Best Practice Intervention Package - Kansas Foundation for Medical ...

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INSIGHTSReducing ACH (whether readmissions or avoidable hospitalization) is theoverarching goal of our program. We have linked the following programs toachieve this goal:• Identification of patients at risk for rehospitalization: At the start of care,every admission is assessed for risk factors that could increase thelikelihood of rehospitalization (Use the ACH Risk Assessment- See theJanuary 2010 BPIP). Using our current technology, interventions havebeen built into our EMR to assist the clinician in developing the plan ofcare for at risk patients. Interventions include: Telephone monitoring,creating “My Emergency Plan”, utilization of available communityresources, and medication management.• Additional programs to support the patients and reduce rehospitalizationare:o Telehealth –offers the use of innovative technology to improveclinical outcomes while keeping patients safe at home.o Transitions in Care Program (TCM) – the goal of the TCMProgram is to improve self management of the chronic diseaseprocess. The program is a hybrid of the evidence-basedTransitional Care Model (TCM). TCM trained RNs utilizeevidence-based assessment tools to identify the patient’s ability,knowledge, and willingness to manage their chronic illness andtransition back to the community.o Chronic Navigation - A telephone support service implementedwhich provides personal navigation services for our chronically illpatients and their physicians to better coordinate care andimprove access to health care services. The service is supportedby Virtua.Diane Costanzo, RN, MSN, MSHA, CMSRN, CNA-BC Director of NursingVirtua Home Care West JerseyPat Quackenbush, BC-RN MBA Director Quality Management Virtua HomeCareRead the Virtua Home Care Success Story- 52 -
TRACKING DATA AND MEASURING PROGRESSWhat are they?• Your agency’s FREE reports for ACH and OralMedications based on OASIS-C data.• A unique look into the potential causativefactors focusing on M2020 from OASIS-C for theOral Medication report and M100 for the ACHreport• Agency, state and national rates are not risk adjusted• Have a look at the first page of the ACH report (next page).How do I access the HHQI Data Reports?• Step 1: Go to the HHQI Web site, www.homehealthquality.org• Step 2: Click on the Quick Link (right side of the page) for HHQI DataAccess.• Step 3: Now, log in with your Data Access username and password. If youdo not have a Data Access username and password yet, please click on thelink to “Register” on the Data Access page.• For more detailed instruction on registering for the data site, pleasedownload our Quick Start Guide or view the new Data Reports Webinarsunder “Resources” at: https://secure.homehealthquality.orgGREAT NEWS!The HHQI Data Reports will no longer include scheduled admissions in youragency’s ACH rates. If the clinician assesses the patient on M2430, answer 19(“scheduled treatment or procedure”), then the patient will be excluded from thecalculation. For data tracking, the ACH rates including scheduledhospitalizations will still be available as the last table on the report, but all othertables will be calculated based upon your unplanned (or unscheduled) ACH rate.• Have you checked your monthly HHQI data reports?• How much did your ACH rate drop (or improve) this month?• What percentile ranking is your agency for ACH and Oral Medications?Contact HHQInfo at HHQI@wvmi.org for further assistance.- 53 -
Page 1: Best PracticeIntervention PackageCr
Page 5 and 6: Quick Start GuideQUICK START GUIDE:
Page 7 and 8: Source: Wu, Shin-Yi and Green, Anth
Page 9: CHRONIC CAREIt may assist leadershi
Page 13 and 14: The Bottom LineLeaders must create
Page 15 and 16: DIABETESCenters for Disease Control
Page 17 and 18: SELF-MANAGEMENT: EMPOWERING THE PAT
Page 19 and 20: What is Patient Activation? How Doe
Page 21 and 22: TELEHEALTHTelehealth encompasses a
Page 23 and 24: Focus Section: Improving Care Trans
Page 25 and 26: Checklist for Agency LeadershipHow
Page 27 and 28: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 29 and 30: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 31 and 32: Motivational Interventions (CMI) Pa
Page 33 and 34: Tools/Resources available through W
Page 35 and 36: The four conceptual areas (referred
Page 37 and 38: and steps toward them.Self-Efficacy
Page 39 and 40: 1. Goals: Something you WANT to do:
Page 41 and 42: Conviction Ruler0 1 2 3 4 5 6 7 8 9
Page 43 and 44: Partnering with Patients and Famili
Page 45 and 46: Are You at Risk for Going to the Ho
Page 47 and 48: Call Me First!Stay safe and well at
Page 49 and 50: SUCCESS STORIESThere are three succ
Page 51: Promoting Telehealth as part of a C
Page 55 and 56: Best Practice Intervention Package
Page 57 and 58: Therapy Track: Focus on Improving C
Page 59 and 60: Home Health Aide Track: Focus on Im
Page 61 and 62: Coleman, E.A. (2003). Falling throu
Page 63: http://www.fda.gov/downloads/Medica

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