Presentation is loading. Please wait.

Presentation is loading. Please wait.

Address Readmission Rate Robust inpatient management but need for streamlined community navigation HF patients have been using the ED as primary care.

Published byPearl Butler Modified over 8 years ago

Similar presentations

Presentation on theme: "Address Readmission Rate Robust inpatient management but need for streamlined community navigation HF patients have been using the ED as primary care."— Presentation transcript:

1

2 Address Readmission Rate Robust inpatient management but need for streamlined community navigation HF patients have been using the ED as primary care Intensify Heart Failure patient discharge education to start on admission

3 Heart Failure Self Management Book One-on-one patient education HF follow-up: phone, Cardiac Rehab referral, PCP Intensify Heart Failure patient discharge education to start on admission hospital wide involvement Streamline community resources Heart Failure Support Group

4 DATESENCOUNTERSEDUCATIONTELEPHONE/ FOLLOW UP May ‘12 – Dec ‘121758529298 Jan ‘13 – Dec ‘1336651452775 Jan ‘14 – Feb ‘1473027459 TOTAL615322551132

5 Rapid Diuresis protocol Utilization of CPC Mid-level managed clinics

6 Grow Support Group Regional Education and Outreach Streamline involvement with population health, community navigation and faith based network Integrate care between inpatient-outpatient-PCP Full utilization of cardiac rehab

7 TJC Disease Specific Certified 4 in the State of Texas ADA Recognized Diabetes Self Management Program 102 in the State of Texas 1758 in the United States

8 High undiagnosed rate of diabetes in Ector County Community unawareness of resources Meaningful education and screening process Restructure the process to be: Risk StratificationScreen CBG/A1CEducationPCP/Follow Up

9 Diabetes community health education Meaningful Screening Tool Education Piece Risk Stratification and Self Assessment CBG testing / A1C Taking the tool to the community/ health Fairs Scheduling free Survival Skills 2-3 hour class in English and Spanish

10 4 Hours Core Class and 3 Hours of Nutrition 3 Hours shadow with clinical educator Designed for organizations without any Nursing Education Department or Diabetes Educators End goal: Staff will develop beginning skills and working knowledge on helping patients with diabetes Permian Regional Medical Center – Andrews Pecos County Memorial Hospital – Ft. Stockton

11 Regional Outreach/ Education in collaboration with PRMC and PCMHFS Grow the current APN based providers for those without PCPs and referred to ProCare Streamline involvement with population health, community navigation and faith based network Integrate care between inpatient-outpatient-PCP

Download ppt "Address Readmission Rate Robust inpatient management but need for streamlined community navigation HF patients have been using the ED as primary care."

Similar presentations

Discharge Advocate Duluth. . St. Lukes Discharge Advocate Discharge Advocate position is part of the Case Management Department In February a pilot study.

Discharge Advocate Duluth. . St. Lukes Discharge Advocate Discharge Advocate position is part of the Case Management Department In February a pilot study.
Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014.

Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014.
The Mount Sinai Health System Experience. What is PACT? The Preventable Admissions Care Team is… An intensive, short-term transitional care program.

The Mount Sinai Health System Experience. What is PACT? The Preventable Admissions Care Team is… An intensive, short-term transitional care program.
Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Community Collaboration.

Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Community Collaboration.
Alachua County Initiative to Reduce Avoidable Hospital Utilization Cathy Cook LCSW, Shands Diane Dimperio, Alachua County Health Department October 12,

Alachua County Initiative to Reduce Avoidable Hospital Utilization Cathy Cook LCSW, Shands Diane Dimperio, Alachua County Health Department October 12,
Department of Vermont Health Access Vermont Blueprint for Health: Using APCD to Evaluate Health Care Reform Pat Jones, MS Blueprint Assistant Director.

Department of Vermont Health Access Vermont Blueprint for Health: Using APCD to Evaluate Health Care Reform Pat Jones, MS Blueprint Assistant Director.
Urgent Care Planning in South Tyneside David Hambleton Urgent Care Everyone’s problem.

Urgent Care Planning in South Tyneside David Hambleton Urgent Care Everyone’s problem.
National rapid access to best-quality stroke services Prevent 1 stroke every day Avoid death or dependence in 1 patient every day National Stroke Clinical.

National rapid access to best-quality stroke services Prevent 1 stroke every day Avoid death or dependence in 1 patient every day National Stroke Clinical.
2.11 Conduct Medication Management University Medical Center Health System Lubbock, TX Jason Mills, PharmD, RPh Assistant Director of Pharmacy.

2.11 Conduct Medication Management University Medical Center Health System Lubbock, TX Jason Mills, PharmD, RPh Assistant Director of Pharmacy.
Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.

Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.
Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research.

Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research.
Heal Teach Discover Serve Geisinger Value 1 Transitions of Care/Personal Health Navigator January 31, 2009.

Heal Teach Discover Serve Geisinger Value 1 Transitions of Care/Personal Health Navigator January 31, 2009.
THE CRITICAL ACCESS HOSPITAL NETWORK’S RURAL HEALTH INFORMATION TECHNOLOGY PROJECT Sue Deitz, MPH.

THE CRITICAL ACCESS HOSPITAL NETWORK’S RURAL HEALTH INFORMATION TECHNOLOGY PROJECT Sue Deitz, MPH.
The Big Puzzle Evolving the Continuum of Care. Agenda Goal Pre Acute Care Intra Hospital Care Post Hospital Care Grading the Value of Post Acute Providers.

The Big Puzzle Evolving the Continuum of Care. Agenda Goal Pre Acute Care Intra Hospital Care Post Hospital Care Grading the Value of Post Acute Providers.
Paul Kaye, MD VP for Practice Transformation Hudson River HealthCare October 1, 2010.

Paul Kaye, MD VP for Practice Transformation Hudson River HealthCare October 1, 2010.
Medicare Patients Rights and Better Care Transitions Michael Burgess New York StateWide Senior Action Council, September 13, 2012.

Medicare Patients Rights and Better Care Transitions Michael Burgess New York StateWide Senior Action Council, September 13, 2012.
RHP 14 Learning Collaborative July 18, 2014. DSRIP Project Overview  Key project areas at Odessa Regional Medical Center Speech Pathology Diabetes Education.

RHP 14 Learning Collaborative July 18, DSRIP Project Overview  Key project areas at Odessa Regional Medical Center Speech Pathology Diabetes Education.
Karen Scott Collins, MD, MPH July 2008. Public Benefit Corporation Governing:  11 Acute Care Facilities  Four Long Term Care Facilities  Six Diagnostic.

Karen Scott Collins, MD, MPH July Public Benefit Corporation Governing:  11 Acute Care Facilities  Four Long Term Care Facilities  Six Diagnostic.
The Health Roundtable Charting a course for change for people with chronic illness: The St George experience Presenters: Linda Soars, Daniel Shaw, Karen.

The Health Roundtable Charting a course for change for people with chronic illness: The St George experience Presenters: Linda Soars, Daniel Shaw, Karen.
2 AMERIGROUP Community Care Entered Maryland market in 1999 Largest MCO in Maryland Serving over 143,000 members in Baltimore City and 20 counties in.

2 AMERIGROUP Community Care Entered Maryland market in 1999 Largest MCO in Maryland Serving over 143,000 members in Baltimore City and 20 counties in.

Similar presentations

Ads by Google