 1.

MiPCT Embedded Case management Barriers to developing an embedded Case Management program.

Emanuel Medical Center Case Management By: Deadre Hadden, RN.

Name Company Date Chronic Condition Management Anand Gaddum iLink Systems March 3, 2010.

A Holistic Approach To Discharge Planning. Due to the regulatory guidelines and changes in healthcare for example: Bounce backs Reduced hospitalizations.

Another Look at Readmissions Katie Westman, RN, CNS United Hospital.

Best Practices in Readmissions Susie Payne, RN MSHA Director Resource Management Clearview Regional Medical Center.

MiPCT Launch Tier 1 and Tier 2 Mary Ellen Benzik,MD Associate Medical Director MiPCT.

Patient Care Coordination Community Health Center Challenges Belma Andric, MD, MPH May 26 th, 2015.

Tiffany Francis, MPH Lori Vollstaedt, BSN, RN. Mercy Physician Community PHO 145 Primary Care and Specialty Care Physicians 38 PCPs, 20 utilizing Crimson.

DATA AND ER VISITS ASSOCIATES IN PRIMARY CARE MEDICINE’S ASSESSMENT AND PLAN.

Thomas Weida, M.D. Professor, Family and Community Medicine Penn State College of Medicine Transitional Care Management Complex Chronic Care Management.

Face to Face (F2F) Documentation Changes for Physicians.

Bundled Payments for Care Improvement (BPCI) Alliance for Health Reform Capitol Hill Briefing Jim Garnham Dir. Contracting & Payment Innovation.

The Pre-Payment audit of applies to Florida First Coast Providers. Audits are usually picked up by other payers. Georgia Update.

Understanding Policy Regulations and Reimbursement Practices Impacting Telehealth Programs Rena Brewer, RN, MA CEO, Global Partnership for Telehealth Lloyd.

1 A Collaborative Approach to Transition Management.

 Proposed Rule by the Centers for Medicare & Medicaid Services on 11/03/2015Centers for Medicare & Medicaid Services11/03/2015  Revises the discharge.

John A Stoukides MD ScD Regional Chief Medical Officer CharterCare Provider Group RI Chief, Division of Geriatrics and Palliative Medicine Roger Williams.

Utilization of Care Coordinators in Patient-Centered Medical Homes Elizabeth Beck MS(c), BSN, RN Mary Jo Welker, MD Randy Wexler, MD.

TRANSITIONAL CARE MANAGEMENT Codes 99495; CMMI September 2015

Turning Best Practice into Common Practice Connecting Michigan for Health Lansing, MI June 8, 2017 Ewa Matuszewski.

Care Integration Pathways for Behavioral Health Patients in Beth Israel Deaconess Hospital-Milton’s Emergency Department Marian Girouard-Spino, RN, MSN,

Medication Reconciliation for SOC

Description of Project

Evaluation and management (E/M) Services

Community and Primary Care Grants

Safe Transitions of Care

CASE PRESENTATION 1 STAT Results from Labs Scenario

Presentation transcript:

JOINT COMMUNITY VENTURE SAVANNAH, GEORGIA CHATHAM COUNTY SHONDRA DAVIS RN AMEDISYS HOME HEALTH DEE DEE SEAGRAVES RN ST. JOSEPH’S/CANDLER HEALTH SYSTEM Face-to-Face

What is Face-to-Face?  Documented face to face encounter with a physician or licensed non-physician practitioner (PA,NP, CNS) evaluating the patient to determine the patient meets guidelines to receive home health care

Guidelines for Face-to-Face  Must be related to the primary reason home health services are being received  Occurs within 90 days prior to or 30 days after date of home health services beginning with SOC date being day 1  Verifies need for skilled services & homebound status per CMS guidelines

Significance in Reducing Readmissions o Establishes appropriate, patient-specific plan of care o Enables continuity of care during transition from inpatient to home setting o Promotes physician involvement

Issues Within Savannah/Chatham County o Lack of understanding of importance of FTF o MD refusing to sign & order home health o Patients discharged to community without appropriate services leading to increased ER visits and avoidable hospital readmissions

Housekeeping Details o Three local hospitals o Four primary home health agencies o One face to face meeting o discussions o Presented results to Savannah Coalition Group

Universal Form

QUESTIONS

Contact Information  Shondra Davis, RN, BSN, MHA-GER Director of Operations Amedisys, Inc.- Savannah 8301 Office Phone: Fax:  Dee Dee Seagraves RN, MSN, CCM, BC-NE Director, Clinical Care Coordination St. Joseph’s/Candler Health System Office Phone: Mobile Fax