1. Understanding and Negotiating Today’s Healthcare System Sponsored by: The Piedmont Hospital & Visiting Nurse/Hospice Atlanta Demonstration Project: Care Transitions An 18 month Health and Human Services Funded Project July 1,2008 through December 31, 2009

2. Care Transitions Demonstration Project Partners: Phase I and Phase II Piedmont Hospital Sixty Plus Older Adult Services Program Piedmont Hospital, Hospitalist Service (Project BOOST) Visiting Nurse /Hospice Atlanta

3. Aren’t you missing some links? YES. It will take hospitals, healthcare providers, housing, aging services providers, the aging network and consumers, all working together to assure safe transitions. Our journey has just been slower than expected!

4. Lessons Learned & Sustainability Factors Start small and go slow Set realistic goals & expectations Identify & fix your own problems first** Never underestimate the impact of data & outcome measures on the project design Incorporate work processes into existing work flow and organizational culture

5. Phase III – Expand Community Linkages (June 1, 2009 through December 31, 2009) Education/Communication Flow Develop Materials/Set up Workshops Train Volunteers and Trainers Professionals Consumers Expand/Establish Partnerships/Collaboration Area Agency on Aging – ARC County Based Aging Programs RSVP Volunteer Program Multipurpose Centers/Senior Centers Home Based Services

6. Phase III (Cont…) Senior Housing Home Health – opportunities to apply lessons learned

7. The Afternoon Overview of Healthcare Challenges and Piedmont’s Care Delivery System – what works and where are the opportunities. Inpatient and Emergency Department Discharge Planning Overview of two Piedmont Hospital Care Transitions Demonstration Projects. Transitions in Care Project BOOST Learn how home health care can implement the principals of care transitions into existing work processes

8. The Afternoon Cont’d Learn how three community organizations plan to address Care Transition best practices through coalitions, education/training and/or program implementation. Georgia Hospital Association (GHA) Center for Medicare Service (CMS) Atlanta Regional Commission, Aging Division (ARC) Discuss implementing a region wide approach to Care Transitions/Safe Discharge Developing an Action Plan Complete Evaluations and Adjourn

9. Excerpt from President Obama’s speech to AMA on Monday - "Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they are not getting the comprehensive care they need. This puts people at risk and drives up costs. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits, but drives up costs for everyone else. That will save us $25 billion over the next decade."