PASS Presentation
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This document discusses care transition interventions for accountable care organizations. It introduces Independent Living Systems, which offers various health and social support services, including care transitions programs to help reduce hospital readmissions. The key is providing a continuum of care as patients transition between settings like hospitals, nursing homes, and home. Independent Living Systems' PASS program adapts the Care Transition Intervention model to assign coaches who work in hospitals and coordinate with care managers. Data on previous programs show reductions in readmission rates and costs through these targeted transition supports. Successful programs require integration into existing workflows and partnerships across care settings.
PASS Presentation
- 1. CARE TRANSITION INTERVENTIONS FOR ACCOUNTABLE CARE ORGANIZATIONS Jeffrey T. King, RN, MBA, CDESVP, Clinical Operations|Independent Living Systems, LLC5201 Blue Lagoon Drive, Suite 270Miami, Florida33126Tel: 888 262 1292www.ilshealth.com
- 2. Care Transition Intervention for ACOsAgenda
- 3. Care Transition Intervention for ACOIntroduction & ILS OverviewIndependent Living systems (ILS)ToolsILS offers innovative health and social support services designed to improve quality of care for health plans, provider organizations and individuals.
- 4. Experience in Managed Long-Term Care, Population Care Management & Home & Community Based Services.
- 5. Non-traditional products & services proven to directly impact outcomes:
- 6. Care Transitions (Readmission Prevention)
- 7. Nutrition Management & Home Delivered Meals
- 8. Home & Community Based Service Coordination
- 10. Turnkey sustainable solutions to integrate into existing business workflows and technology infrastructures.Care Transition Intervention for ACOAccountable Care Organization OverviewThe Key RequirementsThe ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care.
- 11. Partnerships between hospitals and physicians / healthcare professionals.
- 12. Place the patient & family in the center of all activities.
- 13. “An ACO will attend carefully to handoffs, especially as patients journey from one part of the care system to another. It won't drop the baton. It will pass the baton.” - Dr. Don Berwick, CMSCare Transition Intervention for ACOAccountable Care Organization OverviewThe Current Cycle
- 14. Care Transition Intervention for ACOAccountable Care Organization OverviewThe Current Cycle (REALITY)
- 15. Care Transition Intervention for ACOAccountable Care Organization OverviewThe Cycle Where It Should Be
- 16. Care Transition Intervention for ACOAccountable Care Organization OverviewThe Care Transition Focus
- 17. Care Transition Intervention for ACOILS Care Transition Program - PASSPost Acute Support System - PASSPASS focuses on the care transition between the institutional setting back to the home & community setting. Institutional – Acute Inpatient, Sub-Acute.
- 18. Adapted from the Care Transition Intervention (CTI) model developed by Dr. Eric Coleman, University of Colorado.
- 19. Designed to integrate into existing medical management or operational processes:
- 20. Is Not a replacement for case management, discharge planning or home health
- 21. Is patient advocacy, education, communication and coordination.Care Transition Intervention for ACOILS Care Transition Program - PASSPost Acute Support System - PASSProgram driven by the PASS Coach
- 22. LPN, RN, LCSW
- 23. Assigned by facility (Hospital) and visit that facility each day
- 24. Program Supported by PASS Care Coordinators
- 26. Care Management & support service
- 27. PASS Coaches & PASS Care Coordinators communicate and manage patient cases via web-based PASS SystemCare Transition Intervention for ACOILS Care Transition Program - PASSPASS Interactions
- 28. Care Transition Intervention for ACOILS Care Transition Program - PASSPASS Core Pillars (* Original CTI Pillars)
- 29. Care Transition Intervention for ACOCMS National Readmission ProjectTools14 QIOs with 14 target communities
- 30. 70 Hospitals, 277 SNFs, 316 HHAs, 1.1 M Medicare Beneficiaries
- 31. Florida QIO: FMQAI – Miami-Dade Community
- 32. 11 Hospitals, 45 SNFs, 12 HHA, 60,000 Medicare Beneficiaries
- 33. ILS subcontractor to provide Care Transition InterventionmNutrition management and post-discharge meals; Florida Department of Elderly Affairs.
- 34. Home and Community Based Services; Florida Area Agency on Aging Community Living Program.CMS ProjectAdded Components & Partnerships
- 35. Independent Living SystemsSample Program Outcomes – Readmission Rate
- 36. Independent Living SystemsSample Program Outcomes – Readmission Costs
- 37. Independent Living SystemsProgram Outcomes – Care Transition
- 38. Independent Living SystemsProgram Outcomes – Care Transition
- 39. Care Transition Intervention for ACOKeys to Successful ProgramThe “Must Haves” of the Program
- 40. Care Transition Intervention for ACOKeys to Successful ProgramThe “Must Haves” of the Program
- 41. Jeffrey T King, RN, MBASVP, Clinical OperationsEmail: jking@ilshealth.comThank You