from Cindy Hupke to All Participants:
Cindy Hupke, IHI
from Dawn Weeks to All Participants:
Dawn Weeks, Gundersen Health System
fromjuliepeskoe to All Participants:
hello from open door
from Shari Wilson to All Participants:
Shari Wilson, Munson Medical Center
from Kathy Doeschot to Host (privately):
Hi - I'm Kathy Doeschot from the University of Phoenix
from Marie Kayser to All Participants:
Marie KayserUnityPoint Health
from Dawn Cain to All Participants:
Dawn Cain Oregon Department of Human Services
from Lori Bishop to All Participants:
Lori Bishop UnityPoint Health
from Aimee Traugh to All Participants:
Good morning from the case management team in Cedar Rapids IA!
from Samantha Ng to All Participants:
Samantha Ng, Correctional Healthcare Services
frommariefrazzitta to All Participants:
NorthWell Health
from Gayle Pokotylo to All Participants:
Gayle Pokotylo, Canadian Forces Health Services
from Mary Ann Zanotta to All Participants:
Mary Ann Zanotta Ellis Medicine & Care Central
from Consulate (V, Carrie, Andi, Carole) to All Participants:
V, Carrie, Andi, and Carole from Consulate Health Care in central FL.
from Deanna Rice to All Participants:
Central Maine Medical Center, Lewiston Maine
fromjuliepeskoe to All Participants:
Ossining, NY
from Kelly Luther to All Participants:
Rochester, NY
from Sherry Creighton to All Participants:
Hello from DHMC Medical Center- Sherry Creighton
from Kelly Means to All Participants:
Denver, CO
from Deanna Rice to All Participants:
Continuation of care
from Catherine Johnson to All Participants:
Complex!
from Chris Rumpf to All Participants:
:-(
from Marie Kayser to All Participants:
patient centered
fromkimberly powers to All Participants:
Hello from Iowa
from Krissy Bresnan to All Participants:
excellence
from Susan Ott to All Participants:
opportunity, complex
from Aimee Traugh to All Participants:
transitions, communication,
from Jenny Tsinker to All Participants:
Navigation
from Kathy Doeschot to Host (privately):
Maximize client's access to the resources available
from Kelly Means to All Participants:
quality ... a challenge
from Shari Wilson to All Participants:
coordinating safe quality care acrosss the continuum
from Julie Shepard to All Participants:
teamwork
from Lori Bishop to All Participants:
Patient centered and seamless care
from Peg Nelson (Fenway Health) to All Participants:
mutlidisciplianry teams, coordinated programs
from Jessica Bente to All Participants:
team effort
from dawn howard to All Participants:
too many chelfs in the kitchen
from Wendy Hunt to All Participants:
A group of Munson Medical Center leaders are joining you today from Traverse City Michigan-Thanks
frommariefrazzitta to All Participants:
transistions, linking patients to resources
from dawn howard to All Participants:
chelfs
from Consulate (V, Carrie, Andi, Carole) to All Participants:
The continuum of care, including more efficiency and better outcomes.
from Mary Ann Zanotta to Host (privately):
Assisting clients navigating complex medical system
fromjuliepeskoe to All Participants:
challenging
fromjuliepeskoe to All Participants:
documentation challenges
fromjuliepeskoe to All Participants:
engagement
from Marie Kayser to All Participants:
Care managers are integrated - are they embedded in the clinics and/or hopsital
from Pamela Nemec-Olick to All Participants:
What tool do you use for risk stratification?
from Peg Nelson (Fenway Health) to All Participants:
Are the care managers nurses? Social workers?
from Aimee Traugh to All Participants:
Do your medical homes have embedded social workers and behavioral health support?
from Peg Nelson (Fenway Health) to All Participants:
What is HIE connectivit?
from Cindy Hupke to All Participants:
Health Information Exchange
from Consulate (V, Carrie, Andi, Carole) to All Participants:
Can you please define your use of 'medical home'? Thank you.
from Chris Rumpf to All Participants:
Can you define transitional care?
fromelizabeth winders to All Participants:
Mostly disease management
from Sandra Almeida to All Participants:
How do you decide who the most impactable patients are?
from Lori Bishop to All Participants:
We are focused on risk level High, rising, or low/well
from Julie Shepard to All Participants:
we are focusing on all components
from Marie Kayser to All Participants:
risk level - rising and high
from Jeanette Akin to All Participants:
disease management
from Chris Rumpf to All Participants:
we're evolving
from Pamela Nemec-Olick to All Participants:
complex patients
from Peg Nelson (Fenway Health) to All Participants:
we have monthly team meetings focused on disease population
fromjuliepeskoe to All Participants:
program specific focus - HIV, Health Home
from Lee Averill to All Participants:
both
from Susan Ott to All Participants:
Disease management - moving toward population management
from Pamela Nemec-Olick to All Participants:
looking at embedding into cardiology
from Jenny Tsinker to All Participants:
Foxus on complex patients based on risk stratfication and provider referral
fromjuliepeskoe to All Participants:
ACO
from Dawn Weeks to All Participants:
Disease Management has been primary focus. We have care coordinators more based on inpatient entry. Trying to move to risk stratified model.
from Wendy Hunt to All Participants:
We are focusing on complex patients but discussions have taken place about disease management
fromkimberly powers to All Participants:
Not as an entire entity, however we do have a few teams focusing on Heart Failure and COPD.
from Jessica Bente to All Participants:
Disease management, mainly COPD and pneumonia
from Amanda Jusino to All Participants:
We are at Disease Management
from Jill Sipes to All Participants:
We identify complex patients by cross referencing our long term services and supports lists of individuals in long term care and our coordinated care organizations (Medicaid delivery system in Oregon) - we conduct care conferences monthly based on direct referral and target referral utilizaing complex reports
from Sherry Creighton to All Participants:
Complex care and high cost/high risk.
from Merry Norfleet to All Participants:
ACO
from Aimee Traugh to All Participants:
the hand was a mistake. technologically challenged
from dawn howard to All Participants:
stroke as well
from Sherry Creighton to All Participants:
High utilizer with focus on ACO patients.
from Jill Sipes to All Participants:
we handle disease management by direct referral to Sandfordself management programs and aligning them with individualized care plans with PCP office and CCO
from Sandra Almeida to All Participants:
how do you decide who your nostimactable patients are?
frommariefrazzitta to All Participants:
Complex care managers, diabetes disease management, working on developing disease management focused on CHF and COPD
from Pamela Nemec-Olick to All Participants:
what is ROI?
from Peg Nelson (Fenway Health) to All Participants:
does anyone have a good Care Plan template in the EHR?
frommariefrazzitta to All Participants:
ROI means return on investment
from Peg Nelson (Fenway Health) to All Participants:
Are you using group appointments?
from Kelly Means to All Participants:
Is medication adherence an element of your med management?
frommariefrazzitta to All Participants:
yes we do group classes
from Pamela Nemec-Olick to All Participants:
Peg, we have one we are using in NextGen, but I don't have reference to say its better than any other
from Chris Rumpf to All Participants:
transition clinic
from Cindy Hupke to All Participants:
Interventions for high risk patients
from Lori Bishop to All Participants:
Palliative care
from Marie Kayser to All Participants:
Telehealth
from Catherine Johnson to All Participants:
Community Health workers
from Aimee Traugh to All Participants:
Are exploring paramedicine in our community
from Mary Ann Zanotta to All Participants:
Transition team, Pharmacist med review in hospital w/ follow up call to patient once home
from Lee Averill to All Participants:
we collaborate with the local ambulance service for paramedic home visiting
from Peg Nelson (Fenway Health) to All Participants:
Case management Behavioral Health specialistsimbeeded in primary care
fromjoannechen to All Participants:
engaging with community pharmacist
from Aimee Traugh to All Participants:
ED case management- f/u phone calls
fromjoannechen to All Participants:
consolidating medical information from specialists and community programs to share with pcp and client/family
from Amanda Jusino to All Participants:
What is the average panel size of a case manager, navigator, and clinical educator?
from Peg Nelson (Fenway Health) to All Participants:
If nurses aren't making transitional calls including med rec, what are they doing??
from dawn howard to All Participants:
we average 50-80
from Peg Nelson (Fenway Health) to All Participants:
do care managers also have full primary carepanels or do they only do care management?
from Chris Rumpf to All Participants:
how do people graduate from needing care management?
from Marie Kayser to All Participants:
What is average length in the program
from Lee Averill to All Participants:
how do we acess the standardized care managment plans?
fromjuliepeskoe to All Participants:
communication
from dawn howard to All Participants:
shared information
from Kathy Doeschot to Host (privately):
negotiating goals/outcomes
from dawn howard to All Participants:
shared information with outSubacutes- we have weekly meetings
from Lee Averill to All Participants:
strong IT support and integration
from Adam Davis to All Participants:
using the right language to get patient buy-in (care support/care coordination vs. care management)
from Lori Bishop to All Participants:
integrated EHR and developing a common care plan
from Jenny Tsinker to All Participants:
Strong EMR documentation feature for care managers. We are struggling with our NextGen EMR
from Aimee Traugh to All Participants:
common care plan across the continuum
from Marie Kayser to All Participants:
Integrated technology
from Peg Nelson (Fenway Health) to All Participants:
are care managers nurses or SW or other professionals?
from Julie Shepard to All Participants:
I would be interested in learning more about how the common care plan has been implemented
from Chris Rumpf to All Participants:
use of LPNs in the practices for care support
from Pamela Nemec-Olick to All Participants:
do your care coordinators complete AD's or POLST forms?
from dawn howard to All Participants:
pharmacy advocate helps us naviagte coupons/coverage issues and delieveer meds at bedisde before discharge
from Wendy Hunt to All Participants:
Is there a goernment mandate for this that will be tied to money? What year?
from dawn howard to All Participants:
TOC will be part of bundled payment in the future
from Marie Kayser to All Participants:
Is anyone using the PAM? I am interested in what you have learned
from dawn howard to All Participants:
there are transitions of care codes for 1st week.2nd week of discharge in MD offices right now
from dawn howard to All Participants:
what is PAM?
from Cindy Hupke to All Participants:
Patient Activation Measure
from Marie Kayser to All Participants:
Look at Insignia Health for PAM
from Cindy Hupke to All Participants:
fromelizabeth winders to All Participants:
what templates in NextGen (if this is the EMR others use) are helpful in care management?
from Marie Kayser to All Participants:
Anyone using EPIC Healthy Planet
from Sherry Creighton to All Participants:
Yes we are using Healthy Planet
from Dawn Weeks to All Participants:
We are too (Gundersen Health System - La Crosse, WI)
from Chris Rumpf to All Participants:
does it help?
from Sherry Creighton to All Participants:
Yes- Dartmouth Hitchcock Primary Care
from Dawn Weeks to All Participants:
It helps with a piece of the population medicine/health puzzle.
fromjuliepeskoe to All Participants:
patient advocates, behavioral health integration specialists
from Lee Averill to All Participants:
We have found transportation needs to be an important area to provide support
from Peg Nelson (Fenway Health) to All Participants:
who tracks and monitors careplans and how often?
from Peg Nelson (Fenway Health) to All Participants:
what topics do your group class include?
from Amanda Jusino to All Participants:
When do you do the care plan? At the appointment with patient or during a meeting with care providers?
from Pamela Nemec-Olick to All Participants:
has anyone gotten around the $8/momedicare copay
from Cindy Hupke to All Participants:
BAP: Brief Action Planning
from Cindy Hupke to All Participants:
from Julie Shepard to Host & Presenter:
can we get more informatio about how to implement a shared care plan
from Mona Mansour to All Participants:
what are your graduation criteria? do you use a checklist
from Pamela Nemec-Olick to All Participants:
have you been able to drop a charge for social work time?
frommariefrazzitta to All Participants:
Can you please share the link to the standardized care plan? thank you
from Amanda Jusino to All Participants:
When do you do the care plan? At the appointment with patient or during a meeting with care providers?
fromjoannechen to All Participants:
can you please attach the link to the website so we can view care plans
from Mona Mansour to All Participants:
how does she measure effectiveness of CM program
fromjuliepeskoe to All Participants:
what platforms do you use for integrated care planning?
from Marie Kayser to All Participants:
Can we have a list of participants with contact information?
from Denise Hewson to All Participants:
and search for Standardized Care Management Plan