Session 1: Avoiding Redundancies in the Post-Acute Transitional Period
Pamela Foster, MSW, MBA/HCM, LCSW, ACM-SW
Associate Vice President
HonorHealth · Scottsdale, AZ
Post-acute transitional care has become an increasingly important element of healthcare delivery. The shift from volume to value-based care has prompted the creation of many types of post-acute transitional services. While all well-intended, these services can become redundant and confusing to the patient without clear definitions and boundaries. This session will explore one health system’s process of mapping these services, defining caee lanes, and hardwiring referral processes to avoid redundancies that can cause unintentional harm.
- Understand the varied and many types of transitional care services available to patients
- Acknowledge that many services can overlap, creating care redundancy and confusion for patients
- Learn Case Management’s role in defining transitional care lanes and navigating patients to appropriate transitional care services
Session 2: Public Reporting and Readmissions
Ettie Lande, RN, BSN, MS
Associate Director, Care Coordination
Health Services Advisory Group (HSAG) · Phoenix, AZ
With the rapid acceleration of value-based purchasing and Medicare’s goal to tie 50 percent of payments to value by 2018, patients are turning into healthcare shoppers and embracing the transparency of public reporting. With the growth of consumerism driving healthcare decisions and Medicare adding cost and hospital utilization measures to what is publicly reported, providers are faced with financial risks, implications, and opportunities. Concurrently, Medicare is funding quality improvement organizations and other federal contractors to work closely with providers to improve their effectiveness in the delivery of care coordination, transitions, and medication safety services. Discover how Arizona is performing in reducing readmissions; how transparency, public reporting, and incentives are creating a mixed bag of pleasure and pain; and the opportunities we all have to improve outcomes for Medicare beneficiaries.
- Review the history of Medicare’s hospital readmission reduction program and the impact on Arizona’s hospitals
- Identify how provider performance data has been integrated into each of Medicare’s Compare websites for hospitals, nursing homes, and home health agencies
- Describe the risks and implications providers across the continuum face as Medicare adds cost and utilization performance measures to the Compare websites
- Recognize the existing opportunities Arizona providers are tapping into and/or testing to reduce readmissions and improve care coordination
Session 3: How to Standardize Medication History for Best Patient Outcomes: Addressing the Challenge of Polypharmacy
Nicole Murdock, Pharm. D., BCPS
Midwestern University · Glendale, AZ
Polypharmacy is a rising concern across the nation. The geriatric population is at highest risk of polypharmacy and subsequent medication-related complications. Arizona has the unique opportunity to witness polypharmacy concerns before the rest of the nation due to our aging population. What we do to help this patient population will likely help sculpt future medication management around the world.
Providers have substantial, multi-faceted pressure to prescribe medications and there are a number of strategies surrounding polypharmacy that include system and patient level techniques. Evidence to support these techniques is limited due to polypharmacy being newly recognized and exponentially growing. There is a complexity of multiple disease processes and a high variance in patient expectations and desired outcomes.
- Illustrate the progression & significance of polypharmacy in the aging population
- Describe the importance of an accurate medication list to improve patient outcomes
- Utilize various techniques to develop a medication list applicable to multiple providers and healthcare settings
Session 4: Transitioning Pediatric Patients to Adult Medicine- A Mindful Approach
Nicole R. Schuren, LMSW, IMH-E® (III)
Medical Social Worker- Pediatric/Adolescent
Mayo Clinic Arizona · Phoenix, AZ
Pediatric patients are transitioning into the adult health care system each year. Are you prepared for the adolescent/young adult with chronic illness? Whether they are new to the medical system or have been serviced through the pediatric model, the type of care an adolescent/young adult requires is unique. Being mindful of their transitional needs can create a more positive and successful transition resulting in a compliant and healthy patient.
- Identify the developmental stages unique to the older adolescence
- Consider the aspects of transitioning a pediatric patient into the adult healthcare system
- Utilize strategies to help pediatric patients become more independent in their own healthcare
Session 5: Reduction of Readmissions with Home-based Palliative Care/Advanced Illness Management
Jeanne Elnadry, MD
Director of Palliative Care
Yuma Regional Medical Center · Yuma, AZ
Medical home visits have significant potential to address the complex issue of hospital readmissions within 30 days of discharge from the hospital. Many patients who are readmitted to the hospital have advanced chronic illness, multiple chronic conditions, poor social support networks, and functional limitations. This session will highlight a community-based palliative care intervention, using physician home visits, in collaboration with the Transitional Care Clinic and with case management at the hospital. The speaker will review patient selection, characteristics of the intervention, data on reduction of admissions, readmissions, and ED visits, and associated direct costs.
- Identify method of selecting patients for a community-based palliative care/advanced illness management intervention using medical home visits
- Review characteristics of the intervention
- Discuss data that shows a reduction in admissions, readmissions, and ED visits