Elements for Effective Care Transitions, Ideas and Resources for Post-Acute Care Providers

This guide and webinar series identifies four categories of multiple elements that assist in effective care transitions and provides an introduction to ten free AHCA/NCAL webinars that elaborate further on each of these element categories.

  • Sharing advanced INTERACT Success! Series

    Contains 2 Component(s) Recorded On: 05/07/2014

    In this informative session, participants will have the opportunity to hear how four different organizations advanced the use of INTERACT within their setting.

    Part 1:
    In this informative session, participants will have the opportunity to hear how four different organizations advanced the use of INTERACT within their setting. INTERACT has played a key role in helping many organizations reduce unnecessary hospitalizations. Ideas on how to use these tools, how to spread them throughout the organization, how to get buy-in, and the fabulous results of these determined leaders will be some of the stories you will hear.

    Learning Objectives:

    1. Discover ways to advance the use of INTERACT
    2. Question leaders who have successfully implemented advanced INTERACT
    3. Consider ways to advance INTERACT in participant's setting

    Speakers:

    Pamela Zanes, Ed.M, BSN, RN
    Senior Director of Care Transitions
    Integrated Market - Indianapolis
    Kindred Healthcare


    Lenore Williams RN
    Kindred Transitional Care and Rehabilitation - Wildwood, Indianapolis

    Matt Tobalsky, LNHA
    Care Center Administrator

    Misti Valentino
    Senior Executive Director
    Mi Casa Nursing Center

    Part 2:

    In this fascinating program, you will have the opportunity to hear two unique stories of communities, in two separate counties, that put INTERACT to work to improve care. First you will hear how a community worked together to develop INTERACT with their local hospital. This impressive story shares how a combined group of nursing centers worked together on implementation despite being competitors.

    Additionally, a second group in another County, worked on implementation by creating a change package for a Medicaid Collaborative. Through a remarkable mentoring program with an "All Teach , All Learn" structure, those with more advanced skills in using INTERACT tools became mentors to other organizations, helping the community to create better care. In this valuable educational program you will see that the best way to be successful is to work together!

    Learning Objectives:

    1. Recognize new ways that INTERACT can be advanced in your community or organization
    2. Consider ways to connect with other community members
    3. Identify ways to employ mentoring as a strategy for advancing INTERACT

    Speaker:

    Carol Higgins, OTR (Ret.), CPHQ
    Quality Improvement Consultant
    Certified INTERACT® Educator
    Qualis Health

  • An innovative Approach to Identifying and Communicating Change of Condition: Introduction to INTERACT 2

    Contains 1 Component(s) Recorded On: 06/28/2012

    Click for more information

    Moderator: Cathy Lipton, UnitedHealthcare

    Dr. Cathy Lipton is Senior Medical Director of Georgia's UnitedHealthcare Nursing Home Plan and the Evercare Clinical Model and is an Adjunct Clinical Assistant Professor in Geriatrics in the Emory University School of Medicine.

    Background: Deb Kriner
    • Explanation of INTERACT history
    • Identify the tools and explain what they are



    INTERACT 2 Implementation: Pam O'Rourke
    • Explain the GA initiative
    • Explain how INTERACT was incorporated into daily practice


    Program Sustainability: Donna Hendricksen
    • How to do initial training
    • The need for ongoing orientation
    • Discussion around disease management
    • Ongoing validation (getting out on the floor and making sure information/tools are being used)

    Facility Benefits from Implementing Interact & Wrap-Up: Cathy Lipton
    • Having the program in place makes the facility more marketable
    • Many hospitals already using SBAR and expect nursing facilities to be on-board
    • Better resident outcomes will result in more referrals from hospitals
    • Nursing homes save time and money because readmissions are eliminated
    • Reducing transfers to the hospital will help meet the QAPI requirement
    • Where to get help and find information - AHCA website, www.INTERACT2.net, QIOs, State LTC Association

    Q&As: Cathy Lipton

  • Culture Change to Reduce Hospitalization Using Person-Centered Care

    Contains 1 Component(s) Recorded On: 07/30/2013

    Hospitalizations can be a detriment to our residents, impacting their quality of life and resulting in earlier mortality, immobility, or cognitive decline. Assisted living must think about addressing both acute and chronic care while remaining a social model. Now is the time to seek out partnerships with other providers to provide distance monitoring to support the care provided in assisted living so residents can be cared for and not unnecessarily transferred to a hospital. These interventions can be person-centered and individualized.

    Hospitalizations can be a detriment to our residents, impacting their quality of life and resulting in earlier mortality, immobility, or cognitive decline. Assisted living must think about addressing both acute and chronic care while remaining a social model. Now is the time to seek out partnerships with other providers to provide distance monitoring to support the care provided in assisted living so residents can be cared for and not unnecessarily transferred to a hospital. These interventions can be person-centered and individualized.

    Learning Objectives:

    1. Understand the importance of safely reducing hospital readmissions
    2. Learn about how the tools from the INTERACT™ program, POLST, and others can be used in continuing education.
    3. Examine attitudes and individual beliefs about caring for the elderly and the impact these have on culture change.

    Speakers:

    Loretta Kaes, RN B-C, C-AL, LNHA, CALA
    Director of Quality Improvement and Clinical Services
    Health Care Association of New Jersey

  • It’s Not Just the Data, It’s What You Do with It

    Contains 1 Component(s) Recorded On: 08/19/2014

    Join My InnerView by National Research Corporation to discover how to use your data as a powerful ally to achieve quality initiative goals, improve performance, and gain even more referral partners.

    If you're already collecting satisfaction data, then you're on the right track. But, do you know what to do with that wealth of information once you've received your survey results?

    Join My InnerView by National Research Corporation to discover how to use your data as a powerful ally to achieve quality initiative goals, improve performance, and gain even more referral partners.

    Learning Objectives:

    1. Find out how to most effectively survey and ask the right people, the right questions, at the right time.
    2. Once you've collected the right data, discover how to set realistic improvement goals in the most impactful areas.
    3. Learn how to use your data to get the attention of hospitals and health systems and drive more referrals.

    Speaker:
    Jason Stevens
    Vice President of Post-Acute Business Development
    My InnerView by National Research Corporation

  • How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider?

    Contains 1 Component(s) Recorded On: 10/27/2014

    The program briefly explains the impact that Healthcare Reform is having on the healthcare industry on both the acute and post-acute care side. There is a strong emphasis on the importance of accurate data analysis and on implementing potential solutions for facilities. The clinical programs along with the use of cutting edge technology have shown to improve clinical outcomes, allowed centers to become preferred providers for local hospitals and have significantly reduced unnecessary hospital readmissions.

    The program briefly explains the impact that Healthcare Reform is having on the healthcare industry on both the acute and post-acute care side. There is a strong emphasis on the importance of accurate data analysis and on implementing potential solutions for facilities. The clinical programs along with the use of cutting edge technology have shown to improve clinical outcomes, allowed centers to become preferred providers for local hospitals and have significantly reduced unnecessary hospital readmissions.

    Learning Objectives:

    1. Discuss the history of hospital readmission and its impact on the industry.
    2. Discuss and analyze the types of data necessary to appropriately measure hospital readmission rates.
    3. Describe potential solutions within your center that will positively affect clinical outcomes.
    4. Describe how progress is measured after implementation.
    5. Discuss measures to ensure continuous quality improvement.

    Speaker:

    Kim Barrows
    Director of Clinical Services at Health Care Management Group

  • A Model for Collaboration between Hospitals and Assisted Living Communities

    Contains 1 Component(s) Recorded On: 07/17/2013

    The webinar will examine emerging models in which hospitals and assisted living facilities collaborate to manage the continuum of care for ALF residents more effectively, with the objective of reducing unnecessary ER visits and hospital admissions.

    The webinar will examine emerging models in which hospitals and assisted living facilities collaborate to manage the continuum of care for ALF residents more effectively, with the objective of reducing unnecessary ER visits and hospital admissions. The program will examine the populations that represent the most risk for health systems attempting to develop effective population health strategies for the Medicare population. Developing tailored joint programs with ALFs is a valuable element of such an approach when carefully constructed.

    Learning Objectives:

    1. Understanding the risks that the ALF population presents to ACOs and risk-bearing provider networks.
    2. Identifying emergent best practices in coordinating care between health systems and ALFs.
    3. Identifying emergent communication protocols that streamline and improve care transitions.


    Speaker:

    Erik Johnson
    Senior Vice President
    Avalere Health

  • Accountable Care Organizations: What They Are and Why You Need to Know!

    Contains 1 Component(s)

    This webinar will provide an overview of the proposed rules on ACOs and the potential role for post acute care providers.

    Despite the uncertainty surrounding many aspects of health care reform, most health care providers are moving forward with efforts to improve care, reduce costs, and assure that elders have access to services. The latest addition to the stream of innovation is CMS' issuance of the proposed rule on Accountable Care Organizations (ACOs). ACOs were instituted by Congress in the Affordable Care Act (ACA) to further CMS' "triple aim" of better care for individuals, better health for populations, and lower growth in expenditures. Under the ACA's Shared Savings Program (SSP), ACOs that succeed in helping CMS reduce costs for Medicare fee-for-service beneficiaries and that meet certain quality requirements will have an opportunity to share in the savings to the Medicare program.

    However, ACOs under the SSP also will be required to bear downside risk for costs in excess of a predetermined benchmark, and will be subject to extensive up-front and ongoing investment and reporting requirements. Accordingly, many organizations may find it too costly or too uncertain a proposition to participate in an ACO under the SSP. However, whether or not an organization participates in an ACO, the model of care CMS has articulated under the SSP indicates that the Medicare program is shifting toward a risk-based reimbursement model that rewards quality and cost savings across the continuum of care.

    Such a shift will implicate post-acute providers' operations and reimbursement, and may require post-acute providers to consider innovative organizational alliances and structures to remain successful under Medicare.

    This webinar will provide an overview of the proposed rules on ACOs and the potential role for post acute care providers. The ACO webinar will cover the following topics:

    • Short history of the demonstrations leading to the development of the ACO concept and the lessons learned.
    • Detailed discussion of the ACO proposed regulations, including who can participate, the minimum requirements for participation, the beneficiaries who may participate, and the services to be offered.
    • The potential organizational models that might evolve and how SNFs and home health agencies may be involved.
    • The proposed reimbursement methodologies and how payments will be made to the ACO and other participating providers.
    • Overview of ACO-like markets that are already developing and their experience in working with aging services organizations to achieve cost reductions, care model changes and the payment models they are using.
    • How hospitals are considering and approaching ACOs: the difference, if any, between urban and rural hospital centers in thinking about ACOs.
    • The operational and workforce implications of moving to an ACO or ACO-like environment, particularly to increased expectations about quality performance, acceptance of risk and training required to prepare staff for a changing resident.
    • The steps that nursing facilities should take now to prepare to deal with ACOs, either as contractors or participants.

    Presented by:
    Mark Reagan, Hooper Lundy Bookman
    Nancy Rehkamp, LarsonAllen
    Paul Deeringer, Hooper Lundy Bookman

  • Elements for Effective Care Transitions, Ideas and Resources for Post-Acute Care Providers

    Contains 1 Component(s)

    This guide identifies four categories of multiple elements that assist in effective care transitions and provides an introduction to ten free AHCA/NCAL webinars that elaborate further on each of these element categories.

    This guide identifies four categories of multiple elements that assist in effective care transitions and provides an introduction to ten free AHCA/NCAL webinars that elaborate further on each of these element categories.

  • Outcomes Reporting - Be Ready to Negotiate with a Hospital CFO

    Contains 1 Component(s)

    Your clinical data is a powerful gold mine. Are you maximizing it to its fullest potential? This webinar will give you three strategic ways to unleash its power in your organization.

    Your clinical data is a powerful gold mine.  Are you maximizing it to its fullest potential?  This webinar will give you three strategic ways to unleash its power in your organization.  



    Learning Objectives:

    1)  What are outcomes reports? 

    2)  What can outcomes reporting do for me in five strategic ways?

               a.  Re-hospitalization prevention:  attacking and measuring success

               b.  Corporate Compliance:  reporting for requirements in 2012-13

               c.  QAPI:  preparing for upcoming regulations

               d.  Marketing:  creating a 'sales pitch' to win census from hospitals

               e.  Benchmarking: comparing facilities and replicating best practices

    3)  Get concrete ideas from Tanya Procell who will share her best practices.

    Presenters: 

    •  Tanya Procell, RN ADN, Director of Clinical Services for Provider Professional Services

    •  Teresa Chase, President & CEO, American HealthTech

  • Referral Partnerships: A Data-Driven Approach to Cross Continuum Healthcare Coordination

    Contains 1 Component(s)

    With the rise of accountable care organizations (ACOs), readmission penalties, and bundled payment initiatives, providers from across the healthcare continuum are seeking partnerships with long term care organizations to create smoother care transitions and reduce hospitalizations. Attend this exclusive AHCA/NCAL webinar, presented by My InnerView by National Research Corporation, to find out how to use your satisfaction data to position your organization as a preferred referral partner and more easily navigate the new managed care payment system.

    With the rise of accountable care organizations (ACOs), readmission penalties, and bundled payment initiatives, providers from across the healthcare continuum are seeking partnerships with long term care organizations to create smoother care transitions and reduce hospitalizations.

    Attend this exclusive AHCA/NCAL webinar, presented by My InnerView by National Research Corporation, to find out how to use your satisfaction data to position your organization as a preferred referral partner and more easily navigate the new managed care payment system.

    Learning Objectives
    :

    1. Learn how and what to communicate to hospitals, health systems, and home health agencies for potential referrals

    2. Understand what your data is telling you to uncover valuable quality improvement opportunities

    3. Find out why your satisfaction scores open more doors to referrals than proximity or promotional marketing

    Speakers:

    Jason Stevens
    Vice President of Business Development
    National Research Corporation

    Gregg Loughman
    Vice President
    Strategy and Governance

NCAL AHCA