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Guide to Care Transition Management

  • ID: 2640070
  • Report
  • Region: North America
  • 150 Pages
  • Healthcare Intelligence Network
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Transitions of care are a checkpoint not only to engage patients and caregivers in proper post-care but also to confirm providers have a complete picture of patients' health so that handovers are seamless and costly hospitalizations and ER visits can be averted.

According to 2013 HIN market data, 91 percent of healthcare companies have implemented care transition management programs, adapting popular models such as Project RED and the Care Transitions Intervention® to their own populations.

The Guide to Care Transition Management lays the groundwork for a comprehensive care transitions management program:

Chapter 1: 2013 Benchmarks in Care Transition Management
Chapter 2: Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management
Chapter 3: 33 Metrics in Care Transition Management

This 150-page resource delivers a comprehensive set of 2013 transitional care management benchmarks from 86 companies as well as select metrics from related interventions influencing the quality of care transitions: Medication Adherence, Reducing Readmissions, Case Management, Patient-Centered Medical Home and Health Coaching.

Accompanying each metrics grouping is a relevant best practice or case study from industry thought leaders and a list of most effective tactics, workflows and practices - in all, more than 100 ideas to improve the handoff of patients from one site of care to another.

This guide also examines data analytics driving the CMS Care Transitions Demonstration Project as well as some home-grown and award-winning initiatives supporting patients' seamless transitions back into their communities.

In all, hundreds of data points are provided and 20 critical FAQs answered.

Applying the data and best practices documented in the Guide to Care Transition Management can have a positive impact on patient handoffs, utilization management and the patient experience.
Note: Product cover images may vary from those shown
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Chapter 1: 2013 Benchmarks in Care Transition Management
About the Healthcare Intelligence Network
Executive Summary
Survey Highlights
Key Findings
Program Components
Results and ROI
Most Successful Tools for Care Transition Management
Methodology
Respondent Demographics
Using This Report
Responses by Sector
The Hospital Perspective
The Health Plan Perspective
Year-Over-Year Survey Data
Respondents in Their Own Words
Most Successful Strategy, Workflow, Tool or Protocol
Details of Future Care Transition Management Programs
Additional Comments
Conclusion
Responses to Questions
Figure 1: All - Have Program to Improve Care Transitions
Figure 2: All - Care Transitions Addressed by Program
Figure 3: All - Targeted Populations
Figure 4: All - Targeted Conditions
Figure 5: All - Participant Identification Methods
Figure 6: All - Most Critical Care Transition
Figure 7: All - Care Transition Models
Program Components
Figure 9: All - Include Home Visits in Program
Figure 10: All - When Home Visits Occur
Figure 11: All - Who Conducts Home Visits
Figure 12: All - What Occurs During Home Visits
Figure 13: All - Who Coordinates Care Transitions
Figure 14: All - Care Transition Team Training
Figure 15: All - Future Programs
Biggest Challenge in Care Transition Management
Figure 17: All - Program Impact
Measuring Program Success
Figure 19: All - Program ROI
Figure 20: All - Greatest Barrier to Program Implementation
Figure 21: All - Organization Type
Figure 22: Hospital - Have Program to Improve Care Transitions
Figure 23: Hospital - Care Transitions Addressed by Program
Figure 24: Hospital - Targeted Populations
Figure 25: Hospital - Targeted Conditions
Figure 26: Hospital - Participant Identification Methods
Figure 27: Hospital - Most Critical Care Transition
Figure 28: Hospital - Care Transition Models
Figure 29: Hospital - Program Components
Figure 30: Hospital - Include Home Visits in Program
Figure 31: Hospital - When Home Visits Occur
Figure 32: Hospital - Who Conducts Home Visits
Figure 33: Hospital - What Occurs During Home Visits
Figure 34: Hospital - Who Coordinates Care Transitions
Figure 35: Hospital - Care Transition Team Training
Figure 36: Hospital - Future Programs
Figure 37: Hospital - Biggest Challenge in Care Transition Management
Figure 38: Hospital - Targeted Conditions
Figure 39: Hospital - Measuring Program Success
Figure 40: Hospital - Program ROI
Figure 41: Hospital - Greatest Barrier to Program Implementation
Figure 42: Health Plan - Have Program to Improve Care Transitions
Figure 43: Health Plan - Care Transitions Addressed by Program
Figure 44: Health Plan - Targeted Populations
Figure 45: Health Plan - Targeted Conditions
Figure 46: Health Plan - Participant Identification Methods
Figure 47: Health Plan - Most Critical Care Transition
Figure 48: Health Plan - Care Transition Models
Figure 49: Health Plan - Program Components
Figure 50: Health Plan - Include Home Visits in Program
Figure 51: Health Plan - When Home Visits Occur
Figure 52: Health Plan - Who Conducts Home Visits
Figure 53: Health Plan - What Occurs During Home Visits
Figure 54: Health Plan - Who Coordinates Care Transitions
Figure 55: Health Plan - Care Transition Team Training
Figure 56: Health Plan - Future Programs
Figure 57: Health Plan - Biggest Challenge in Care Transition Management
Figure 58: Health Plan - Program Impact
Figure 59: Health Plan - Measuring Program Success
Figure 60: Health Plan - Program ROI
Figure 61: Health Plan - Greatest Barrier to Program Implementation
Appendix A: Managing Care Transitions in 2013 Survey Tool

Chapter 2: Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management
Community Collaborations That Improve Care Transitions
Community-Based Approach to Reducing Readmissions
Reexamining Readmissions Data
Intervention and Comparison Communities
Examining Hospitalizations Per 1,000 Beneficiaries
Final Overall Community Results
QIOs as Conveners and Supporters
Nursing Home Coalition
QIOs Move Ahead with Care Transition Improvement
Shifting from ‘Handoffs’ to ‘Handovers’
Reviewing the Readmissions Numbers
Actual Versus Percentage of Readmissions
Changing Focus from Readmissions to Care Transitions
Medication Boot Camp
Closing Home Care Gaps
After-Visit Summaries
Care Plan Interventions
Making Sure the Newly Discharged Are ‘Good to Go’
‘Good to Go’ Trial and Rollout
Recording Hospital Discharge Instructions
Patients’ Reactions and Engagement
Accountability and Compliance
Results from ‘Good to Go’
Challenges and Expansion
Q&A: Ask the Experts
Defining Patient Contact
‘Good to Go’ Beyond the Hospital
Process for Obtaining Real-Time Data
Engagement with ‘Good to Go’
Developing Risk Scores
Discharge Video Distribution and Engagement
Adherence Levels for Medication Boot Camp
Communication’s Role in Discharge Planning
Sharing Hospital Discharge Instructions
Interventions for Mental Health, CHF
Care Plan Process
Initial ‘Good to Go’ Pushback
Role of Medication Adherence in Care Transition Management
Health Coaching Interventions
Sample Care Transition Interventions
Community Factors That Drive Readmissions
Choosing Community Partners
Data Sharing Requirements within Partnerships
Patient Engagement and Education
Home Visits and Care Transitions
Glossary
For More Information
About the Speakers

Chapter 3: 33 Metrics in Care Transition Management
Medication Adherence
Looking Closely at Compliance During Transitions of Care
Targeted Populations for MA Initiatives
Components of MA Programs
MA Tools and Technologies
Opportunities to Initiate MA
Primary Responsibility for MA
Top Medication Adherence Tools, Workflows and Processes
Reducing Readmissions
Considerations for Transitional Care in a Penalty-Based System
Targeted Health Conditions for Readmission Reduction Efforts
Strategies to Prevent Readmissions
Hospital Discharge Checklist
Tools to Identify ‘At-Risk’ Individuals
Barriers to Reducing Readmission Rates
Top Readmissions Tools, Workflows and Processes
Case Management
Case Management in Home Health, SNFs and Care Transitions
Competitors Collaborate in SNF Care Coordination Network
Populations Targeted by Case Management
Conditions Targeted by Case Management
Typical Duties of Case Management
Identification of Individuals for Case Management
Top Case Management Tools, Workflows and Processes
Patient-Centered Medical Home
Standards in HRHC’s Enhanced Care Model
Medical Home with Embedded Case Managers
Patient Engagement and Education Strategies
Impact of Medical Home on Clinical Metrics
Impact of Medical Home on Operational Metrics
Top Medical Home Tools, Workflows and Processes
Health Coaching
Integrated Health Coaching Spans Risk Continuum with Health Behavior
Change Management
Health Risk Levels Encompassed by Health Coaching
Health Areas Addressed by Health Coaching
Identification of Indi
viduals for Health Coaching
Populations Served by Health Coaching
Top Health Coaching Tools, Workflows and Processes
Care Transition Management
In Transitional Care Management, Hospital Discharge is ‘Tipping Point’
Care Transitions Addressed by Program
Most Critical Care Transition
Care Transition Model for Program
Transition Management Program Components
Training for Care Transitions Team
Frequency of Home Visits
Home Visit Checklist
Top Transitional Care Tools, Workflows and Processes
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