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

2. Patient Care Transition Care transition paths funnel through primary care physician Common risk stratification method Common care planning and patient action plan techniques Common method of measurement tracking for results Lean process improvement methods used to develop processes and improve access Community Screenings Inpatient ER

3. Patient Care Transition Inpatient Discharge Planning Pre-Discharge Orders Risk Analysis for Readmission Project Red Scheduled PCP Appointment Post Discharge Phone Call Readmission Data and Analysis Team Lean Kaizen to Improve Process

4. Patient Care Transition Medical Home Inpatient Discharge Planning EMR Pre-Discharge Orders Risk Analysis for Readmission Project Red Scheduled PCP Appointment Post Discharge Phone Call Readmission Data and Analysis Team Lean Kaizen to Improve Process Missouri Medicaid Collaborative and PCMH High Risk Identification Pre-visit Planning Care Plans Patient Involvement Standing Orders Templates Data Collection for Outcomes Lean Tools Used to Improve Patient Flow

5. Patient Care Transition ER Medical Home EMR Care Continuity Software Patient Stratification Patient PCP Identified No PCP Patient Referral Kaizen to Develop Processes Missouri Medicaid Collaborative and PCMH High Risk Identification Pre-visit Planning Care Plans Patient Involvement Standing Orders Templates Data Collection for Outcomes Lean Tools Used to Improve Patient Flow

6. Patient Care Transition Community Screenings Medical Home EMR Community Health Needs Assessment Community Collaborative Risk Identification Community Needs Mapping Patient Stratification Patient PCP Identified No PCP Patient Referral Kaizen to Develop Processes Care Continuity Software Missouri Medicaid Collaborative and PCMH High Risk Identification Pre-visit Planning Care Plans Patient Involvement Standing Orders Templates Data Collection for Outcomes Lean Tools Used to Improve Patient Flow

7. Patient Care Transition Care Continuity Medical Home Community Screenings Inpatient ER Discharge Planning EMR Pre-Discharge Orders Risk Analysis for Readmission Project Red Scheduled PCP Appointment Post Discharge Phone Call Readmission Data and Analysis Team Lean Kaizen to Improve Process Patient Stratification Patient PCP Identified No PCP Patient Referral Kaizen to Develop Processes Community Health Needs Assessment Community Collaborative Risk Identification Community Needs Mapping Missouri Medicaid Collaborative and PCMH High Risk Identification Pre-visit Planning Care Plans Patient Involvement Standing Orders Templates Data Collection for Outcomes Lean Tools Used to Improve Patient Flow

8. Thank you