Presentation is loading. Please wait.

Presentation is loading. Please wait.

Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional.

Published byBrett Doidge Modified over 9 years ago

Similar presentations

Presentation on theme: "Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional."— Presentation transcript:

1 Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional Care Inova System of Care Strategy

2 Resourceful, Community Oriented Flexible Quality Driven Efficient Accountable Clinical Outcomes & score cards Quality measures Wellness PCMH EBM Research Programs/ Plans aligned to strategy IT integration Shared service synergy Business unit synergy Integrated Transitional Care Case management, Ambulatory Inpatient, Observation, ED- Discharges Pharmacy Home Services Discharge clinics PACE, FQHC Data Driven Strategic Planning Analytics Medicare, Medicaid Indigent, Commercial population Internal customers External customers Relationships Satisfaction

3 Inova Transitional Care Management There is no longer a discharge process as traditionally understood by the physicians Discharge became a relay, passing the baton with all health related information among patients, nurses, caregivers, physicians, pharmacists, clinics, community services, FQHC, home services, SNF Results: a.reducing duplication of services b.improved decision support c.chronic disease management d.high patient satisfaction

4 Inova Transitional Care Medication reconciliation MD follow-up appointment in 7-10 days Education - Patient and/or caregiver knowledge of red flags Individualized treatment plan Multidisciplinary rounds Case managers Social workers Palliative care Rehab / Nutritionist Nursing Inpatient – MD Driven Multidisciplinary Discharge

5 Inova Transitional Care TCM – CM Driven Execution of discharge instructions Medication reconciliation 7 day follow up Warning signs and self management

6 Strategies for Safe Transitions Inova Transitional Services Discharge Clinics Inova hospitalist oversight Focus: Unmanaged Medicare, Medicaid, Uninsured and no medical care Comprehensive medical care, pharmacy assistance, case management, disease management and education RN assigned specifically for TCM population > 30 days if still waiting for medical home

7 Scope of Inova TCM Disease Groups CHF Diabetes COPD/Pneumonia Complex medical Payer Types Unmanaged Medicare Unmanaged Medicaid Uninsured Source/Status of Referrals Inpatients/Observation ED TCM Hospital CM Others Exclusions Commercial payers SNF/ALF ESRD Hospice

8 Inova’s Approach to a Transitions Model Enhanced Tools, Services and Strategies Wider scope Inpatient Case Management Transitional Services Discharge Clinic Home Visits Shared documentation software Community partnerships SNF collaborative approaches

9 Enhanced Tools and Strategies Home Visits Use Inova VNA Home Health Provide 1-3 non-skilled home visits as needed Use existing nurse staffing/scheduling Work with hospital liaisons Shared Software and Communication Allscripts for referrals EPIC conversion Milliman Care Guidelines Analytics- create reports to assist with comprehensive screening Readmission notification in real time

10 Enhanced Tools and Strategies Community Partnerships Safety net clinics Coordination of diabetic supplies Appointments fast tracked Pre-enrollment Identified contacts Participation with Allscripts Community partnerships with AAA 5 counties Shared fax form SNF Collaborative Visits, group meetings, Medical Director relationships Share data Education support

11 TCM Admissions by Disease March - December 2012

12 TCM Admissions by Payer March - December 2012

13 TCM Admissions by Patient Status March - December 2012

14 Overall Inpatient 30 Day Readmission Rate by Length of Engagement Inpatient Payer/DiseaseTCM Patient CategoryTotal ReferralsIP 30-Day Readmission Rate Total 30 Day Readmissions AllEnrolled > 28 Days462 4.3% 20 Enrolled 15-28 Days12025.8%31 Enrolled < 15 Days8850.0%44 Unable to Contact19711.2%22 Declined928.7%8 Other2330.4%7 All Payers Total98213.4%132 March – August 2012

15 Inpatient 30 Day Readmission Rate by Payer Inpatient PayerTCM Patient CategoryTotal ReferralsIP 30-Day Readmission RateTotal 30 Day Readmissions MedicareEnrolled > 28 Days 286 5.2% 15 Enrolled 15-28 Days8127.2%22 Enrolled < 15 Days4643.5%20 Unable to Contact10310.7%11 Declined729.7%7 Other2025.0%5 Medicare Total60813.2%80 UninsuredEnrolled > 28 Days 137 2.2% 3 Enrolled 15-28 Days3423.5%8 Enrolled < 15 Days3250.0%16 Unable to Contact7910.1%8 Declined156.7%1 Other366.7%2 Uninsured Total30012.7%38 MedicaidEnrolled > 28 Days 39 5.1% 2 Enrolled 15-28 Days520.0%1 Enrolled < 15 Days1080.0%8 Unable to Contact1520.0%3 Declined50.0% Medicaid Total7418.9%14 March – August 2012

16 ED Referrals TCM Enrollment length Total Referrals Total 30-Day IP admissions Overall IP 30-Day admission % >28 Days1050 0.0% 15 to 28 Days19210.5% 8 to 14 Days8337.5% 1 to 7 Days55100.0% Referred: Unable to Contact3937.7% Referred: Declined9222.2% March – August 2012

Download ppt "Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional."

Similar presentations

Care Transitions – Critical to Quality and Patient Safety Society of Hospital Medicine Lakshmi K. Halasyamani, MD.

Care Transitions – Critical to Quality and Patient Safety Society of Hospital Medicine Lakshmi K. Halasyamani, MD.
Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014.

Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014.
Health Care Reform and Its Impact on EMS: Volume to Value, Improving Population Health and Other Paradigm Shifts.

Health Care Reform and Its Impact on EMS: Volume to Value, Improving Population Health and Other Paradigm Shifts.
Care Coordination in the Patient-Centered Medical Home New York Academy of Medicine May 24, 2011.

Care Coordination in the Patient-Centered Medical Home New York Academy of Medicine May 24, 2011.
Advanced Illness Management Sutter Health Lois Cross RN BSN ACM Sutter Health

Advanced Illness Management Sutter Health Lois Cross RN BSN ACM Sutter Health
Tad P. Fisher Executive Vice President Florida Academy of Family Physicians Patient Centered Medical Home A Medicaid Managed Care Alternative.

Tad P. Fisher Executive Vice President Florida Academy of Family Physicians Patient Centered Medical Home A Medicaid Managed Care Alternative.
INSTITUTIONAL SPECIAL NEEDS PROGRAM Best Practices in Care Coordination and Care Transitions Beth Ann Martucci, DNP, CRNP Director of Clinical Operations.

INSTITUTIONAL SPECIAL NEEDS PROGRAM Best Practices in Care Coordination and Care Transitions Beth Ann Martucci, DNP, CRNP Director of Clinical Operations.
UAMC – Discharge Medication Optimization Lauren Miller, PharmD. Instructor University of Arizona College of Pharmacy Clinical Staff Pharmacist Ambulatory.

UAMC – Discharge Medication Optimization Lauren Miller, PharmD. Instructor University of Arizona College of Pharmacy Clinical Staff Pharmacist Ambulatory.
Collaboration Between a Health Plan and a Community Health System to Improve Care Coordination for a Medicaid Population Karen Michael, RN, MSN, MBA Vice.

Collaboration Between a Health Plan and a Community Health System to Improve Care Coordination for a Medicaid Population Karen Michael, RN, MSN, MBA Vice.
Pharmacists Transforming Care in Patient Centered Medical Home and Accountable Care Organization Hae Mi Choe, PharmD Director, Pharmacy Innovations & Clinical.

Pharmacists Transforming Care in Patient Centered Medical Home and Accountable Care Organization Hae Mi Choe, PharmD Director, Pharmacy Innovations & Clinical.
2.11 Conduct Medication Management University Medical Center Health System Lubbock, TX Jason Mills, PharmD, RPh Assistant Director of Pharmacy.

2.11 Conduct Medication Management University Medical Center Health System Lubbock, TX Jason Mills, PharmD, RPh Assistant Director of Pharmacy.
Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.

Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.
HFMA December 2012. Attacking Rising Costs 23% of the Medicare population has a chronic condition with 5 or more co-morbid conditions that compel them.

HFMA December Attacking Rising Costs 23% of the Medicare population has a chronic condition with 5 or more co-morbid conditions that compel them.
Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research.

Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research.
Improving care transitions at Harborview Medical Center Frederick M. Chen, MD, MPH Chief of Family Medicine Associate Professor, University of Washington.

Improving care transitions at Harborview Medical Center Frederick M. Chen, MD, MPH Chief of Family Medicine Associate Professor, University of Washington.
Risk Assessment - What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH 1 Presented by Washington State Hospital Association.

Risk Assessment - What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH 1 Presented by Washington State Hospital Association.
Presentation by Bill Barcellona Sr. V. P

Presentation by Bill Barcellona Sr. V. P
A Model to Reduce Acute Care Readmissions Susan Weber, RN Chief Nursing Officer Angela Venditte, LPN, CMCO Assurance HealthCare.

A Model to Reduce Acute Care Readmissions Susan Weber, RN Chief Nursing Officer Angela Venditte, LPN, CMCO Assurance HealthCare.
COMMUNITY BASED HOME HEALTH SERVICES Denise Looker, LSW, MHSM Director of Operations Visiting Nurse Assn. of Arkansas.

COMMUNITY BASED HOME HEALTH SERVICES Denise Looker, LSW, MHSM Director of Operations Visiting Nurse Assn. of Arkansas.
Good Samaritan Hospital Readmission Risk Assessment and Intervention Algorithm John Robinson, MD, VP Medical Affairs, Good Samaritan Hospital Theresa Wnek.

Good Samaritan Hospital Readmission Risk Assessment and Intervention Algorithm John Robinson, MD, VP Medical Affairs, Good Samaritan Hospital Theresa Wnek.

Similar presentations

Ads by Google