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As part of its CMS' Community-based Care Transitions Program demonstration project, the Council on Aging (COA) of Southwestern Ohio has been conducting home visits for Medicare fee-for-service patients at high-risk of readmission to the nine hospitals participating in the program.
The program has reduced readmissions from a baseline readmission rate of 22 percent to between 9 and 12 percent since its inception in March 2012.
During Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, a 45-minute webinar on April 21, 2015, now available for replay, Danielle Amrine, transitional care business manager at the Council on Aging Southwestern Ohio, shared the key features of this home visits program, from how the visit is scheduled, what's assessed during the visit, the touch points that occur after the home visit and how the program has evolved since its launch.
You will learn:
- The strategic importance of hospital-based health coaches scheduling a home visit at the time of discharge;
- How the hospital-based coaches stratify patients to determine who receives a home visit and the top five disease states that these coaches target;
- The fifth pillar that COA added to Eric Coleman’s Care Transitions Intervention ® and why this was critical to a patient-empowered home visit process for COA;
- The goals for 30 days post-discharge – how many days post-discharge is the visit conducted, visit expectations and assessment goals for the coaches and what happens after the home visit;
- What approach COA takes for patients who transition to a nursing home or post-acute facility after a hospital discharge;
- How COA has addressed documentation and case load challenges and is working toward a disease specific home visit; and
- The impact the program has had on readmission rates and medication reconciliation.
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You can attend this program right in your office and enjoy significant savings — no travel time or hassle; no hotel expenses. It's so convenient! Invite your staff members to gather around a conference table to listen to the conference.
WHO WILL BENEFIT FROM THIS CONFERENCE?
Presidents/CEOs/CFOs, medical directors, quality improvement executives, physician executives, health plan executives, discharge planners, case managers, care managers, care coordinators and strategic planning directors and consultants.