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April 30, 2014
Community Partner Perspective:
The Role of Health Information Exchange in Improving Care Transitions
By: Pamela Russell, Development and Outreach Manager, Long-Term Care, CORHIO
There's a lot at stake when a patient is transitioned between care providers, such as between a hospital and a nursing home or between a skilled nursing facility and a home health agency. The common practice of "chest charts," when the paper medical record is sent with the patient and many times placed on their chest during the physical transition, is simply not good enough in today's high-tech environment. Providers need immediate electronic access to all of the details of the patient's history. 
Curious to Know What the ACA Means for Home Health Accountability and Reimbursement?

By: Kristin Paulson, Senior Manager of Policy and Initiatives, CIVHC

In the April HTC webinar, Maria Oren from Angels Care Home Health gave a fantastic presentation about the history of the Affordable Care Act and the rise of value based purchasing in health care. Maria also addressed changes in reimbursement and how the shift in payment and accountability will directly affect outcomes, efficiency and ultimately impact reimbursement under Medicare. This presentation was chock full of useable detail and a fantastic resource for anyone who wants to know what the changes under the ACA mean for home health and other care facilities. The webinar is also archived on the HTC website under the Education tab. Check it out!

Community Factors and HospitaReadmission Rates
By: Jeph Herrin, Justin St. Andre, Kevin Kenward, Maulik S. Joshi, Anne-Marie J. Audet, and Stephen C. Hines
From Health Services Research, April 2014
We all know community factors and socioeconomic factors play a role in readmissions, but exactly what that role is hadn't been defined until now. Researchers recently examined readmissions over a three year period and found that a number of characteristics of the county of residence were found to be independently associated with higher readmission rates, the strongest associations were for measures of access to care. 
Palliative Care Should Start with the Diagnosis
By: Susan Devore
From Wall Street Journal Blog, 2.27.14

It's clear that costs associated with end-of-life care are significant -- estimates suggest approximately one out of every four Medicare dollars is spent on services for beneficiaries in their last year of life. But the real focus should be on early empowerment of patients and their families with information on their options. If this is done well, the rest will follow.  To read this article, click the link below.

Top Boston Hospital Begins To Tackle Readmissions Problem
By: Rachel Gotbaum
From Kaiser Health News, 4.3.14

Beth Israel Deaconess Medical Center was charged $1 million in federal fines for having one of the highest readmission rates among Medicare patients in the country - at one point over 30%. Intensely examining their procedures, they found a damaging disconnect once the patients were discharged from the hospital. The hospital was awarded a $5 million federal grant to establish the Post-Acute Care Transition (PACT) program to improve care transitions and reduce readmissions for Medicare and dually-eligible beneficiaries. Read how the esteemed teaching hospital has used that opportunity to effectively reduce readmissions and improve patient care.

Reduce Readmissions by Activating Patients to Do 'Self-Care'
By: Tinker Ready
From Health Leaders Media, 4.10.14

Has your organization been talking about patient activation? Encouraging patients to become engaged in their own care goes a long way towards reducing readmissions and improving patient quality-of life. New tools that measure patient activation are giving providers a way find out which patients need the most assistance and help reduce readmissions.

How Doctors Rate Patients: What's Your 'Activation' Level? How Involved Patients Are in Their Own Care 
By: Laura Landro
From Wall Street Journal 3.31.14

Patients that are "activated" in their own care have better outcomes and lower costs, but almost half of Americans don't have the skills to be an activated patient. More hospitals, health plans and employers are scoring patients on how engaged they will be in their care using an assessment called the Patient Activation Measure, or PAM. Scores make it easier to customize information, coaching and other interventions. Read more about how this tool is affecting the care given:

Best Practice Intervention Packages

 HHQI will publish an addendum to their BPIP later this month that will provide an overview of the new hypertension management guidelines.  When available, the Cardiovascular Health Part 1 BPIP Update and the focused BPIP on Disease Management: Heart Failure will be posted on the Best Practices page under the Education tab on the HHQI website

Take 5 with The Joint Commission: Understanding Transitions of Care
Studies show that one fourth to one third of patients who experience an ineffective transition of care wind up back in the hospital. Hear Margherita Labson, R.N., home care executive director, and Ron Wyatt, M.D., medical director in the Division of Healthcare Improvement, discuss their views on transitions of care. 
Healthy Transitions Webinars Available 

Recordings and slides of our monthly webinars are located on the Education page of the Healthy Transitions Colorado Website. 

Healthy Transitions Colorado Education Page 

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Healthy Transitions Colorado is a collaborative effort, focused on aligning and accelerating existing efforts to improve transitions of care for Coloradans. Our guiding principles are simple - by working together to break down the silos of health care, we can foster true community care coordination across facilities, specialties, and practices. 



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