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

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Acute Care Hospitalization Monthly ReportName:ACH Sample AgencyMedicare#:999999Location: Any City, PAReport Date: 01/10/2011Dec2009Jan2010Monthly Hospitalizations vs. Transfers/DischargesNumber of Monthly Hospitalizations out of Total Transfers/Discharges (Excludes planned hospitalizations)Feb2010Mar2010Apr2010May2010Hospitalizations 261 257 245 257 222 283 238 243 232 243 222 2703Transfers/Discharges 801 836 1064 1021 911 986 897 975 944 924 952 10311Hospitalization % 32.6 30.7 23.0 25.2 24.4 28.7 26.5 24.9 24.6 26.3 23.3 26.2State Rate % 25.9 24.9 23.2 23 24.1 23.1 23.5 24.2 22.7 23.8 23.4 23.7National Rate % 30.2 28.8 27.5 26.8 27.8 26.5 26.8 27.6 26.9 27.4 27.1 27.5Jun2010Jul2010Aug2010Sep2010Oct2010Nov2010TotalData shown is from the Oasis. January 2010 and forward utilizes Oasis-C data.CONFIDENTIAL ACH Sample Agency (#999999) Page 1 of 7
Best Practice Intervention Package TimelineHHA BPIP Implementation TimelineRelease Datebegin on1/28/2011DownloadBPIP packageBeginpreliminarystaff educationon caretransitionsconcepts andwhy agencyneeds to getinvolvedSchedule abrainstormingsession andseek staffinput in otherways—through emailor othermeansIdentify waysyour agencymay need toimprove careto chronicallyill patients.Within 3-4weeks_/_/2011Schedule teamto reviewpackageDoes youragency have adiseasemanagementprogram? Doyour cliniciansunderstand selfmanagementsupport (SMS)?Do you have atelehealthprogram and isit usedeffectively?(Phone orTelemonitoring)Does it enhanceyour diseasemanagementprogram? Whatmeasures doyou use toassess this?Team decideson a plan andselectstools/resourcesbased on auditand staff inputWithin 4-6 weeks_/_/2011Plan higher leveleducationalopportunities forstaffConduct small testsof change (e.g.,Plan/Do/Study/Act)Review your datacollection to assessthe effectiveness ofyour TelehealthprogramTalk with patients/caregivers to gettheir perspective onself-caremanagementWithin 6-8weeks_/_/2011Implementationof newtools/processchangesMeet with otherproviders to seehow a diseasemanagement/telehealthprogram can beused acrosssettings toimprove patientcare.During teammeetingsdiscuss patient/caregivers inputand seekadditional inputfrom staffWithin 8-12weeks_/_/2011Beginevaluationof processchangesReviseprocess asnecessary- 55 -
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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 and 52: Promoting Telehealth as part of a C
Page 53: TRACKING DATA AND MEASURING PROGRES
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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