Understanding and Negotiating Today’s Healthcare System

Sponsored by:

The Piedmont Hospital & Visiting Nurse/Hospice Atlanta Demonstration Project: Care Transitions

An 18 month Health and Human Services Funded ProjectJuly 1,2008 through December 31, 2009

Care Transitions Demonstration Project Partners: Phase I and Phase II

Piedmont Hospital Sixty Plus Older Adult Services Program

Piedmont Hospital, Hospitalist Service(Project BOOST)

Visiting Nurse /Hospice Atlanta

Aren’t you missing some links?

YES. It will take hospitals, healthcare providers, housing, aging services providers, the aging network and consumers, all working together to assure safe transitions.

Our journey has just been slower than expected!

Lessons Learned & Sustainability Factors

Start small and go slow Set realistic goals & expectations Identify & fix your own problems first** Never underestimate the impact of data &

outcome measures on the project design Incorporate work processes into existing

work flow and organizational culture

Phase III – Expand Community Linkages (June 1, 2009 through December 31, 2009)

Education/Communication Flow Develop Materials/Set up Workshops Train Volunteers and Trainers

Professionals Consumers

Expand/Establish Partnerships/Collaboration Area Agency on Aging – ARC

County Based Aging Programs RSVP Volunteer Program Multipurpose Centers/Senior Centers Home Based Services

Phase III (Cont…)

Senior Housing

Home Health – opportunities to apply lessons learned

The Afternoon

Overview of Healthcare Challenges and Piedmont’sCare Delivery System – what works and where are the opportunities. Inpatient and Emergency Department Discharge Planning

Overview of two Piedmont Hospital Care Transitions Demonstration Projects. Transitions in Care Project BOOST

Learn how home health care can implement the principals of care transitions into existing work processes

The Afternoon Cont’d

Learn how three community organizations plan to address Care Transition best practices through coalitions, education/training and/or program implementation.

Georgia Hospital Association (GHA) Center for Medicare Service (CMS) Atlanta Regional Commission, Aging Division (ARC)

Discuss implementing a region wide approach to Care Transitions/Safe Discharge

Developing an Action Plan

Complete Evaluations and Adjourn

Excerpt from President Obama’s speech to AMA on Monday -

"Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they are not getting the comprehensive care they need. This puts people at risk and drives up costs. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits, but drives up costs for everyone else. That will save us $25 billion over the next decade."