Heart Failure Collaborative Kick-Off Meeting Affinity Group Notes Effective Transitions & Using Transitional Coordinators Facilitator: Len Fromer, MD, Group Practice Forum Root cause of readmission/care Poor communication the little things” – “it’s Poor hand-offs (fall through cracks) Not just post-hospital (home, pharmacy) Who is responsible person? Specified person? (care manager) Needs to patient “touch” Start in ED- Follow patient in continuum Team that cares for patient ONE IP/OP TEAM – Coordinate anything patient needs Discharge PA’s to post acute –communicate practitioners (takes 45 minutes to do discharge) Duties: calls medication reconciliation, follow-up appointment electronic record documentation Task list Billing: 85% for NP/PA for discharge Value compensation for hospitalists –based LOS Readmissions Team-measure Some individual Outside cardiologist, competition for billing Inpatient/outpatient? Or the inpatient? Risk stratification- workflow that includes transition avoid duplication, most efficient use of RN – Are hospitalist/case managers aligned? (Employed by hospital vs. group) Does hospital want to develop its own program? Measure outcomes- readmission rates (opportunity to improve) Pharmacy: Give two weeks for free (brown bag) Coordination with outpatient pharmacy (owned)—can bill for pharmacy services Med adherence pharmacist, vendor (WellMed), medical assistants, pharmacy – residents authorization Managing outpatient studies? Genomics and medicine Natural medicine
Heart Failure Collaborative Kick-Off Meeting Affinity Group Notes Effective Transitions & Using Transitional Coordinators Facilitator: Len Fromer, MD, Group Practice Forum Root cause of readmission/care Poor communication – “it’s the little things” Poor hand-offs (fall through cracks) Not just post-hospital (home, pharmacy) Who is responsible person? Specified person? (care manager) Needs to “touch” patient Start in ED- Follow patient in continuum Team that cares for patient – ONE IP/OP TEAM Coordinate anything patient needs Discharge PA’s –communicate to post acute practitioners (takes 45 minutes to do discharge) Duties: calls medication reconciliation, follow-up appointment electronic record documentation Task list Billing: 85% for NP/PA for discharge Value –based compensation for hospitalists LOS Readmissions Team-measure Some individual Outside cardiologist, competition for billing Inpatient/outpatient? Or the inpatient? Risk stratification- workflow that includes transition – avoid duplication, most efficient use of RN Are hospitalist/case managers aligned? (Employed by hospital vs. group) Does hospital want to develop its own program? Measure outcomes- readmission rates (opportunity to improve) Pharmacy: Give two weeks for free (brown bag) Coordination with outpatient pharmacy (owned)—can bill for pharmacy services Med adherence – pharmacist, vendor (WellMed), medical assistants, pharmacy residents authorization Managing outpatient studies? Genomics and medicine Natural medicine
effectiveTransitions.docx