SlideShare ist ein Scribd-Unternehmen logo
Implementation of Timely and Effective
Transitional Care Management Processes
Tuesday, March 21, 2023
3:00-4:00pm Eastern / 12:00-1:00pm Pacific
1
Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be available
after the end of the series, Summer 2023.
2
Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would
be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation
(not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or
that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-governmental
sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an
endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
3
At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
4
National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity sessions,
trainings, research, publications, etc.
5
Speakers
• Mary Blankson, DNP, APRN, FNP-C, FAAN
• Chief Nursing Officer, Community Health Center, Inc.
• Veena Channamsetty, MD, FAAFP
• Chief Medical Officer, Community Health Center, Inc.
• Bibian Ladino-Davis
• Behavioral Health Coordinator, Community Health Center, Inc.
6
Objectives
• Describe processes for following up on ER visits and hospital discharges, including
roles and responsibilities
• Discuss a best practice for centralized notification of ER visits and hospitalizations
• Review other use cases for managing centralized notifications of hospital events:
• Risk stratification and management - Integrated Care Team Meetings
• Report of death of a patient and caring for the family
7
Areas Identified as Opportunities
• Prior to 2016 - Decentralized sources of data where notification of ER visits and
hospitalizations was provided to care teams directly through discharge
notifications and ER visit notes, rather than a central source disseminating the
information with robust processes
• Standardized processes for reporting death of a patient
• Consistency around Integrated Care Meetings to support our most complex
patients
• Standardized workflows to update and document in the EHR with regard to care
transitions
8
Daily Follow-up on ER Visits and Discharges
9
Daily Follow-up on ER Visits and Discharges
• CHC processes have evolved over time to reflect our priorities as well as our evolving
understanding of our patient population and their use of the ER and hospital.
• Overview: The BI Department sends a list of CHC patients to Bamboo Health on a monthly basis
who have had a medical visit in the last 12 months OR who are on a Value Based Roster regardless
of last visit date.
• This ensures that we are notified if a patient visits a hospital for an ER visit or admission.
• While Bamboo Health has an app that some groups use to manage their patient workflow in the
hospital, we instead ingest a file with that information on a daily basis so that a file with a list of
patients is distributed each morning.
10
Daily Follow-up
on Hospital Discharges
Triage nurses call each patient who meets
certain criteria (e.g., Value Based Roster patient,
specific dx, etc.) and, using a structured
template, ask the patient a series of questions:
1. Why were you hospitalized?
2. How are you feeling today?
3. Were you discharged with any new meds to take
at home? If yes, what are they?
4. Do you have any nurses or therapists visiting you
at home?
5. Were you told to schedule appointments with any
doctors besides your primary care provider? If yes,
who?
11
• Nurses make up to three attempts to reach the patient by
phone. Note: Bamboo Health does at times, provide a new
phone number for the patient based on what the patient
reported at the hospital and this can be valuable!
• This same list of patients is also sent to the MA and they
retrieve the hospital discharge note and scan into chart.
• Our follow up rates are about 54% which is well above the
rates for other health centers in our state (43%) and the
Medicaid rate of 38.5%.
• This information can be reviewed by the provider during the
post-hospital visit.
Daily Follow-up
on Hospital Discharges
12
Other uses of Hospital Discharge
Information
1. Complete SDoH (PRAPARE) with patients who had a hospital
discharge by the Triage Nurses.
2. Mail a congratulations card to new moms upon the notification of
a birth.
3. Alert in NOVO so that if a patient was high risk/who met certain
criteria (e.g., multiple ER visits; recent hospitalizations; high risk
score) the PSA would delegate the call to Triage to talk with
patients.
Daily Follow-up on ER Visits
• MA reviews the list and notifies PCP of any ER visits that require follow up
• Other uses of ER information
1. For pediatric patients with an ER visit for asthma, a text message is sent to
the patient to encourage them to schedule follow up with PCP (if a visit is not
already scheduled)
2. For patients in a value based program that requires complex care patients
who meet certain criteria to have follow up we send a text message to
patient to schedule follow up visit
13
ER Discharge Follow Up
Best Practices
15
Bamboo Health Process
16
• All patients in a Value Based Program
• All patients who are discharged for COPD, Diabetes, Asthma, Hypertension, Delivery of
newborn, Poisoning; F code (all BH diagnoses)
Consider whether there are sufficient resources to follow up on all
hospital events. Prioritizations may include:
Other considerations
Special Considerations
17
Patients who have not been
seen in the last 3 years
School Based Health Center
patients who do not have
CHCI as their PCP
Other opportunities – upon
patient admission to ER or
hospital
Report of Death of a Patient Process
18
19
Notification
of a Patient Death
• Weekly report of patients who, according to Bamboo Health, have passed away the prior
week AND/OR whom we were notified about a patient’s passing.
• The report includes:
• Patient ID and Name
• Date of passing
• Hospital/facility
• PCP
• PCP Site
• The report is disseminated to the Operations Managers, Senior Program Manager for
Population Health and the Senior VP/Clinic Director.
20
Response upon Learning
of the Death of a CHC Patient
Procedure addresses:
• Sympathy Calls or Cards
• Ensure family members are supported
• Opportunity to offer further supportive services
• Clarity on when calling family members is appropriate
• Deactivation of the Patient Chart:
• Ensures canceling of follow up calls and reminders
• Updates the E.H.R status
21
Response upon Learning
of the Death of a CHC Patient
Sympathy Calls or Cards to Family Member
AND
Contacting the family member would NOT be inconsistent with any prior expressed preference of the patient.
Either:
The family member was involved in a supportive and
positive manner in the patient’s care per the
professional judgment of the patient’s provider, or
The patient signed a Permission to Share form
allowing CHC to communicate with the family
member about the patient’s care;
Provider may call or send a written communication to the patient’s family member to
express sympathy if all of the following criteria are met:
22
Response upon Learning
of the Death of a CHC Patient
Deactivation of the Patient Chart
1. The staff person who is notified creates a telephone encounter (TE) with reason of “Report of
Death”. TE is sent to site’s Operations Manager (OM).
•The Provider or OM may enter details of the patient’s passing.
•Information must include the date of passing
•TE serves as documentation of passing.
2. OM cancels all future appointments and suppresses all recalls
3. IF TE was not generated by PCP, OM assigns TE to PCP as FYI
•PCP may assigns to relevant BH or Dental provider if applicable for review/FYI
•PCP/BH/Dentist assigns back to OM
4. OM updates the patient records as “deceased” to inactivate the patient’s chart
5. Any documentation about the patient death is scanned into patient record by the OM
6. OM marks TE as addressed
Integrated Care Team Meetings
23
Integrated Care Team Meetings
• The purpose of the Integrated Care Meeting (ICM) is to coordinate a
comprehensive plan to address risk factors impacting the health and
well-being of our patients. Input from all team members is shared at
these meetings to support optimal patient outcomes.
• A dedicated Behavioral Health Coordinator is responsible for
coordinating ICM at every site once a month for patients identified as
high risk who would benefit.
24
Integrated Care Meeting:
CHC Criteria for Patient Selection
• Patients with a high risk score who have a PCP and BH Provider in common
• Patients with recent hospital discharges or ER visits
• Patients with recent discharge for BH diagnoses
• Patients identified by PCP
25
Integrated Care Meetings
• 7 to 10 ICMs are held per month at different sites
• 3 to 9 patients discussed at each ICM
• PCP, BH Provider, Nurse, MA and other staff are present with
psychiatric providers attending as feasible
26
Patient
Primary
Care Provider
Behavioral
Health Provider
RN and/or MA
Behavioral Health Care
Coordinator
Patient Case Study
27
• PCP Report:
• Alcohol use disorder
• Morbid obesity and is medically fragile
• Behavioral Health Provider Report:
• Last seen in therapy 4 months prior and recommended the patient return to therapy.
• Auditory hallucinations, depression, anxiety and inconsistent part of suboxone program.
• Recent hospitalization for chronic alcoholism, cardiac problems, seizures
• RN and/or MA Report:
• Patient due for any vaccines, labs, or DIs
• Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.)
• Behavioral Health Care Coordinator:
• Patient declined SDOH screening
• As a result of the ICM, the patient was referred to CHW and outreach to patient to
reengage in therapy.
• Information about medications prescribed outside of CHC by external provider, added to
medication list by Pharmacy Team
• Collaboration between CHW and RN resulted in a motorized wheelchair for the patient
Patient
Primary
Care
Provider
Behavioral
Health
Provider
RN
and/or
MA
Behavioral
Health Care
Coordinator
Patient
Case Study 1
The Patient:
•45 year old male who is cared for at our homeless shelter site
•Selected for discussion because of his high risk score (11.4, where 1.0 is the average risk score) from the payor.
28
• PCP Report:
• Reported the patient had a history of osteoporosis, cannabis use disorder and memory
problems.
• Behavioral Health Provider Report:
• Patient had PTSD; anxiety, borderline personality disorder and major depression.
• Engaged in therapy (last seen the week prior) but BH provider indicated patient would
benefit from a higher level of care.
• Patient prefers to stay with CHC given the time going to IOP would be too much. The
patient was also engaged with psychiatry at CHC.
• RN and/or MA Report:
• Patient due for any vaccines, labs, or DIs
• Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.)
• Behavioral Health Care Coordinator:
• Patient completed SDOH screening
• The patient was referred to a CHW to support visit adherence.
• Patient presented to PCP differently than to BH provider. Essential to have the discussion
with all members of the care team.
• Identified free transportation program to ensure access to the site.
Patient
Case Study 2
The Patient:
•63 year old female selected for ICM b/c high risk score, 11.4.
Patient
Primary
Care
Provider
Behavioral
Health
Provider
RN
and/or
MA
Behavioral
Health Care
Coordinator
29
Today's presentation covered ...
• The processes for following up on ER visits and hospital discharges
• A Best practice for centralized notification of ER visits and hospitalizations
• Managing centralized notifications of hospital events:
• Integrated Care Team Meetings for risk stratification and management
• Report of death of a patient and caring for the family
30
Questions?
31
Contact Information
32
For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca

Weitere ähnliche Inhalte

Was ist angesagt?

Integrating HIV Prevention into Primary Care
Integrating HIV Prevention into Primary CareIntegrating HIV Prevention into Primary Care
Integrating HIV Prevention into Primary Care
CHC Connecticut
 
Emergency room nurse kpi
Emergency room nurse kpiEmergency room nurse kpi
Emergency room nurse kpi
ratasjommi
 
Hospital supportive services
Hospital supportive servicesHospital supportive services
Hospital supportive services
Study Stuff
 
Utilization Management
Utilization ManagementUtilization Management
Utilization Management
Slehri
 
Patient Empowerment from an Integrated Care Approach
Patient Empowerment from an Integrated Care ApproachPatient Empowerment from an Integrated Care Approach
Patient Empowerment from an Integrated Care Approach
Eloisa Vargiu
 
Registered nurse kpi
Registered nurse kpiRegistered nurse kpi
Registered nurse kpi
jommiratas
 
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...An Overview of Kaiser Permanente - Integration and Information Systems in Hea...
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...
Empreender Saúde
 
HIV Prevention: Combating PrEP Implementation Challenges
HIV Prevention: Combating PrEP Implementation ChallengesHIV Prevention: Combating PrEP Implementation Challenges
HIV Prevention: Combating PrEP Implementation Challenges
CHC Connecticut
 
Strategic management for health care organization
Strategic management for health care organization Strategic management for health care organization
Strategic management for health care organization
ibrahimzubairu2003
 
CCM
CCMCCM
What is a health system?
What is a health system?What is a health system?
Overview of Hospital Information Systems
Overview of Hospital Information SystemsOverview of Hospital Information Systems
Overview of Hospital Information Systems
Nawanan Theera-Ampornpunt
 
Strategic Planning For Healthcare Services
Strategic Planning For Healthcare ServicesStrategic Planning For Healthcare Services
Strategic Planning For Healthcare Services
alberpaules
 
The Patient Journey Evolution: A case study
The Patient Journey Evolution: A case studyThe Patient Journey Evolution: A case study
The Patient Journey Evolution: A case study
SKIM
 
Machine Learning + Analytics in Splunk
Machine Learning + Analytics in SplunkMachine Learning + Analytics in Splunk
Machine Learning + Analytics in Splunk
Splunk
 
Quality Assurance in Hospitals
Quality Assurance in HospitalsQuality Assurance in Hospitals
Quality Assurance in Hospitals
Nc Das
 
Ob gyn nurse kpi
Ob gyn nurse kpiOb gyn nurse kpi
Ob gyn nurse kpi
kenfurasfos
 
Activity 1 Nursing Informatics
Activity 1 Nursing InformaticsActivity 1 Nursing Informatics
Activity 1 Nursing Informatics
ethelOcana
 
Webinar on Quality Improvement Strategies in a Team-Based Care Environment
Webinar on Quality Improvement Strategies in a Team-Based Care Environment Webinar on Quality Improvement Strategies in a Team-Based Care Environment
Webinar on Quality Improvement Strategies in a Team-Based Care Environment
CHC Connecticut
 
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt wai
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt waiPatient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt wai
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt wai
Mmedsc Hahm
 

Was ist angesagt? (20)

Integrating HIV Prevention into Primary Care
Integrating HIV Prevention into Primary CareIntegrating HIV Prevention into Primary Care
Integrating HIV Prevention into Primary Care
 
Emergency room nurse kpi
Emergency room nurse kpiEmergency room nurse kpi
Emergency room nurse kpi
 
Hospital supportive services
Hospital supportive servicesHospital supportive services
Hospital supportive services
 
Utilization Management
Utilization ManagementUtilization Management
Utilization Management
 
Patient Empowerment from an Integrated Care Approach
Patient Empowerment from an Integrated Care ApproachPatient Empowerment from an Integrated Care Approach
Patient Empowerment from an Integrated Care Approach
 
Registered nurse kpi
Registered nurse kpiRegistered nurse kpi
Registered nurse kpi
 
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...An Overview of Kaiser Permanente - Integration and Information Systems in Hea...
An Overview of Kaiser Permanente - Integration and Information Systems in Hea...
 
HIV Prevention: Combating PrEP Implementation Challenges
HIV Prevention: Combating PrEP Implementation ChallengesHIV Prevention: Combating PrEP Implementation Challenges
HIV Prevention: Combating PrEP Implementation Challenges
 
Strategic management for health care organization
Strategic management for health care organization Strategic management for health care organization
Strategic management for health care organization
 
CCM
CCMCCM
CCM
 
What is a health system?
What is a health system?What is a health system?
What is a health system?
 
Overview of Hospital Information Systems
Overview of Hospital Information SystemsOverview of Hospital Information Systems
Overview of Hospital Information Systems
 
Strategic Planning For Healthcare Services
Strategic Planning For Healthcare ServicesStrategic Planning For Healthcare Services
Strategic Planning For Healthcare Services
 
The Patient Journey Evolution: A case study
The Patient Journey Evolution: A case studyThe Patient Journey Evolution: A case study
The Patient Journey Evolution: A case study
 
Machine Learning + Analytics in Splunk
Machine Learning + Analytics in SplunkMachine Learning + Analytics in Splunk
Machine Learning + Analytics in Splunk
 
Quality Assurance in Hospitals
Quality Assurance in HospitalsQuality Assurance in Hospitals
Quality Assurance in Hospitals
 
Ob gyn nurse kpi
Ob gyn nurse kpiOb gyn nurse kpi
Ob gyn nurse kpi
 
Activity 1 Nursing Informatics
Activity 1 Nursing InformaticsActivity 1 Nursing Informatics
Activity 1 Nursing Informatics
 
Webinar on Quality Improvement Strategies in a Team-Based Care Environment
Webinar on Quality Improvement Strategies in a Team-Based Care Environment Webinar on Quality Improvement Strategies in a Team-Based Care Environment
Webinar on Quality Improvement Strategies in a Team-Based Care Environment
 
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt wai
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt waiPatient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt wai
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt wai
 

Ähnlich wie Implementation of Timely and Effective Transitional Care Management Processes

2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care
CHC Connecticut
 
Annual provider health stream learning session 2015 draft #7 on 4 17
Annual provider health stream learning session 2015 draft #7 on 4 17Annual provider health stream learning session 2015 draft #7 on 4 17
Annual provider health stream learning session 2015 draft #7 on 4 17
gsisson
 
IAFCC-Presentation-12-7-15-EH.pptx
IAFCC-Presentation-12-7-15-EH.pptxIAFCC-Presentation-12-7-15-EH.pptx
IAFCC-Presentation-12-7-15-EH.pptx
ashokkumarm27
 
Centers of Excellence
Centers of ExcellenceCenters of Excellence
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...
CHC Connecticut
 
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
Donte Murphy
 
Webinar - High Value Primary Care: How Can Employers Identify and Promote It?
Webinar - High Value Primary Care:  How Can Employers Identify and Promote It? Webinar - High Value Primary Care:  How Can Employers Identify and Promote It?
Webinar - High Value Primary Care: How Can Employers Identify and Promote It?
Pacific Business Group on Health
 
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...
CHC Connecticut
 
Michigan Hospital Association Governance meeting
Michigan Hospital Association Governance meetingMichigan Hospital Association Governance meeting
Michigan Hospital Association Governance meeting
Mary Beth Bolton
 
36 (1)
36 (1)36 (1)
36 (1)
lightbrain
 
February 22 2018 team based care webinar 2
February 22 2018 team based care webinar 2February 22 2018 team based care webinar 2
February 22 2018 team based care webinar 2
CHC Connecticut
 
referral system chn.pptx
referral system chn.pptxreferral system chn.pptx
referral system chn.pptx
Harpreet99
 
The Value of Hospice in Medicare
The Value of Hospice in MedicareThe Value of Hospice in Medicare
The Value of Hospice in Medicare
VITAS Healthcare
 
Closing the Loop: Strategies to Extend Care in the ED
Closing the Loop: Strategies to Extend Care in the EDClosing the Loop: Strategies to Extend Care in the ED
Closing the Loop: Strategies to Extend Care in the ED
EngagingPatients
 
Innovation in Care Delivery: The Patient Journey
Innovation in Care Delivery: The Patient JourneyInnovation in Care Delivery: The Patient Journey
Innovation in Care Delivery: The Patient Journey
Jane Chiang
 
Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...
Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...
Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...
CHC Connecticut
 
Roadmap to the Patient-Centered Medical Home
Roadmap to the Patient-Centered Medical HomeRoadmap to the Patient-Centered Medical Home
Roadmap to the Patient-Centered Medical Home
PYA, P.C.
 
MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013
MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013
MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013
MassEHealth
 
Adams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinal
Adams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinalAdams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinal
Adams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinal
PATRICK ADAMS
 
Genesis Presentation
Genesis PresentationGenesis Presentation
Genesis Presentation
Hai Duong
 

Ähnlich wie Implementation of Timely and Effective Transitional Care Management Processes (20)

2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive Care
 
Annual provider health stream learning session 2015 draft #7 on 4 17
Annual provider health stream learning session 2015 draft #7 on 4 17Annual provider health stream learning session 2015 draft #7 on 4 17
Annual provider health stream learning session 2015 draft #7 on 4 17
 
IAFCC-Presentation-12-7-15-EH.pptx
IAFCC-Presentation-12-7-15-EH.pptxIAFCC-Presentation-12-7-15-EH.pptx
IAFCC-Presentation-12-7-15-EH.pptx
 
Centers of Excellence
Centers of ExcellenceCenters of Excellence
Centers of Excellence
 
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...
 
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
How to Achieve a PCMH Certification - Small Practice - Practice-centered medi...
 
Webinar - High Value Primary Care: How Can Employers Identify and Promote It?
Webinar - High Value Primary Care:  How Can Employers Identify and Promote It? Webinar - High Value Primary Care:  How Can Employers Identify and Promote It?
Webinar - High Value Primary Care: How Can Employers Identify and Promote It?
 
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...
 
Michigan Hospital Association Governance meeting
Michigan Hospital Association Governance meetingMichigan Hospital Association Governance meeting
Michigan Hospital Association Governance meeting
 
36 (1)
36 (1)36 (1)
36 (1)
 
February 22 2018 team based care webinar 2
February 22 2018 team based care webinar 2February 22 2018 team based care webinar 2
February 22 2018 team based care webinar 2
 
referral system chn.pptx
referral system chn.pptxreferral system chn.pptx
referral system chn.pptx
 
The Value of Hospice in Medicare
The Value of Hospice in MedicareThe Value of Hospice in Medicare
The Value of Hospice in Medicare
 
Closing the Loop: Strategies to Extend Care in the ED
Closing the Loop: Strategies to Extend Care in the EDClosing the Loop: Strategies to Extend Care in the ED
Closing the Loop: Strategies to Extend Care in the ED
 
Innovation in Care Delivery: The Patient Journey
Innovation in Care Delivery: The Patient JourneyInnovation in Care Delivery: The Patient Journey
Innovation in Care Delivery: The Patient Journey
 
Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...
Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...
Advancing Team-Based Care: A Team Approach to Prevention and Chronic Illness ...
 
Roadmap to the Patient-Centered Medical Home
Roadmap to the Patient-Centered Medical HomeRoadmap to the Patient-Centered Medical Home
Roadmap to the Patient-Centered Medical Home
 
MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013
MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013
MeHI Regional Health IT Meetings - Worcester, MA - Nov, 2013
 
Adams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinal
Adams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinalAdams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinal
Adams-HFMA_TranscendDeck_HFMA_6-2-2015_PAfinal
 
Genesis Presentation
Genesis PresentationGenesis Presentation
Genesis Presentation
 

Mehr von CHC Connecticut

Re-engaging Patients in Dental Care
Re-engaging Patients in Dental CareRe-engaging Patients in Dental Care
Re-engaging Patients in Dental Care
CHC Connecticut
 
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...
CHC Connecticut
 
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...
CHC Connecticut
 
Newborn Screening - May 9, 2023
Newborn Screening - May 9, 2023Newborn Screening - May 9, 2023
Newborn Screening - May 9, 2023
CHC Connecticut
 
Health Professions Student Training Webinar: Assessing Organizational Capacity
Health Professions Student Training Webinar: Assessing Organizational CapacityHealth Professions Student Training Webinar: Assessing Organizational Capacity
Health Professions Student Training Webinar: Assessing Organizational Capacity
CHC Connecticut
 
Training the Next Generation: Investing in Workforce Training
Training the Next Generation: Investing in Workforce TrainingTraining the Next Generation: Investing in Workforce Training
Training the Next Generation: Investing in Workforce Training
CHC Connecticut
 
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...
CHC Connecticut
 
Addressing Genetics Workforce Shortage - April 11, 2023
Addressing Genetics Workforce Shortage - April 11, 2023Addressing Genetics Workforce Shortage - April 11, 2023
Addressing Genetics Workforce Shortage - April 11, 2023
CHC Connecticut
 
Direct to Consumer Test and Ancestry Testing - March 14, 2023
Direct to Consumer Test and Ancestry Testing - March 14, 2023Direct to Consumer Test and Ancestry Testing - March 14, 2023
Direct to Consumer Test and Ancestry Testing - March 14, 2023
CHC Connecticut
 
Genetic Connections to Breast Cancer - February 14, 2023
Genetic Connections to Breast Cancer - February 14, 2023Genetic Connections to Breast Cancer - February 14, 2023
Genetic Connections to Breast Cancer - February 14, 2023
CHC Connecticut
 
Connective Tissue Disorders Slides - January 17, 2023
Connective Tissue Disorders Slides - January 17, 2023Connective Tissue Disorders Slides - January 17, 2023
Connective Tissue Disorders Slides - January 17, 2023
CHC Connecticut
 
Implementation of Facial Recognition Software for Clinical Genetics Practice...
 Implementation of Facial Recognition Software for Clinical Genetics Practice... Implementation of Facial Recognition Software for Clinical Genetics Practice...
Implementation of Facial Recognition Software for Clinical Genetics Practice...
CHC Connecticut
 
Genetics Cases and Resources Webinar Slides - November 8, 2022
Genetics Cases and Resources Webinar Slides - November 8, 2022Genetics Cases and Resources Webinar Slides - November 8, 2022
Genetics Cases and Resources Webinar Slides - November 8, 2022
CHC Connecticut
 
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...
CHC Connecticut
 
Training the Next Generation within Primary Care
Training the Next Generation within Primary CareTraining the Next Generation within Primary Care
Training the Next Generation within Primary Care
CHC Connecticut
 
COVID-19's Impact on the Interdisciplinary Primary Care Workforce
COVID-19's Impact on the Interdisciplinary Primary Care WorkforceCOVID-19's Impact on the Interdisciplinary Primary Care Workforce
COVID-19's Impact on the Interdisciplinary Primary Care Workforce
CHC Connecticut
 
NTTAP Health Professions Student Training Webinar
NTTAP Health Professions Student Training WebinarNTTAP Health Professions Student Training Webinar
NTTAP Health Professions Student Training Webinar
CHC Connecticut
 
Inclusive Strategies for Workforce Retention and Engagement - May 11 2022
Inclusive Strategies for Workforce Retention and Engagement - May 11 2022Inclusive Strategies for Workforce Retention and Engagement - May 11 2022
Inclusive Strategies for Workforce Retention and Engagement - May 11 2022
CHC Connecticut
 
Webinar on Integrating HIV Education
Webinar on Integrating HIV EducationWebinar on Integrating HIV Education
Webinar on Integrating HIV Education
CHC Connecticut
 
Assessing Health Center Readiness to Train Health Professionals
Assessing Health Center Readiness to Train Health ProfessionalsAssessing Health Center Readiness to Train Health Professionals
Assessing Health Center Readiness to Train Health Professionals
CHC Connecticut
 

Mehr von CHC Connecticut (20)

Re-engaging Patients in Dental Care
Re-engaging Patients in Dental CareRe-engaging Patients in Dental Care
Re-engaging Patients in Dental Care
 
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...
 
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...
 
Newborn Screening - May 9, 2023
Newborn Screening - May 9, 2023Newborn Screening - May 9, 2023
Newborn Screening - May 9, 2023
 
Health Professions Student Training Webinar: Assessing Organizational Capacity
Health Professions Student Training Webinar: Assessing Organizational CapacityHealth Professions Student Training Webinar: Assessing Organizational Capacity
Health Professions Student Training Webinar: Assessing Organizational Capacity
 
Training the Next Generation: Investing in Workforce Training
Training the Next Generation: Investing in Workforce TrainingTraining the Next Generation: Investing in Workforce Training
Training the Next Generation: Investing in Workforce Training
 
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...
 
Addressing Genetics Workforce Shortage - April 11, 2023
Addressing Genetics Workforce Shortage - April 11, 2023Addressing Genetics Workforce Shortage - April 11, 2023
Addressing Genetics Workforce Shortage - April 11, 2023
 
Direct to Consumer Test and Ancestry Testing - March 14, 2023
Direct to Consumer Test and Ancestry Testing - March 14, 2023Direct to Consumer Test and Ancestry Testing - March 14, 2023
Direct to Consumer Test and Ancestry Testing - March 14, 2023
 
Genetic Connections to Breast Cancer - February 14, 2023
Genetic Connections to Breast Cancer - February 14, 2023Genetic Connections to Breast Cancer - February 14, 2023
Genetic Connections to Breast Cancer - February 14, 2023
 
Connective Tissue Disorders Slides - January 17, 2023
Connective Tissue Disorders Slides - January 17, 2023Connective Tissue Disorders Slides - January 17, 2023
Connective Tissue Disorders Slides - January 17, 2023
 
Implementation of Facial Recognition Software for Clinical Genetics Practice...
 Implementation of Facial Recognition Software for Clinical Genetics Practice... Implementation of Facial Recognition Software for Clinical Genetics Practice...
Implementation of Facial Recognition Software for Clinical Genetics Practice...
 
Genetics Cases and Resources Webinar Slides - November 8, 2022
Genetics Cases and Resources Webinar Slides - November 8, 2022Genetics Cases and Resources Webinar Slides - November 8, 2022
Genetics Cases and Resources Webinar Slides - November 8, 2022
 
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...
 
Training the Next Generation within Primary Care
Training the Next Generation within Primary CareTraining the Next Generation within Primary Care
Training the Next Generation within Primary Care
 
COVID-19's Impact on the Interdisciplinary Primary Care Workforce
COVID-19's Impact on the Interdisciplinary Primary Care WorkforceCOVID-19's Impact on the Interdisciplinary Primary Care Workforce
COVID-19's Impact on the Interdisciplinary Primary Care Workforce
 
NTTAP Health Professions Student Training Webinar
NTTAP Health Professions Student Training WebinarNTTAP Health Professions Student Training Webinar
NTTAP Health Professions Student Training Webinar
 
Inclusive Strategies for Workforce Retention and Engagement - May 11 2022
Inclusive Strategies for Workforce Retention and Engagement - May 11 2022Inclusive Strategies for Workforce Retention and Engagement - May 11 2022
Inclusive Strategies for Workforce Retention and Engagement - May 11 2022
 
Webinar on Integrating HIV Education
Webinar on Integrating HIV EducationWebinar on Integrating HIV Education
Webinar on Integrating HIV Education
 
Assessing Health Center Readiness to Train Health Professionals
Assessing Health Center Readiness to Train Health ProfessionalsAssessing Health Center Readiness to Train Health Professionals
Assessing Health Center Readiness to Train Health Professionals
 

Kürzlich hochgeladen

Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
bellared2
 
Respectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science studentsRespectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science students
Debre Berhan University
 
RNA AND DNA VIRUSES morphology,chemical composition
RNA AND DNA VIRUSES morphology,chemical compositionRNA AND DNA VIRUSES morphology,chemical composition
RNA AND DNA VIRUSES morphology,chemical composition
BenjaminMutisyaMuimi
 
ppt on National health mission copy - pptx
ppt on National health mission copy - pptxppt on National health mission copy - pptx
ppt on National health mission copy - pptx
AbinanthanLekhashree
 
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
grandmotherprocess99
 
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.pptMind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
Karuna Yoga Vidya Peetham
 
Assessment and Management of Disruptive Behaviors in Persons with Dementia We...
Assessment and Management of Disruptive Behaviors in Persons with Dementia We...Assessment and Management of Disruptive Behaviors in Persons with Dementia We...
Assessment and Management of Disruptive Behaviors in Persons with Dementia We...
VITASAuthor
 
Top 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in IndiaTop 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in India
DM Pharma
 
Inflammation.pptx (type , cellular event of infllmation .etc)
Inflammation.pptx (type , cellular event of infllmation .etc)Inflammation.pptx (type , cellular event of infllmation .etc)
Inflammation.pptx (type , cellular event of infllmation .etc)
AviralSharma91
 
Drugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor Drugs
Drugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor DrugsDrugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor Drugs
Drugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor Drugs
sanjayudps2016
 
3.INFLAMMATION Of Nursing Second Students
3.INFLAMMATION Of Nursing Second Students3.INFLAMMATION Of Nursing Second Students
3.INFLAMMATION Of Nursing Second Students
tamiratdebebe303
 
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
pinkichadda23 #v08
 
kneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asanakneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asana
Karuna Yoga Vidya Peetham
 
Welco to PowerPointhihhlljjjllasfafafkkk
Welco to PowerPointhihhlljjjllasfafafkkkWelco to PowerPointhihhlljjjllasfafafkkk
Welco to PowerPointhihhlljjjllasfafafkkk
TngHunh31
 
Week 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdf
Week 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdfWeek 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdf
Week 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdf
Reliable Assignments Help
 
Acute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdfAcute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdf
RawanAlakwaa
 
How Claims Management Software is Leading the Way
How Claims Management Software is Leading the WayHow Claims Management Software is Leading the Way
How Claims Management Software is Leading the Way
DataGenix
 
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdfVisual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
Occupational Therapist
 
RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.
RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.
RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.
BinduBandheBarman
 
Massage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa AjmanMassage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa Ajman
Malayali Kerala Spa Ajman
 

Kürzlich hochgeladen (20)

Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
 
Respectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science studentsRespectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science students
 
RNA AND DNA VIRUSES morphology,chemical composition
RNA AND DNA VIRUSES morphology,chemical compositionRNA AND DNA VIRUSES morphology,chemical composition
RNA AND DNA VIRUSES morphology,chemical composition
 
ppt on National health mission copy - pptx
ppt on National health mission copy - pptxppt on National health mission copy - pptx
ppt on National health mission copy - pptx
 
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
 
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.pptMind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
 
Assessment and Management of Disruptive Behaviors in Persons with Dementia We...
Assessment and Management of Disruptive Behaviors in Persons with Dementia We...Assessment and Management of Disruptive Behaviors in Persons with Dementia We...
Assessment and Management of Disruptive Behaviors in Persons with Dementia We...
 
Top 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in IndiaTop 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in India
 
Inflammation.pptx (type , cellular event of infllmation .etc)
Inflammation.pptx (type , cellular event of infllmation .etc)Inflammation.pptx (type , cellular event of infllmation .etc)
Inflammation.pptx (type , cellular event of infllmation .etc)
 
Drugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor Drugs
Drugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor DrugsDrugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor Drugs
Drugs Used for the Hyperlipidemic drugs, HMG-CoA Reductase Inhibitor Drugs
 
3.INFLAMMATION Of Nursing Second Students
3.INFLAMMATION Of Nursing Second Students3.INFLAMMATION Of Nursing Second Students
3.INFLAMMATION Of Nursing Second Students
 
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
Girls Call Hyderabad 000XX00000 Provide Best And Top Girl Service And No1 in ...
 
kneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asanakneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asana
 
Welco to PowerPointhihhlljjjllasfafafkkk
Welco to PowerPointhihhlljjjllasfafafkkkWelco to PowerPointhihhlljjjllasfafafkkk
Welco to PowerPointhihhlljjjllasfafafkkk
 
Week 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdf
Week 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdfWeek 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdf
Week 8 Case of Tiana-DIAGNOSIS OF FEEDING AND EATING DISORDERS CASE STUDY.pdf
 
Acute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdfAcute complications of sickle cell disease .pdf
Acute complications of sickle cell disease .pdf
 
How Claims Management Software is Leading the Way
How Claims Management Software is Leading the WayHow Claims Management Software is Leading the Way
How Claims Management Software is Leading the Way
 
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdfVisual Processing, Visual Perception & Visual-Motor Deficit.pdf
Visual Processing, Visual Perception & Visual-Motor Deficit.pdf
 
RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.
RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.
RTI STD TORCH UTI ,HIV/AIDS BY BINDU PRE.
 
Massage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa AjmanMassage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa Ajman
 

Implementation of Timely and Effective Transitional Care Management Processes

  • 1. Implementation of Timely and Effective Transitional Care Management Processes Tuesday, March 21, 2023 3:00-4:00pm Eastern / 12:00-1:00pm Pacific 1
  • 2. Continuing Education Credits In support of improving patient care, Community Health Center, Inc. / Weitzman Institute is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. A comprehensive certificate will be available after the end of the series, Summer 2023. 2
  • 3. Disclosure • With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. • The views expressed in this presentation are those of the presenters and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. • We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. • This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. 3
  • 4. At the Weitzman Institute, we value a culture of equity, inclusiveness, diversity, and mutually respectful dialogue. We want to ensure that all feel welcome. If there is anything said in our program that makes you feel uncomfortable, please let us know via email at nca@chc1.com 4
  • 5. National Training and Technical Assistance Partnership Clinical Workforce Development Provides free training and technical assistance to health centers across the nation through national webinars, learning collaboratives, activity sessions, trainings, research, publications, etc. 5
  • 6. Speakers • Mary Blankson, DNP, APRN, FNP-C, FAAN • Chief Nursing Officer, Community Health Center, Inc. • Veena Channamsetty, MD, FAAFP • Chief Medical Officer, Community Health Center, Inc. • Bibian Ladino-Davis • Behavioral Health Coordinator, Community Health Center, Inc. 6
  • 7. Objectives • Describe processes for following up on ER visits and hospital discharges, including roles and responsibilities • Discuss a best practice for centralized notification of ER visits and hospitalizations • Review other use cases for managing centralized notifications of hospital events: • Risk stratification and management - Integrated Care Team Meetings • Report of death of a patient and caring for the family 7
  • 8. Areas Identified as Opportunities • Prior to 2016 - Decentralized sources of data where notification of ER visits and hospitalizations was provided to care teams directly through discharge notifications and ER visit notes, rather than a central source disseminating the information with robust processes • Standardized processes for reporting death of a patient • Consistency around Integrated Care Meetings to support our most complex patients • Standardized workflows to update and document in the EHR with regard to care transitions 8
  • 9. Daily Follow-up on ER Visits and Discharges 9
  • 10. Daily Follow-up on ER Visits and Discharges • CHC processes have evolved over time to reflect our priorities as well as our evolving understanding of our patient population and their use of the ER and hospital. • Overview: The BI Department sends a list of CHC patients to Bamboo Health on a monthly basis who have had a medical visit in the last 12 months OR who are on a Value Based Roster regardless of last visit date. • This ensures that we are notified if a patient visits a hospital for an ER visit or admission. • While Bamboo Health has an app that some groups use to manage their patient workflow in the hospital, we instead ingest a file with that information on a daily basis so that a file with a list of patients is distributed each morning. 10
  • 11. Daily Follow-up on Hospital Discharges Triage nurses call each patient who meets certain criteria (e.g., Value Based Roster patient, specific dx, etc.) and, using a structured template, ask the patient a series of questions: 1. Why were you hospitalized? 2. How are you feeling today? 3. Were you discharged with any new meds to take at home? If yes, what are they? 4. Do you have any nurses or therapists visiting you at home? 5. Were you told to schedule appointments with any doctors besides your primary care provider? If yes, who? 11 • Nurses make up to three attempts to reach the patient by phone. Note: Bamboo Health does at times, provide a new phone number for the patient based on what the patient reported at the hospital and this can be valuable! • This same list of patients is also sent to the MA and they retrieve the hospital discharge note and scan into chart. • Our follow up rates are about 54% which is well above the rates for other health centers in our state (43%) and the Medicaid rate of 38.5%. • This information can be reviewed by the provider during the post-hospital visit.
  • 12. Daily Follow-up on Hospital Discharges 12 Other uses of Hospital Discharge Information 1. Complete SDoH (PRAPARE) with patients who had a hospital discharge by the Triage Nurses. 2. Mail a congratulations card to new moms upon the notification of a birth. 3. Alert in NOVO so that if a patient was high risk/who met certain criteria (e.g., multiple ER visits; recent hospitalizations; high risk score) the PSA would delegate the call to Triage to talk with patients.
  • 13. Daily Follow-up on ER Visits • MA reviews the list and notifies PCP of any ER visits that require follow up • Other uses of ER information 1. For pediatric patients with an ER visit for asthma, a text message is sent to the patient to encourage them to schedule follow up with PCP (if a visit is not already scheduled) 2. For patients in a value based program that requires complex care patients who meet certain criteria to have follow up we send a text message to patient to schedule follow up visit 13
  • 16. Bamboo Health Process 16 • All patients in a Value Based Program • All patients who are discharged for COPD, Diabetes, Asthma, Hypertension, Delivery of newborn, Poisoning; F code (all BH diagnoses) Consider whether there are sufficient resources to follow up on all hospital events. Prioritizations may include: Other considerations
  • 17. Special Considerations 17 Patients who have not been seen in the last 3 years School Based Health Center patients who do not have CHCI as their PCP Other opportunities – upon patient admission to ER or hospital
  • 18. Report of Death of a Patient Process 18
  • 19. 19 Notification of a Patient Death • Weekly report of patients who, according to Bamboo Health, have passed away the prior week AND/OR whom we were notified about a patient’s passing. • The report includes: • Patient ID and Name • Date of passing • Hospital/facility • PCP • PCP Site • The report is disseminated to the Operations Managers, Senior Program Manager for Population Health and the Senior VP/Clinic Director.
  • 20. 20 Response upon Learning of the Death of a CHC Patient Procedure addresses: • Sympathy Calls or Cards • Ensure family members are supported • Opportunity to offer further supportive services • Clarity on when calling family members is appropriate • Deactivation of the Patient Chart: • Ensures canceling of follow up calls and reminders • Updates the E.H.R status
  • 21. 21 Response upon Learning of the Death of a CHC Patient Sympathy Calls or Cards to Family Member AND Contacting the family member would NOT be inconsistent with any prior expressed preference of the patient. Either: The family member was involved in a supportive and positive manner in the patient’s care per the professional judgment of the patient’s provider, or The patient signed a Permission to Share form allowing CHC to communicate with the family member about the patient’s care; Provider may call or send a written communication to the patient’s family member to express sympathy if all of the following criteria are met:
  • 22. 22 Response upon Learning of the Death of a CHC Patient Deactivation of the Patient Chart 1. The staff person who is notified creates a telephone encounter (TE) with reason of “Report of Death”. TE is sent to site’s Operations Manager (OM). •The Provider or OM may enter details of the patient’s passing. •Information must include the date of passing •TE serves as documentation of passing. 2. OM cancels all future appointments and suppresses all recalls 3. IF TE was not generated by PCP, OM assigns TE to PCP as FYI •PCP may assigns to relevant BH or Dental provider if applicable for review/FYI •PCP/BH/Dentist assigns back to OM 4. OM updates the patient records as “deceased” to inactivate the patient’s chart 5. Any documentation about the patient death is scanned into patient record by the OM 6. OM marks TE as addressed
  • 23. Integrated Care Team Meetings 23
  • 24. Integrated Care Team Meetings • The purpose of the Integrated Care Meeting (ICM) is to coordinate a comprehensive plan to address risk factors impacting the health and well-being of our patients. Input from all team members is shared at these meetings to support optimal patient outcomes. • A dedicated Behavioral Health Coordinator is responsible for coordinating ICM at every site once a month for patients identified as high risk who would benefit. 24
  • 25. Integrated Care Meeting: CHC Criteria for Patient Selection • Patients with a high risk score who have a PCP and BH Provider in common • Patients with recent hospital discharges or ER visits • Patients with recent discharge for BH diagnoses • Patients identified by PCP 25
  • 26. Integrated Care Meetings • 7 to 10 ICMs are held per month at different sites • 3 to 9 patients discussed at each ICM • PCP, BH Provider, Nurse, MA and other staff are present with psychiatric providers attending as feasible 26
  • 27. Patient Primary Care Provider Behavioral Health Provider RN and/or MA Behavioral Health Care Coordinator Patient Case Study 27
  • 28. • PCP Report: • Alcohol use disorder • Morbid obesity and is medically fragile • Behavioral Health Provider Report: • Last seen in therapy 4 months prior and recommended the patient return to therapy. • Auditory hallucinations, depression, anxiety and inconsistent part of suboxone program. • Recent hospitalization for chronic alcoholism, cardiac problems, seizures • RN and/or MA Report: • Patient due for any vaccines, labs, or DIs • Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.) • Behavioral Health Care Coordinator: • Patient declined SDOH screening • As a result of the ICM, the patient was referred to CHW and outreach to patient to reengage in therapy. • Information about medications prescribed outside of CHC by external provider, added to medication list by Pharmacy Team • Collaboration between CHW and RN resulted in a motorized wheelchair for the patient Patient Primary Care Provider Behavioral Health Provider RN and/or MA Behavioral Health Care Coordinator Patient Case Study 1 The Patient: •45 year old male who is cared for at our homeless shelter site •Selected for discussion because of his high risk score (11.4, where 1.0 is the average risk score) from the payor. 28
  • 29. • PCP Report: • Reported the patient had a history of osteoporosis, cannabis use disorder and memory problems. • Behavioral Health Provider Report: • Patient had PTSD; anxiety, borderline personality disorder and major depression. • Engaged in therapy (last seen the week prior) but BH provider indicated patient would benefit from a higher level of care. • Patient prefers to stay with CHC given the time going to IOP would be too much. The patient was also engaged with psychiatry at CHC. • RN and/or MA Report: • Patient due for any vaccines, labs, or DIs • Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.) • Behavioral Health Care Coordinator: • Patient completed SDOH screening • The patient was referred to a CHW to support visit adherence. • Patient presented to PCP differently than to BH provider. Essential to have the discussion with all members of the care team. • Identified free transportation program to ensure access to the site. Patient Case Study 2 The Patient: •63 year old female selected for ICM b/c high risk score, 11.4. Patient Primary Care Provider Behavioral Health Provider RN and/or MA Behavioral Health Care Coordinator 29
  • 30. Today's presentation covered ... • The processes for following up on ER visits and hospital discharges • A Best practice for centralized notification of ER visits and hospitalizations • Managing centralized notifications of hospital events: • Integrated Care Team Meetings for risk stratification and management • Report of death of a patient and caring for the family 30
  • 32. Contact Information 32 For information on future webinars, activity sessions, and learning collaboratives: please reach out to nca@chc1.com or visit https://www.chc1.com/nca

Hinweis der Redaktion

  1. Bianca (3:00-3:02) Would the audience want to know how many people are in the triage department? How many people does it take? How many discharges?
  2. Bianca (3:00-3:02)
  3. Bianca (3:00-3:02)
  4. Bianca (3:00-3:02)
  5. Bianca (3:00-3:02)
  6. Bianca (3:00-3:02) Tierney
  7. Mary (3:03-3:21) Describe processes for following up on ER visits and hospital discharges, including roles and responsibilities Discuss a best practice for centralized notification of ER visits and hospitalizations Other use cases for managing centralized notifications of hospital events: -Risk stratification and management - Integrated Care Team Meetings -Reports of patient passings, caring for the family
  8. Mary (3:03-3:21) elements were in place of course—but definitely time for a new look Prior to 2016 - Decentralized sources of data where notification of ER visits and hospitalizations was provided to care teams directly through discharge notifications and er visit notes, rather than a central source disseminating the information with robust processes
  9. Mary (3:03-3:21)
  10. Mary (3:03-3:21) Speak to joys and concerns
  11. Mary (3:03-3:21) Hospital Discharges – -Triage Nurses call each of the patients who meet certain criteria, (e.g., Value Based Roster pt, specific dx, etc.) and using a structured template they ask the patient a series of questions 1. Why were you hospitalized 2. How are you feeling today? 3. Were you discharged with any new meds to take at home? If yes, what are they? 4. Do you have any nurses or therapists visiting you at home? 5. Were you told to schedule appts w/any doctors besides your primary care provider? If yes, who? Nurses make up to three attempts to reach the patient by phone. Note: Bamboo Health does at times, provide a new phone number for the patient based on what the pt reported at the hospital and this can be valuable! This same list of patients is also sent to the MA and they retrieve the hospital discharge note and scan into chart. Our follow up rates were are about 54% which is well above the rates for other FQHCs in our state (43%) and the Medicaid rate of 38.5%. OTHER ways we’ve worked this data 1. SDoH/PRAPARE completed with patients who had a hosp discharge by the Triage Nurses. 2. Mail a congratulations card to new moms upon the notification of a birth 3. Alert in NOVO so that if a patient was high risk/who met certain criteria (e.g., multiple ER visits; recent hospitalizations; high risk score) the PSA would delegate the call to Triage to talk with patients ER VISITS -MA reviews the list and notifies PCP of any ER visits that require follow up OTHER ways we’ve worked w/ER visits 1. For pedi patients with an ER visit for asthma, a text message is sent to the patient to encourage them to schedule f/up with PCP (if a visit is not already scheduled) 2. For patients in a value based roster that requires complex care pts who meet certain criteria to have f/up we send a text msg to patient to schedule f/up visit
  12. Mary (3:03-3:21) Mental illness – we have complicated process for managing patients who are discharged from the hospital for mental illness Hospital Discharges – -Triage Nurses call each of the patients who meet certain criteria, (e.g., Value Based Roster pt, specific dx, etc.) and using a structured template they ask the patient a series of questions 1. Why were you hospitalized 2. How are you feeling today? 3. Were you discharged with any new meds to take at home? If yes, what are they? 4. Do you have any nurses or therapists visiting you at home? 5. Were you told to schedule appts w/any doctors besides your primary care provider? If yes, who? Nurses make up to three attempts to reach the patient by phone. Note: Bamboo Health does at times, provide a new phone number for the patient based on what the pt reported at the hospital and this can be valuable! This same list of patients is also sent to the MA and they retrieve the hospital discharge note and scan into chart. Our follow up rates were are about 54% which is well above the rates for other FQHCs in our state (43%) and the Medicaid rate of 38.5%. OTHER ways we’ve worked this data 1. SDoH/PRAPARE completed with patients who had a hosp discharge by the Triage Nurses. 2. Mail a congratulations card to new moms upon the notification of a birth 3. Alert in NOVO so that if a patient was high risk/who met certain criteria (e.g., multiple ER visits; recent hospitalizations; high risk score) the PSA would delegate the call to Triage to talk with patients ER VISITS -MA reviews the list and notifies PCP of any ER visits that require follow up OTHER ways we’ve worked w/ER visits 1. For pedi patients with an ER visit for asthma, a text message is sent to the patient to encourage them to schedule f/up with PCP (if a visit is not already scheduled) 2. For patients in a value based roster that requires complex care pts who meet certain criteria to have f/up we send a text msg to patient to schedule f/up visit
  13. Mary (3:03-3:21) -May want to say something about CONNIE and how this may impact our processes
  14. Mary (3:03-3:21) Dashboard utilized to drill down on data for what we’re doing
  15. Mary (3:03-3:21) Ensure that patients who do not need to return to PCP but rather need to go to their OB/GYN or their surgeon as a first step are identified so outreach is not the same to them - priority is for them to see the specialist
  16. Mary (3:03-3:21) This is a level of detail not needed -> it is noting WHICH PATIENTS we do the hosp f/up process on – so we f/up on: ALL pts with are on a Value Based Roster ALL pts who are discharged for COPD, Diabetes, Asthma, Hypertension, Delivery of newborn, Poisoning; F code (all BH diagnoses)
  17. Mary (3:03-3:21) ~18 min Other types: -incarceration So this is like, special circumstances and how to handle them
  18. Veena 3:22-3:32 ~10 mins Or Process upon receiving report of a patient death Veena can speak on from provider perspective?
  19. Veena 3:22-3:32 We may be notified of a patient death in may ways. This may come from the family, the staff may know from the community, sometimes from others involved in the patient care, and sometimes it may be discharge summary or ED note. In addition to these ways, CHC do also have patient deaths as part of this larger ‘Bamboo Health” report which is reviewed by Pop Health. Tierney made modifications to this slide
  20. Veena 3:22-3:32 While may not be transition of care, it is important that this procedure be followed with sympathy, respect, and closure . Generally, the patient’s primary medical provider or primary behavioral health provider initiate the communication, but this may process may also be started by the Bamboo Health Report or even the Population Health team, when we learn of a patient death. The response procedure really has 2 parts…
  21. Veena 3:22-3:32 While may not be transition of care, does involve Generally, the patient’s primary medical provider or primary behavioral health provider should initiate the communication.
  22. Veena 3:22-3:32 Once CHC has received notification of passing, through any means, the following steps will be completed: Generally, the patient’s primary medical provider or primary behavioral health provider should initiate the communication. OM marks TE as addressed
  23. Bibian 3:33-3:48
  24. Bibian 3:33-3:48 When did we start doing them? 2017.
  25. Bibian 3:33-3:48 High risk score – where do we get it?
  26. Bibian 3:33-3:48
  27. Bibian 3:33-3:48
  28. Bibian 3:33-3:48 SDOH: Housing, transportation and food insecurity
  29. Bibian 3:33-3:48 Patient requested a letter for DCF and PCP declined to write it the way the patient requested it so patient went to BH provider.
  30. Mary 3:49-3:50 Describe processes for following up on ER visits and hospital discharges, including roles and responsibilities Discuss a best practice for centralized notification of ER visits and hospitalizations Other use cases for managing centralized notifications of hospital events: -Risk stratification and management - Integrated Care Team Meetings -Reports of patient passings, caring for the family
  31. Bianca 3:51-3:59
  32. Bianca 4:00