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Published byMervyn Robert Ward Modified over 9 years ago
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Care Management: Developing an Integrated Model of Care.
CTC RI NCM Best Practice Sharing Meeting January 12, 2016 Janice Romagnolo, VP Post Acute Care Services, SPN/ACO Care Management Southcoast Health January 12, 2016
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Southcoast Health Southcoast Hospital Group Charlton Memorial Hospital
804 Licensed Beds Charlton Memorial Hospital Southeast Inpatient Rehabilitation Facility St. Luke’s Hospital Tobey Hospital Southcoast VNA Home Care Hospice and Palliative Care Infusion Services Southcoast Physicians Network Southcoast Physicians Group 600 + Physicians and Advanced Practice Providers Boston
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SPN/ACO Care Management
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GOALS A Team approach to
manage care for Patients in a timely manner as they move across the continuum. Improve quality outcomes during transitions of care, provide excellent customer service and reduce cost appropriately.
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STRATEGY Process Standardization – Workflows Define Program Goals
Establish Patient:Care Manager Ratios Language Consistency Education and Training Productivity Monitoring and Tracking Clinical Review Process Post Acute Integration Implementation of Accepted Tools to determine Patient Activation and Engagement. Integration with SHG Case Management, SCVNA and Population Health Programs at Southcoast Health.
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SPN/ACO Care Management Team Based Model of Care
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Care Management Integration with Post Acute - MA
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Service Alignment and Integration
SPN/ACO Care Management Post Acute Services PACN Post Acute Care Practice SER Technology SPN/SPG PCP – Patient Community Integration SCVNA Behavioral Health Heart Failure Palliative Care Hospice SHG Case Management Heart Failure/COPD Program Diabetes Management Program
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Challenges & Opportunties
Communication Recruitment Opportunities Case Management + ACO Care Management Integration Access Services = Patient Education Emergency Department – direct admit process to SNFs Hospitalist – improve transitions of care for re-admissions from SNFs and Community. Live-handoffs Hospital - Post Acute - Home
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Post Acute Care Network
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Post Acute Care Network Team Based Model of Care
Post Acute Practice VP, Post Acute Care Services Medical Directors (6 SNFs) 4 Physicians Transitional Care Medical Directors (9 SNFs) 8 Physicians Clinical Manager 6 APPs Liaison SPN Post Acute Care Program Service Agreements 9 SNFs Specialty Programs Cardiac Pulmonary NP On Call Program providing coverage for 30 physicians at 16 SNFs 10 APPs
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Perfection is unattainable, but if we chase Perfection, we can catch Excellence.”
Vince Lombardi
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DISCUSSION
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