Maine Physician Hospital Organization Home
About MPHO Provider Directory Practice Support Clinical Improvement Links Contact MPHO Members
MH Learning Community
Sign up for the MHLC Newsletter!
Click on tabs to learn more
 

April 7, 2011: Preventable Admissions - Safe Transitions of Care

typeface

A Partnership of MaineHealth and the Maine Physician Hospital Organization

Welcome to the Practice Improvement Series Meeting (PRISM), webpage!

Preventable Admissions - Safe Transitions of Care

Here you will find all of the presentations, tools and resources available to you from the April 7, 2011 PRISM.

Agenda

Morning Plenary Session: 8:00a.m. - 10:05a.m.

Welcome and Introductions
Presenter: Jeff Aalberg, MD, Senior Medical Director, MMC PHO

Readmissions: Defining the Issue
Presenter: David Bachman, MD, Sr. Medical Director, MaineHealth

  • Objectives: Understand why readmissions have emerged as area of focus in health care reform; Recognize value of risk assessment as a tool to identify patients with highest likelihood of readmission

Preventable Hospitalizations: Challenges/Opportunities for the MaineHealth System
Presenter: Vance Brown, MD, CMO, MaineHealth

  • Objectives: Understand system-wide resources available to use in improving patient outcomes and reducing preventable readmissions; Recognize the importance of improved transitions of care as a core strategy in development of Accountable Care Organizations

Keynote - Strategies to Reduce Readmissions: Risk Stratification and Targeted Interventions
Presenter: Eric A. Coleman, MD, MPH, Professor of Medicine within the Division of Health Care Policy and Research and Geriatric Medicine at the University of Colorado at Denver and Health Sciences Center

  • Objectives: Understand patterns of cross setting care; Discuss developments in national health policy relevant to transitional care; Articulate key principles for identifying high risk patients

Workshop 1: 10:20 - 11:10 a.m.

Hi Alert Medications, Polypharmacy, and Avoidable Hospitalizations
Presenters: Katherine P. Cabral, Pharm.D, BCPS, CACP, Clinical Pharmacy Specialist-Anticoagulation; Lisa Wendler, Pharm.D, Clinical Pharmacy Specialist, Family Medicine/Geriatrics; MMC

  • Objectives: Understand which medications have been identified as "High Alert"; Risks of polypharmacy; Strategies to reduce readmissions

Improving Medication Reconciliation During Transitions
Presenter: Eric A. Coleman, MD, MPH

  • Objectives: Describe the frequency of medication discrepancies among hospital patients discharged; Identify 2-3 contributing factors for these medication discrepancies; Summarize the advantages for using the validated Medication Discrepancy Tool

It Takes a Village to Prevent an Admission: Working with Community Resources
Presenters: Naomi Anderson Schucker, MPH, Program Director, MaineHealth; Katlyn Blackstone, MS, LSW, Director, Southern Maine Agency on Aging; Ann Clark, MS, RN, Program Manager, Healthy Choices for ME!, MaineHealth

  • Objectives: Understand the community resources available to help ameliorate a variety of risk factors; Gain access to specific content info for community resources

Meaningful Use
Presenters: Jeff Aalberg, MD, Sr. Medical Director, MMC PHO; Jackie Cawley, DO, Sr. Medical Director, MaineHealth

  • Objectives: Understand the most updated interpretation of "meaningful use" of health information systems; Understand the resources available to meaningful use in practices

Workshop 2: 11:20 a.m. - 12:10 p.m.

Effective Patient and Family Learning
Presenters: Peggy Chausse, MA, CHES, Health Educator, MaineHealth Learning Resource Center; Kathleen Beers, RN, Care Transitions Coach, MMC PHO

  • Objectives: Understand key elements of effective patient/family education; Learn practical application of "teach back" technique; Understand how to implement "teach back" in practices

Improving Medication Reconciliation During Transitions
Repeat from Session One

Depression & Anxiety as Risk for Readmission
Presenters: George "Joe" Dreher, MD, Attending Physician for Psychiatric Consultation; Sandra Horne, LCSW; MMC Family Medicine; Neil Korsen, MD, Medical Director, MaineHealth

  • Objectives: Understand the prevalence of mood disorders and anxiety amongst patient population & impact of these conditions on their risks for readmission; Available screening/monitoring tools

COPD: Best Practices to Reduce Admissions
Presenters: Scott Morin, MD, Pulmonary, Internal & Critical Care Medicine, SMMC Prime Care Pulmonary Medicine; Martine Eon, BS, RPT, NPS, RPSGT, Lung Health Specialist, MMC

  • Objectives: Understand current best practice guidelines to identify/manage COPD; Understand ways to incorporate these best practices to improve patient outcomes

Workshop 3: 1:10 - 2:00 p.m.

Do You Know Where Your Patients Are…
Presenters: Jeff Aalberg, MD, Sr. Medical Director, MMC PHO; Michael Clark, MD, Lifespan Family Healthcare

  • Objectives: Understand ways to maximize care coordination resources; Assemble health care teams to improve health outcomes

Timely Communications in Post Hospital Transitions
Presenter: Debra McGill, RN, Care Transitions Nurse, Maine Medical Partners

  • Objectives: Understand current best practices for telephonic follow up in the management of patients at high risk for poor outcomes and readmission

CHF: How to Optimize Care in Hospital Transitions
Presenters: Joseph Wight, Sr., MD, Director of Heart Failure, Maine Cardiology Associates; Doreen Roy, RN, BSN, CRNI, COS-C, HomeHealth Visiting Nurses

  • Objectives: Understand the potential causes of readmission and strategies to address these issues; Understand current best practice guidelines to identify and manage CHF in primary care practice; Understand the role of home health in the management of high risk CHF patients

Medicare Annual Visits - A Roundtable Discussion
Moderators: Peggy Haynes, MPA, Director, Partnership for Healthy Aging/Elder Care Services; Donna Levi, MS, Program Manager, MaineHealth

  • Objectives: Understand the key elements of Medicare Annual Wellness Visits; Learn of at least three promising practices now being employed by colleagues in Maine to meet the objectives of the Medicare Annual Wellness Visits

Afternoon Plenary Session: 2:15 - 3:30 p.m.

Panel Discussion: End of Life Care, Easing the Transition
Moderators: David Bachman, MD, Sr. Medical Director, MaineHealth; David Giansiracusa, MD, Medical Director, MaineHealth
Panel: Lauren Michalakes, MD, Medical Director, MMC; Elizabeth Hart, MD, Maine General; Kitty Garlid, Director, Pastoral Care, MMC; Deb Alpren, LCSW, OSW-C, Mid Coast Health Services; Jacqueline Fournier, NP-C, CNS-BC, Central Maine Healthcare; Arlene Wing, RN, Executive Director, Hospice of Southern Maine

  • Objectives: Understand current best practice guidelines to identify patients who should receive counseling/referral to palliative care and ways to incorporate into practices

Finding the Humor in Transitions of Care
Presenter: Susan Goran, RN, Director-Nursing, EICU, MMC

Closing Remarks
Presenter: Jackie Cawley, DO, Sr. Medical Director, MaineHealth

THANK YOU!!

Thank you for taking the time to review the day's activities for the Safe Transitions of Care PRISM. We hope that you found the day to be a valuable use of your time.

Please contact us if you would like any additional information on PRISM or other MaineHealth Learning Community offerings.

We look forward to hearing from you.

  
Email Us