1. Readmissions Office Hours AHA/HRET – FHA - FMQAI June 27, 2013 Web Participants should also connect via phone access to hear audio broadcast Web Login: https://cc.readytalk.com/r/hskkr0mduvus&eom Dial-In Number - 866.740.1260 (Access Code - 8416230)https://cc.readytalk.com/r/hskkr0mduvus&eom

2. Today’s Topic & Presenters Topic: Follow-up with Community Providers Moderator: David Schulke, Vice President, Research Programs, Health Research and Educational Trust (HRET) Panel: – Judy Fenton, RN, BS, Director of Clinical Integration, Senior Home Care, Inc. – Carmen Creed, RN, Transitions Project Specialist, Senior Home Care, Inc. – David Sylvester, MBA, FACHE, NHA, VP/Post-Acute and Transition Services, Orlando Health Resource Contacts: – Sally Forsberg, Florida Hospital Association – Beth Kramer & Amy Osborn, FMQAI – Matthew Schreiber MD, HRET

3. Process for the Webinar FHA welcome participants, introduce resource people and moderator FHA will conduct live polling questions to get to know the participants in the webinar, report answers to each before moving on Moderator request that each person, when responding to each question, state their name and care setting (more important than company name) Moderator moves through the questions by asking LTCF/HHA panelists each question, then ask participants to respond to the same question (resource people also free to do so) 3

4. Polling Question 1 for Participants What is your primary role in re: care transitions? a.Short stay acute hospital staff (nurse, case manager) b.Short stay acute hospital pharmacist c.Short stay acute hospital physician (hospitalist) d.Community-based physician in clinic or practice e.Long term acute care hospital staff (LTAC) f.Long term care facility staff (nursing home) g.Home health agency staff (e.g., VNA, etc.) h.Hospice and/or Palliative Care provider i.Community pharmacist j.Area Agency on Aging staff or volunteer k.Patient/Family member of patient 4

5. Polling Question 2 for Participants Are you involved in a care transitions improvement team that includes people from other care settings outside your organization? a.Yes b.No 5

6. Questions for LTCF/HHA Panelists and Participants For those working successfully with other practitioners and organizations to improve care transitions, what was the most important first step? What is the 1 thing hospitals have done (or could do) differently in the transition process to improve care transitions for patients who need post-acute care services? What is the most important thing hospitals need to know about the finances of your organization? How do you promote cooperation between nursing and pharmacy and other disciplines? What would it take for you to help develop shared care protocols with health systems and individual hospitals? What is most important thing health plans can do to improve care transitions? 6