A Sense of Urgency? An Important Piece of Chronic Care Management

It’s your last chance for early registration for the Integrated Chronic Care Management: A Strategic Plan for Homecare & Healthcare Workshop if you haven’t already!  It will be held on June 15 (Executive Training) & June 16 (Train the Trainer) in Baton Rouge.

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A Sense of Urgency? Care Transitions Funding Available:  An Important Piece of Chronic Care Management

The HCLA educational offerings on June 15th & 16th could give your agency a head start on the competition as care at home evolves.  Care transitions projects have been ongoing for CMS and the QIOs over the past few years. Preventing rehospitalization continues to be a priority for CMS. And CMS is betting $500 million in incentives that providers will invest in helping to reduce readmission rates. Interested parties can apply at any time, on a rolling basis and funds will be distributed on a first come first serve basis. (See the link to the attachment for an application.) A friend shared that at a New England home health conference this past week providers had robust conversations around their agencies’ application for the funds. These care transitions are critical to sound Chronic Care Management.

While the majority of agencies are hunkered down focusing on the multitude of regulatory changes, reductions in reimbursement, and oversight in the form of ZPICs, we might be, no we are missing current, active opportunities in the areas chronic care management and care transitions. Relatively new models that we need to know about and become articulate in discussing exist today.  Re-Engineered Hospital Discharges, or Project RED. Care transitions are also being impacted through Project BOOST, Better Outcomes for Older Adults through Safe Transitions. AIM, Advanced Illness Management, that focuses on end of life care– is another important connection that progressive providers of care at home will embrace. Patient Activation Measures, PAM– is a model published in 2004, focused on having chronic care patients active and involved in their own care.

We all know how critical that transition, or handoff is between hospital and home. Chronic Care Management is a key component of home health today. Progressive agencies are already actively implementing such care models, or even tweaking the ones that were already in place. Home care is evolving rapidly. Yes, the regulatory changes, reimbursement reductions, challenges around enhancing efficiencies while fending off ZPICs are part of your day to day life. But your organization will only evolve into the future if someone is alert and exploring the new opportunities that your competition will certainly be ready to capitalize on, if you aren’t there first.

I hope you see this as more than a sales pitch for the workshop. Forward thinking agencies across the country are preparing today for the new environment for care at home. We hope you will consider joining these astute providers as we prepare for the next evolution of care at home. Take care.
CLICK HERE FOR CCTP APPLICATION SUMMARY

Warren Hebert, RN, BSN, CAE
RWJF Executive Nurse Fellow ’06-’09
Chief Executive Officer