Acute Care Session = Acute Care Session
Long Term and Skilled Care Session = Long Term and Skilled Care Session
Physician Advisor, Medical Director Session = Physician Advisor, Medical Director Session
Ambulatory Session = Ambulatory-Session
Pediatric Session = Pediatric Session
Rehabilitation Session = Rehabilitation Session
Home Health Session = Home Health Session
Primary Care Session = Primary Care Session
Veterans Care Session = Veterans Care Session

None
Sunday, April 14, 2019

Pre-Conference Intensives
8:00 AM - 12:30 PM

Abstract:





Afternoon Pre-Con Breakout Sessions
2:00 PM - 5:30 PM

Abstract:





None
Monday, April 15, 2019

Keynote Session: Lessons in Leadership
8:00 AM - 9:30 AM

Carey Lohrenz

Abstract:

As the first female U.S. Navy F-14 Tomcat fighter pilot, Carey Lohrenz knows what it takes to succeed in one of the most demanding, extreme environments imaginable: the cockpit at Mach 2. As a former combat-mission-ready U.S. Navy pilot, Lohrenz is an expert at working in fast-moving, dynamic environments, where inconsistent execution can generate catastrophic results.

By seamlessly translating the lessons she learned to challenges in business, she provides applicable insight on market change, customer evolution and the importance of adaptability. Author of the Wall Street Journal bestselling book, Fearless Leadership: High-Performance Lessons from the Flight Deck, she outlines her experiences and advice on how to supercharge performance in today’s competitive business environments. Praised by top business leaders, from Fortune 500 executives to middle managers, her book provides insight on the importance of setting a bold vision to bring the team together and stay resilient through hard times.




Breakout Session A
Monday, April 15, 2019

1A - ED Transitions: Using Social Determinants of Health to Reduce Re-visit Rates
Practice Setting:  

9:45 AM - 10:45 AM

Lene Hudson, MSN, RN, CCM, CCDS,

Sondra King, MSN, ACM-RN

Abstract:

Patients who present to the ED with chronic medical and behavioral health needs, in conjunction with two or more adverse social determinants of health, are at risk for high ED re-visit rates. This program focuses on establishing care in the appropriate post-ED setting through coordinating the required outpatient resources to support those patients who are ready for discharge but at high risk of a 30-day re-visit to the emergency department as evaluated by the social determinants of health screening. The outcomes of ED Transitions-360 Transitional Care Program are: a reduction of the 30-day ED revisit rate, and an increase in plans to address patients’ social determinants of health that negatively impact the current episode of care.



Learning Objectives:
  1. Identify social determinants of health that often lead to inappropriate emergency department utilization
  2. Master the use a social determinants of health screening tool to assess patients with chronic medical and/or behavioral health needs
  3. Master the use a social determinants of health screening tool to assess patients with chronic medical and/or behavioral health needs

2A - Business Case for Cross-Continuum Care Management: An ACO Solution
Practice Setting:  

9:45 AM - 10:45 AM

Nancy Turner, BSN, ACM-RN

Abstract:

This presentation will provide a toolkit for selling and implementing a Cross-Continuum Care Management Model. This model has demonstrated results with high risk/high needs patients for five years. The model includes inpatient, ambulatory and community care management components as well as a high-risk clinic for the top 3% high utilizing patients who account for 50% of the annual healthcare spend. The inpatient team works to transition patients to the appropriate level of care. The ambulatory team is focused on high-risk patients to prevent readmissions, close gaps in care and engage patients in self-care. The community care managers support the Preferred Provider Skilled Nursing Network, working to reduce readmissions and length of stay. Results are positive on all metrics, including $4M cost savings for Medicare Share Savings patients and a nearly 50% reduction in readmissions rates.



Learning Objectives:
  1. Define the strategies used to build a Cross-Continuum Care Management Model
  2. Identify the key elements needed to build: a. an Ambulatory Care Management program b. a Preferred Provider Network and Community Care Management Program c. Care Management support for a high risk clinic

3A - Negotiating with Patients: Overcoming Resistance to Home Services
Practice Setting:  

9:45 AM - 10:45 AM

Lee Lindquist, MD, MPH, MBA

Annie Seltzer, LCSW, CSW-G

Abstract:

Older adults who need support in the home will sometimes refuse it even when it is the best strategy to allow them to safely age in place. Research with 68 older adults from multiple rural, suburban and urban sites revealed what is often behind the reluctance and insights to overcome resistance. This presentation will connect these insights with business school-taught negotiation tactics, demonstrating a practical means to achieve acceptance of home services. These Refusal of Care (ROC) negotiation techniques have been taught to nurses, social workers, case managers and providers. Case studies to illustrate how ROC negotiation techniques were successfully used in discharging patients from the hospital, in ambulatory/outpatient care, and home settings will be shared.



Learning Objectives:
  1. Identify common reasons why older adult patients refuse home-based services
  2. Determine strategies that can help older adults accept home services
  3. Master use of ROC negotiation tactics in real-world health care settings

4A - Building Resilience and Gratitude in Case Management Practice
Practice Setting:  

9:45 AM - 10:45 AM

Joan Brueggeman, RN, BSN, ACM-RN

Abstract:

Case management professionals work in a rapidly changing and evolving health care environment. Personal attributes and skills are necessary to navigate change successfully. The use of disciplined rather than default behaviors
during stressful interactions and techniques of resilience that are relevant to case management practice will be reviewed. Interactive exercises will build upon strengths and weaknesses that each individual can contribute to moving the team forward. The session will conclude with a discussion and exercise on gratitude that will enhance self-care and fulfillment.



Learning Objectives:
  1. Describe the concept of resilience and the value within case management practice
  2. Review disciplined versus default behaviors and what can trigger the behaviors during stressful situations
  3. Perform an exercise in gratitude to replicate within practice settings

5A - Pediatric Care Coordination: Best Practices to Avoid Readmissions
Practice Setting:  

9:45 AM - 10:45 AM

Cyndi Fisher, RN, MSN, CPNP, ACM-RN

Abstract:

This children’s hospital required a strategy to reduce seven-day readmission rates by 10% over the course of a year. Evidence-based interventions known to lower readmission rates include identification of at-risk patients, clinician feedback, scheduling follow-up appointments and evaluation of the efficiency of discharge planning. This session will provide an overview of focused improvements that resulted in a 13.7% reduction in the seven-day readmission rate rolling average. Case management surveys in the emergency department, garnering and sharing feedback on quality of discharge plans, technical improvements in arranging follow-up appointments and follow-up calls have proven to be effective interventions.



Learning Objectives:
  1. Demonstrate effectiveness of a collaborative approach to reduce pediatric readmissions
  2. Discuss the involvement of parent partners in readmission prevention
  3. Share tools for readmission review that enhance effectiveness in metrics reporting

6A - High Demand Session (Repeated)
9:45 AM - 10:45 AM

Abstract:
You asked, and we listened. Based on feedback from attendees one high demand session will be repeate during the conference. 


7A - Improving Outcomes and Experiences with Palliative Care Skills
Practice Setting:  

9:45 AM - 10:45 AM

Ruth Maclntosh, BS, RN, CCM

Allison Silvers, MBA

Abstract:

Participants in this session will be introduced to a new set of skills – drawn from the field of palliative care that impact patient quality-of-life, satisfaction and avoidable utilization. These skills include: clarifying patient’s values and goals; assessing symptom burden, emotional and spiritual needs, and caregiver burden; and communicating with the care team to align treatment with what is most important to the patient. The session will describe how this skill training was implemented in a health plan, accountable care organization (ACO) and hospital transitions program. After a didactic presentation, there will be brief role play to illustrate these skills in action, and then participants will learn about resources available for skill training and assessment tools. An interactive Q & A will conclude the session.



Learning Objectives:
  1. Describe the differences in need between the seriously-ill and other high-risk patients
  2. Describe at least 4 assessments needed for the seriously-ill population that are not commonly completed
  3. Demonstrate and apply skills to communicate with patients about their values, helping to ensure shared decision-making and alignment

8A - Combatting the Opioid Epidemic and Drug Misuse
Practice Setting:  

9:45 AM - 10:45 AM

Darren E. Totty, Pharm.D., APh

Abstract:

Prescription opioid misuse results in 115 deaths each day in the United States and is growing. Strategies are needed in outpatient settings to bring a creative approach to addressing the growing opioid crisis. The speaker will present multifaceted, integrated approaches to combating this particular crisis, spanning various settings and applying techniques to demonstrate a positive impact.



Learning Objectives:
  1. Describe opioid crisis manifestations in health care
  2. Review key identification strategies, screening and assessment techniques as well as interventions
  3. Identify multidisciplinary approaches to apply in combating the opioid epidemic

Breakout Session B
Monday, April 15, 2019

1B - Integrating Episodic and Longitudinal Care Management: A 30-Day Transition Model
Practice Setting:  

11:00 AM - 12:00 PM

Stephanie Kleier, RN

Verda Weston
LSSBB

Abstract:

A transition of care phone call after discharge from an inpatient hospital stay is critical, but it is only the beginning. To lower risk of readmission, improve patient quality of life and integrate self-care and preventive care into a patient’s post-discharge routine, a comprehensive Transition of Care Management program is required. Hospitals and ambulatory clinics can provide more cohesive transitions between care settings. The session will detail a model that incorporates the relationship between transition of care nurses that work alongside case managers on the hospital floors and care managers who are embedded into the primary care clinics, showcasing how that relationship can provide better management of the patient through complex post-discharge transitions.



Learning Objectives:
  1. Discuss the Transition of Care model that integrates acute and ambulatory care management
  2. Identify the benefits of the three unique roles: acute care managers, transitions care managers and longitudinal care managers in ambulatory clinics
  3. Define the steps to implement a Transition of Care Management Program

2B - Centralized Authorizations, Denials & Appeals: A Model for a Multi-Hospital System
Practice Setting:  

11:00 AM - 12:00 PM

Michael McEntire, RN, ACM-RN, CRCR, IQCI

Deborah Wener, RN, CCM, CRCR, IQCI

Abstract:

One multi-hospital region of Adventist Health System introduced a centralized model for authorizations, denials and appeals rather than a centralized utilization review function and achieved a decrease in claims denials from $95 million in 2015 to $24 million in 2017. Expanding on this success, a new pilot program this year will broaden the department’s scope past the initial focus of inpatient and observation authorizations by adding elective surgical procedures, working to pre-authorize 100% by collaborating with coders, physicians and payers to obtain authorizations for all potential CPTs. This year, other regions adopted this model and results from all regions will be presented, including what has worked well and what has not.



Learning Objectives:
  1. Describe the impacts of increased UR productivity, reduced AR, and decreased denials
  2. Explain the benefits of tracking payer behaviors across a region, insuring accountability to contractual standards
  3. Identify the advantages in keeping UR staff onsite

3B - Intersection of Human Trafficking and Healthcare
Practice Setting:  

11:00 AM - 12:00 PM

Tejal S. Patel, Esq.

Karen B. Silva, PhD., MFN, MSN, RN-BC

Abstract:

A 2017 survey from the Coalition to Abolish Slavery & Trafficking (CAST) of labor and sex trafficking victims, shows nearly 50% of human trafficking victims reported at least one healthcare encounter during victimization and 97% received no information about human trafficking. Medical care providers are often unprepared to identify and appropriately respond to trafficked persons. Less than .01% of the more than 5,500 hospitals in the U.S. have a plan in place for treating trafficked patients. Cedars-Sinai Medical Center’s Human Trafficking Task Force, made up of social workers, nurses, PhDs, a forensic nurse-educator and an attorney-risk manager, educates healthcare providers about the physical, emotional and behavioral symptoms of a potential victim. An action plan involving a trauma- informed approach and a sample conversation/template for clinicians is part of the training.



Learning Objectives:
  1. Define Human Trafficking
  2. Describe Trauma and Effects on Victims
  3. Master identification of and response to victims

4B - Pathway Home: Bridging Behavioral Inpatient Stays with Community Services
Practice Setting:  

11:00 AM - 12:00 PM

Mark Graham, LCSW

Barry Granek, LMHC

Abstract:

Traditional Behavioral Health Care Management services offered to Medicaid recipients in New York City often lack the scope and expertise to address the complex needs of individuals with serious mental illness (SMI). The challenges faced after being discharged from long inpatient stays at psychiatric hospital facilities are unique. CBC Pathway Home (PH) is designed to bridge the post-discharge period when individuals are most vulnerable and face significant challenges engaging with community-based services. Multidisciplinary teams offer community-based time-limited intensive support to adults with SMI returning to the community. The audience will learn how the PH teams engage this reluctant population and address clinical and social determinants of health and improved health outcomes.



Learning Objectives:
  1. Recognize how the evidenced-based Critical Time Intervention (CTI) model-of-care provides intensive, personalized services, and how the three phases of the CTI model can be adapted for a Community-Based Care Management Program
  2. Identify the resources necessary to effectively implement the Five Guiding Principles of Pathway Home within other local care transitions model programs
  3. Apply key operational factors that lead to positive outcomes and best practices for Care Transition Programs

5B - Pediatric Case Management and Outpatient Service Coordination in the Emergency Department
Practice Setting:  

11:00 AM - 12:00 PM

Mary Daymont, RN, MSN, CCM

Abstract:

Emergency department and urgent care utilization by the pediatric patient population can create challenges for any health system. On-site care coordination and case management services along with increased awareness and availability of community resources are imperative. These capabilities enhance emergency department efficiency and promote patient and caregiver satisfaction, especially for pediatric clients. This session will provide examples of services provided within healthcare settings to achieve improved efficiency and patient satisfaction results.



Learning Objectives:
  1. Describe common pediatric patient emergency department and urgent care needs
  2. Discuss emergency department case management and social work services and processes
  3. Review case examples and approaches to apply within a variety of settings

6B - Improved Hospital/SNF Partnerships: Expediting Transfer of Complex Patients
Practice Setting:  

11:00 AM - 12:00 PM

Mona Chambers

Abstract:

Faced with high census, high daily boarder-patient counts and increasing length of stay, Harborview Medical Center’s Bed Readiness Program partners with three local skilled-nursing facilities to expedite the discharge of clinically and socially complex patients. The program provides financial incentives for the skilled-nursing facility, as well as care coordination support and collaboration. This helps the hospital with patient throughput, which improves the hospital’s ability to serve more patients in the community.



Learning Objectives:
  1. Identify the impetus for the establishment of the program
  2. Understand the key elements of the program.
  3. Recognize the key quality measures for the program

7B - Non-Medical Home Care: How It’s Accessed/Funded
Practice Setting:  

11:00 AM - 12:00 PM

Gavin Ward, BS
Certified in Readmission Prevention and Bundled Payments

Abstract:

This presentation will discuss the growing utilization of non-medical caregivers as care extenders to health care organizations throughout the country. Providing this non-medical care is demonstrated to reduce acute care episodes of those receiving the support. As many as 90% of aging adults wish to age in place, and care models are responding by delivering in-home care. Complementary non-medical home care must also become more available. In fact, 31 state Medicaid programs now provide funding for non-medical care as an alternative to nursing home placement. Attendees will learn from existing models of care that leverage the non-medical workforce and are showing some promising results with lower costs of care. A variety of funding sources will be uncovered, including grants and Medicare Advantage Plans funding.



Learning Objectives:
  1. Define non-medical home care
  2. Explain why non-medical homecare is being utilized and funded by healthcare organizations, health plans, community-based organizations, and government entities
  3. Name different funding sources for in-home care

8B - Providing Integrated Behavioral Health Services
Practice Setting:  

11:00 AM - 12:00 PM

Catrina Litzenburg, Ph.D.

Mark McGovern, Ph.D.

Twinchit Salcedo Singer, MS, LCSW

Abstract:

Accessible, affordable and available ambulatory behavioral health resources are limited in many communities. Integration of behavior health with primary care settings is important to meet the needs of patients seeking care for mental illness. This session will explore options and present community programs piloted among leading institutions to meet the care management needs of the behavioral health population.



Learning Objectives:
  1. Describe current state, gaps and barriers within ambulatory behavioral health services
  2. Review strategies, resources and delivery models to meet patients’ needs
  3. Investigate and apply community program pilot options that address needs within local communities

Breakout Session C
Monday, April 15, 2019

1C - Managing Readmissions Across 28 Hospitals: A “How To” Transitions of Care Manual
Practice Setting:  

2:00 PM - 3:00 PM

Devonne Grizzle, RN, MSN, CCM

Sue Muchler, RN, MSN, MBA, FACHE

Abstract:

Quorum Health Corporation is a nationwide health system with locations in non-urban markets. In January of 2017, to address the ongoing impact of CMS readmission penalties, Quorum instituted a readmissions management program that included a “how-to” manual with electronic forms, tools and resources. The focus is a transitions of care program that includes COPD, CHF and Pneumonia DRGs and is implemented at each of the 28 hospitals in the system. Each hospital operationalizes the program according to facility size and patient population served. By Q3 2017 penalty reductions in several of the facilities were below 1.0. Now with an ACO and with the transitions of care program in place, acute care case management will connect with a population health nurse to improve care transitions and chronic care management, improving performance further.



Learning Objectives:
  1. Define the scope of work for a successful readmission management program: the four basic elements
  2. Determine the components of Transitions of Care Program implementation
  3. Identify the metrics for measurement of program success

2C - Managing Observation Status and Reducing Denials
Practice Setting:  

2:00 PM - 3:00 PM

Susan O'Connell, RN, BSN, MPA

Abstract:

Management of Medicare and Medicare Advantage observation status is best accomplished with a multidisciplinary team and process. This presentation will be both a primer on the observation rules and nuances, as well as an overview of the components of a successful multidisciplinary process. The process integrates the daily observation huddle, the monthly observation data review and the escalation process for delays in service. Implementing this approach has led to a reduction from 33% to 22% in initial observation rates and a corresponding reduction in claim denials during the first half of 2018.



Learning Objectives:
  1. Define the rules of Medicare and Medicare Advantage observation status
  2. Identify the impact interdisciplinary management can have on observation rate and length of stay
  3. Evaluate the benefit of using observation patient cohorts

3C - Elder Abuse in Healthcare Settings: Early Identification and Comprehensive Assessment
Practice Setting:  

2:00 PM - 3:00 PM

Lisa Bednarz, LCSW, ACM-SW

Abstract:

Elder abuse is a complex and under-reported issue associated with increased use of health care services including emergency rooms, sub-acute rehabilitation programs and long-term care facilities. These institutions are uniquely positioned to address this reporting crisis. During discharge planning, case managers assess patients’ functional status, environment and support system. This responsibility provides an opportunity and the authority to identify survivors of elder abuse and to provide prevention and intervention services. This presentation will discuss assessments of physical, financial, emotional and sexual abuses through both questionings and using medical records to identify forensic biomarkers that may point to such abuse. Case studies highlighting successful and missed interventions will be presented.



Learning Objectives:
  1. Recognize factors that contribute to severe or escalating abuse going undetected within the healthcare setting
  2. Identify forensic biomarkers that can indicate elder abuse
  3. Modify current practice to include elder abuse assessment techniques and reporting procedures

4C - Speed Learning: Case Management Innovation Showcase
Practice Setting:  

2:00 PM - 3:00 PM

Stacy Wright, LCSW, MHA, MBA, ACM-SW

Abstract:

This session will feature case management innovations that have been successfully implemented in health care settings. Panelists representing five innovations will provide a ten-minute overview of project goals, implementation and outcomes. Interactive Q & A and audience participation will follow the panel presentations.



Learning Objectives:
  1. Discuss new innovations within case management practice
  2. Explain implications for case management practice and provide performance data to track outcomes
  3. Review implementation strategies and key components to achieve desired outcomes

5C - Improving Hospital Throughput Using Discharge Milestones
Practice Setting:  

2:00 PM - 3:00 PM

Joan Cullen, MSN, RN, CCM, CNL

Lesly Whitlow, DNP, MBA, RN, CCM

Abstract:

Ineffective hospital throughput contributes to decreased patient satisfaction, decreased quality of care and missed revenue opportunities. Since most children at this institution are discharged in the evening, a multidisciplinary campaign was launched to identify discharge tasks that resulted in delays. Common barriers to timely discharges include: ordering medications, arranging transportation and entering discharge orders. Interdisciplinary collaborative efforts resulted in an improved patient and family experience as well as smooth, efficient transitions.



Learning Objectives:
  1. Develop improved communication techniques within multidisciplinary teams to ensure a target discharge date is met
  2. Define the impact the case manager role has on timely discharges
  3. Identify inefficiencies that can be targeted with improvement strategies

6C - Post-Acute Care: Authorization and Denial Avoidance
Practice Setting:  

2:00 PM - 3:00 PM

Janeen Foreman, RN, BSN, MHHS, CPHQ

Karla White, MSW, LCSW

Abstract:

Securing authorization for services and treatment and accessing funds for underfunded patients is becoming increasingly difficult. Long-term Acute Care (LTAC) facilities, skilled facilities and acute rehab settings are increasingly scrutinized by both payers and regulatory bodies in order to certify care. In this session, successful approaches to obtain authorization for the right care at the right level and transition from acute short-term to LTAC while avoiding payment denials will be presented.



Learning Objectives:
  1. Develop the case for obtaining authorization for post-acute care
  2. Review success strategies to obtain authorization and avoid denials
  3. Describe resources for underfunded patients

7C - Strategies to Improve Patient and Family Satisfaction
Practice Setting:  

2:00 PM - 3:00 PM

Russell Hilliard, Ph.D.

Abstract:

What are the keys to achieving patient and family satisfaction within the community? Does this differ from the acute care experience? During this session, case examples will highlight factors influencing patient satisfaction. Cultural sensitivity and communication styles will be explored. The presenter will discuss innovative approaches, strategies and outcome data to apply and improve performance.



Learning Objectives:
  1. Describe common factors that influence satisfaction and engagement
  2. Identify creative solutions to improve the patient experience
  3. Discuss case examples and provide data to monitor patient satisfaction outcomes

8C - Best Practices in Population Health Management
Practice Setting:  

2:00 PM - 3:00 PM

James Whitfill, MD

Abstract:

Best practices in population health management require integration of several aspects of care delivery. This session will include a discussion of best use technologies, predictive analytics and access to electronic medical record information. Approaches to complex care planning, chronic disease management, multiple provider or setting coordination, identification of high-risk patients and patient/family navigation will all be presented.



Learning Objectives:
  1. Describe the evolving practices within ambulatory population health
  2. Discuss common challenges to integrating care delivery and promoting population health in community settings

Breakout Session D
Monday, April 15, 2019

1D - Bedside Case Managers: Using an Actionable Dashboard
Practice Setting:  

3:15 PM - 4:15 PM

Todd McClure Cook, MBA, MSW, Ed.D, FAIHQ, FABQAURP, FABC, ACM-SW

Abstract:

An opportunity to bring real-time, measurable data to the bedside case manager arose as part of a training re-design process. Bedside case managers identified a need to quickly focus on the most important variances related to a patient’s stay. Importantly, these variances must respond to immediate actions with measurable and meaningful outcomes. An Actionable Dashboard (AD) was created. The AD is a real-time reporting function embedded in the institution’s EMR system. This AD facilitates the objective measurement and communication of work performance and ties dollar impact to that work. Over a nine-month period, the AD has resulted in multi-million dollar measurable contribution to the bottom line, directly related to case manager action. This has a favorable impacted case manager engagement and a positive impact on system executive perception of case management’s contribution.



Learning Objectives:
  1. Describe an actionable dashboard
  2. Identify critical metrics for dashboard inclusion
  3. Use provided examples as a framework to design their own actionable dashboard

2D - Clinical Documentation Improvement: Analytical Tools and Physician Education to Improve Results
Practice Setting:  

3:15 PM - 4:15 PM

Debra Scavitto Jaeger, MSN, RN

Abstract:

Clinical documentation improvement will lead to improved outcomes and increase efficiency for all teams involved in documentation and coding. Analytics support the assessment of risk and identification of improvement opportunities. Assessments focused on the identification of cases requiring further evaluation, including physician documentation review. Physician chart reviews followed to determine whether the greatest impact would be process improvement or physician education. This session will highlight tools the participants can apply in their organizations to identify and prioritize cases for review and share specific examples of quality outcomes and tools used for physician education.



Learning Objectives:
  1. Identify the key metrics that determine risk and opportunities for hospital documentation
  2. Recommend metrics, process and implementation plan to improve Clinical Documentation
  3. Recommend metrics, process and implementation plan to improve Clinical Documentation

3D - Health System-Payer Partnership: Shared Data and Coordinated Care
Practice Setting:  

3:15 PM - 4:15 PM

Nancy Magee, RN, MSN, ACM-RN

Phyllis Rebholz, RN, MSEd

Abstract:

The merger of a health system with a major payer in our market positioned us to impact health outcomes and the cost of care within our shared population. Community partnerships were created, and primary care and chronic disease delivery models were transformed. Data transparency provided solid metrics to analyze shared data and identify at-risk populations. An assessment tool and common patient-centered interdisciplinary documentation care plans span the continuum. This session will equip you with ideas and tools to streamline processes and apply strategies within an integrated delivery system.



Learning Objectives:
  1. Identify key goals of an integrated delivery and finance system
  2. Articulate key social determinants influencing patients' health
  3. Describe key strategies to create effective payor-provider parternships for transition planning

4D - Pediatric Case Management When Medical Child Abuse Is Suspected
Practice Setting:  

3:15 PM - 4:15 PM

Candice Ferguson, ADN, RN

Amy Munoz, LMSW

Abstract:

Medical child abuse, often a result of Munchausen by Proxy behavior of the caregiver, occurs when a parent or caregiver is suspected of lying about their medical history or causing symptoms that lead to unnecessary treatments or procedures. There are no reliable statistics regarding the number of children who suffer this type of abuse. While commonly considered rare, evidence suggests this is not the case. The staff at Cook Children’s Medical Center recently identified processes to monitor, track and case manage these types of situations. Presenters will discuss the development and implementation of the Medical Child Abuse Monitoring Program (MCAMP), highlighting the importance of a multidisciplinary approach, which includes internal medical and legal teams and outside agencies such as child protective services, law enforcement, the district attorney’s office and local advocacy centers. Case scenarios will be reviewed.



Learning Objectives:
  1. Describe components of medical child abuse and the possible motives of the perpetrator
  2. Explain the value of a multidisciplinary approach and proper case management plan in place to identify and monitor medical child abuse cases
  3. Develop the ability to engage local agencies to create a multidisciplinary team

5D - Pediatric Case Management Models: A Panel Discussion
Practice Setting:  

3:15 PM - 4:15 PM

Deborah Hill-Rodriguez, MSN, MBA-HMA, ARNP, NE-BC

Gay Matthews, MSN, RN, CCRN-K

Susan Navarro, RN, ACM-RN

Abstract:

Changes in the healthcare delivery system have led to restructuring pediatric case management departments and service delivery processes. During this session, panelists will review indications for change, as well as compare the structure of case management models, role delineation, assignments, caseloads and service sites. Model strengths and challenges will be discussed. Outcomes and key performance indicators (KPIs) will be shared.



Learning Objectives:
  1. Compare the benefits and challenges of current case management models
  2. Describe training, standard work, tools and resources for successful implementation of a new model
  3. Review lessons learned, process matrixes and outcomes

6D - Successful Transitions and Hand-offs to Community Providers and Facilities
Practice Setting:  

3:15 PM - 4:15 PM

Lory Arquilla-Maltby, DNP, ANP, APRN-BC

Donna Smith, MSN, MHA, RN, CCM, CRRN

Abstract:

Communication is critical to ensure safe, effective care transitions to skilled, rehab and long-term care facilities. During this session, health care professionals representing various care settings will provide tips, tools and examples applied at the point of hand-off within their practice. Transitions of care standards and best practices will be presented related to the multifaceted communication process involving: preplanning and goals of care establishment, hospital-to-post acute facility communications and preparation of patient and family.



Learning Objectives:
  1. Discuss obstacles faced during transitions between facilities
  2. Share tools and best practices for safe, effective transitions between facilities
  3. Provide outcome data showing impact of use of effective transition planning and tools

7D - Home Care Industry: Overview and Update
Practice Setting:  

3:15 PM - 4:15 PM

William Dombi, Esq.

Abstract:

Obtain insights on the expected direction within the home health and hospice arena to address upcoming industry changes and meet standards for cost-effective quality care and services. During this session updates on new regulatory requirements such as the Home Health Groupings Model (HHGM), the revised CoPs and quality initiatives such as value-based purchasing, 5-star ratings, face-to-face reviews and bundled payment models will be shared.



Learning Objectives:
  1. Discuss upcoming home care industry regulatory changes and quality initiatives
  2. Identify potential impact on current home care service delivery and care transitions planning
  3. Apply information to prepare for changes and achieve healthcare outcomes

8D - Building Patient Engagement Beyond Hospital Walls
Practice Setting:  

3:15 PM - 4:15 PM

Jeanne Fears-Wickliffe, RN, BSN, MHA, CPN

Peggy Tyndall, RN, MBA

Abstract:

Involving patients in care before, during and after outpatient or ambulatory services can improve outcomes and lower costs. During this session, tips, tools and best practices to provide patient-centric care will be reviewed. Identification of key strategies, performance metrics and essential components for patient engagement will be discussed.



Learning Objectives:
  1. Discuss the challenges within ambulatory care delivery sites that impact engagement
  2. Compare approaches, tools and successes within various sites
  3. Identify strategies to enhance engagement with patients and providers

Breakout Session E
Monday, April 15, 2019

1aE - Speed Learning: Weekend Interdisciplinary Rounds – An Implementation Tool Kit
Practice Setting:  

4:30 PM - 5:30 PM

Lisa Bednarz, LCSW, ACM-SW

Tanya Mighty, RN, MS, BSN

Abstract:

This presentation will provide an implementation toolkit with a focus on staffing models, strategic partnerships and information technology necessary to implement efficient interdisciplinary rounds on the weekends. Weekend rounding programs can lead to meaningful increases in weekend discharges and decreases in length of stay. Data will demonstrate success in increasing Saturday and Sunday discharges between 40–60% with the corresponding decrease in length of stay.



Learning Objectives:
  1. Assess patient volume and overall staffing to determine weekend assignments
  2. Identify key stakeholders for the implementation of weekend rounds
  3. Determine information technology tools that can support weekend rounds

1bE - Speed Learning: Twenty Strategies to Reduce Inpatient Readmissions to Implement Now
Practice Setting:  

4:30 PM - 5:30 PM

Kimberly Jungkind, MPH, MBA, BSN, CCM

Abstract:
As many as 1 in 4 readmissions are defined as potentially avoidable, meaning there is a 50% chance the readmission could have been avoided. This presentation will provide 20 ideas and strategies to reduce inpatient readmissions for quick implementation. Each innovative solution presented will be reviewed with examples to consider implementing right away.  In addition, high risk populations will be discussed with unique ways of utilizing resources.

Learning Objectives:
  1. Explain specific strategies that include interdisciplinary teams
  2. Evaluate CM metrics and trends to create innovative solutions

2E - Leveraging Predictive Analytics to Drive Estimated Day of Discharge
Practice Setting:  

4:30 PM - 5:30 PM

Elizabeth Halbert, RN, BSN

Ginna Parker, LCSW

Abstract:

Individual patient variance in healing and recovery create such uncertainties in length of stay (LOS) that providers are often reluctant to predict a specific patient’s estimated discharge date. DRG guidelines fall short of predictive value for the complex patient. Learn how an integrated academic health care delivery system improved LOS and patient outcomes by predicting estimated date of discharge (EDD) using analytics and technologies such as data mining and artificial intelligence. This presentation will share the important elements of a predictive tool, some of the challenges of implementing predictive analytics and specific outcomes.
These analyses are paired with virtual interdisciplinary rounding boards and cross-department teams that address social and intra-institutional barriers to discharge.



Learning Objectives:
  1. Determine the best practices in utilizing predictive analytics and the application to healthcare
  2. Identify the necessary elements and appropriate patient populations to include in the predictive algorithms
  3. Explain how to create a culture of shared responsibility among the healthcare team for timely transitions of care

3aE - Speed Learning: A Clinical Supervision Cohorts Model – Managing Social Workers in a Case Management Practice
Practice Setting:  

4:30 PM - 5:30 PM

Dawn St. Aubyn, MSW, LICSW

Abstract:

Many case management departments include a mix of RN and MSW case managers. Often RN case managers are tenured nurses while many MSW staff members are new to case management. These MSWs work under a provisional license that includes a requirement of formalized clinical supervision. Clinical Supervision (CS) Cohorts, is a specific supervisory format designed to meet targeted clinical and professional development needs of provisionally licensed MSW case managers using a combination of didactic and practical learning in a focused, supportive environment. The presentation will introduce this format, discuss outcomes and share lessons learned. Finally, we will demonstrate how CS Cohorts can be customized to a variety of case management practice environments.



Learning Objectives:
  1. Outline Clinical Supervision Cohort format including sample curriculum
  2. Illustrate 3 outcomes CS Cohorts have achieved toward supporting the professional development needs of social workers and how the organization has benefited by those outcomes
  3. Develop a framework for best practice in customizing CS Cohorts to a variety of case management settings

3bE - Speed Learning: Practice-Changing Insights: A Case Management Critique from the Patient Perspective
Practice Setting:  

4:30 PM - 5:30 PM

Mari C. Wagner-Davis, RN, BSN, ACM-RN

Abstract:
Learn from the patient experience through a case manager lens. This presentation will share a unique critique and recommendations that reflect the professional training and experience of a case manager in combination with a comprehensive experience as a patient in a number of settings along the recovery continuum. Struck at work with new onset seizures, a diagnosis of Limbic Encephalitis followed, as did lasting memory complications. The hospital stay, rehab programs, cognitive medicine program and ongoing multiple medical encounters revealed gaps in understanding a case manager may have despite years working in the profession. Case managers’ knowledge of the system, combined with the necessary emotional distance from our patients, hide a multitude of inefficiencies and opportunities to respond to unmet patient needs. The best medical outcomes and quality of life for patients require a more holistic care model.


Learning Objectives:
  1. Identify ways to address the fragmented medical system
  2. Identify ways to support patients and families with chronic illness
  3. Identify ways to assist patients in adapting to their chronic illness

4E - Impact of Evidence-Based Protocols on Remote Patient Monitoring
Practice Setting:  

4:30 PM - 5:30 PM

Karen Hercules-Doerr, MBA

Abstract:

Ensuring long-term patient engagement is imperative in population health and value-based care initiatives. Barriers include patients not understanding the importance of reporting key symptoms to their providers on a timely basis and the cumulative effect often experienced when multiple co-morbidities exist. Accessible technology should require low patient activation that can be used by any patient regardless of health literacy or tech savvy. Remote patient monitoring should facilitate an increased understanding of signs and symptoms related to the patient’s chronic disease so that they are more active in their health management. Evidence-based protocols presented in this session will consider patient engagement, ease of patient accessibility and impact on utilization demonstrated with verifiable clinical outcomes.



Learning Objectives:
  1. Describe three ways care managers can identify rising risk patients and the importance in population health and value-based care
  2. Associate outcomes with dialysis, COPD, diabetes and depression using evidence-based tools in various clinical settings
  3. Quantify the impact on care management capacity to monitor patients via remote patient monitoring and digital health tools

5aE - Speed Learning: Providing Well-Coordinated Care for Pediatric Behavioral Health Patients
Practice Setting:  

4:30 PM - 5:30 PM

Carey Spain, MSW, MBA, LCSW, LSCSW, CCM

Mindy Schneider, MSW, LCSW, LMSW, ACM-SW

Abstract:

Managing youth with complex behavioral health needs in the acute medical setting is common. To meet the growing centers for medicare and medicaid services (CMS) demands required by increased volume and limited community resources, children’s hospitals create safe spaces, policies and education programs. One children’s hospital saw a 56% increase in the number of children admitted for behavior health concerns during 2016-17. Pediatric facilities are not equipped to be safe spaces, lack staff with specialized skills and may often be overwhelmed by the demands created by these patient needs. Attendees will learn how one facility addressed this challenge.



Learning Objectives:
  1. Analyze the challenges in managing behavioral health patients in the acute care setting
  2. Review a new method to coordinate care for behavioral health patients
  3. Describe the importance of collaboration to make changes necessary to improve behavioral health patient outcomes

5bE - Speed Learning: Managing Pediatric Behavioral Health Issues
Practice Setting:  

4:30 PM - 5:30 PM

Caroline Cortezia, M.S. CCLS III

Abstract:
Limited financial and community resources, as well as common regulatory and legal commitment bottlenecks, pose challenges when coordinating plans for pediatric patients who have behavioral health problems. During this session, the presenter will describe one institution’s efforts to address these challenges so that children’s needs are met.

Learning Objectives:
  1. Describe common challenges and barriers in pediatric behavioral health
  2. Review regulatory and commitment issues
  3. Discuss strategies to address bottlenecks and overcome barriers

6E - A Post-Acute Network for Elderly Patients: The HOPE SNF Collaborative
Practice Setting:  

4:30 PM - 5:30 PM

Heather N. Jacobson, MHA, MS, CCC-SLP

Abstract:

Value-based payment models encourage hospital systems to collaborate with post-acute care (PAC) providers to integrate resources and reduce health care spending and hospital readmission rates. There is a variety of approaches in scope and objectives as well as in financial benefit. In 2017, Duke University Health System Accountable Care Organization launched the HOPE Skilled Nursing Facility (SNF) Collaborative. It includes facilities with varied Star rankings, geographic locations and re-hospitalization rates. This presentation will review the steps involved from the initial working group to the final assembly of participants. Goals were set to improve transitional care processes and 30-day readmission rates, and five additional goals were established to focus on improving care transitions and creating infrastructure for larger strategic initiatives and integration. Specific goals and performance data will also be shared.



Learning Objectives:
  1. Identify and evaluate SNFs for collaboration beyond using Star Ratings
  2. Determine the process to set mutually beneficial goals and performance metrics
  3. Discern best practices to engage stakeholders and implement strategies to improve transitional care across the healthcare continuum

7E - Improving Outcomes for COPD Patients Through Clinical Consensus
Practice Setting:  

4:30 PM - 5:30 PM

Pam Foster, LCSW, MBA, ACM-SW

Nina Shah, D.O.

Abstract:

COPD is a leading cause of mortality and morbidity, causing the death of more than 150,000 Americans each year. More than 20% of hospitalized patients over the age of 40 have COPD, and readmissions of COPD patients cost Medicare $475 million each year. Improving the inpatient management of COPD patients through well-designed, evidence-based care pathways can improve patient outcomes, reduce functional decline and decrease the likelihood of readmission. In addition, there are positive implications for Medicare cost per beneficiary by implementing pathways that reduce unnecessary consultations and medications. This presentation will explore one health system’s journey of bringing multiple clinical stakeholders together to build a pathway through a unique, physician-lead clinical consensus process. The pathway includes: appropriate triage, admission status, medication regimens, triggers for pulmonary consultation, vaccinations, smoking cessation, patient education and transition planning. It will explore case management’s integral role in building and executing the pathway and will share positive outcomes on the length of stay, readmissions and cost per episode.



Learning Objectives:
  1. Recognize the implications for poor COPD management on patients, health systems, and payers
  2. Explain the importance and value of evidence-based clinical pathways for chronic disease management
  3. Describe the process of bringing multiple clinical stakeholders together to build a pathway through the clinical consensus process

8E - Longitudinal Care: TOC Roundtable Discussion
Practice Setting:  

4:30 PM - 5:30 PM

William Dombi, Esq.

Daren Giberson, RN, MSN, ACM-RN

Abstract:

During this session common care coordination challenges encountered within various care delivery sites will be reviewed. Best practices will be shared though interactive audience group discussion providing audience members with networking opportunities and ideas to apply within their settings.



Learning Objectives:
  1. Review common longitudinal care planning challenges
  2. Discuss best practices to resolve common barriers
  3. Apply innovative ideas within various practice settings

None
Tuesday, April 16, 2019

Sunrise 3: Public Policy
Practice Setting:  

6:45 AM - 7:45 AM

Max Perkins, BA

Suzanne Wilson, RN, MBA, ACM-RN

Abstract:

ACMA Public Policy Committee strives to inform the membership of current and relevant legislation that impacts the practice of case management. This session will provide an overview of legislation that is currently being monitored for ACMA advocacy, and also give an update on the ACMA Public Policy focus and activity.




Sunrise 2: Increase Appropriate Admission Authorizations for Pediatric Short Stays
Practice Setting:  

6:45 AM - 7:45 AM

Ethan Leonard, MD, MBA, FAAP, FIDSA

Kimberly Littell, BSN, MPA, ACM-RN

Abstract:

Increasing denials on inpatient claims for short stays indicated that process changes were necessary at this pediatric hospital. Physician and case management undertook a multifaceted approach including chart review, physician education, medical necessity criteria application review and UM process updates. This co-led effort resulted in decreased denials with increased appropriate inpatient claims and an increase from 18–22% in observation status patients.




Sunrise 1: Engaging Physicians in Care Management Initiatives
Practice Setting:  

6:45 AM - 7:45 AM

Marijke (May) McAnally, RN, BSN

Pat Metzger, RN, BSN, MSA, ACM-RN, FABC

Abstract:

Physician partnerships are critical to facilitate efficient, effective care. The care management team must engage physician partners to coordinate care, plan for early discharge, review performance metrics and develop strategies to address areas of opportunity. During this session, panelists will share tools and strategies they successfully applied to promote early discharges, length of stay reduction and denial avoidance.




General Session: The Future of Health Care
8:00 AM - 9:15 AM

Martin Makary, MD, M.P.H., F.A.C.S.

Abstract:

Dr. Martin Makary is a surgeon, New York Times bestselling author and Johns Hopkins health policy expert. He is the author of Unaccountable and The Price We Pay, creator of the Surgery Checklist and former leader of the W.H.O. work-group to create

global measures of surgical quality. Makary has written for The Wall Street Journal, TIME, Newsweek, and appears as a medical commentator on NBC, CNN and Fox News.

A leading voice on patient safety and quality, Dr. Makary describes the current health care marketplace and new trends
that represent a disruption in the industry and the hope of a more patient-centered, value base with accountable care. Finding the best care and navigating the system can be a challenge, even for the most educated consumer. In his presentation, he describes a new movement as American health care seeks to make medical care safer, more transparent and patient-centric.




General Session: Assuring Successful Transitions of Care: TOC Standards for the Care Continuum 
1:30 PM - 2:30 PM

Debra McElroy, MPH, RN
Senior Vice President
Practice Development and Education

Abstract:

Currently the term “transitions of care” is used widely by regulators, providers, payers and community agencies – yet there is wide variability across the service components, minimal standards of service, and the skillsets of people managing care transitions. It is well understood that poorly managed transitions impact health care quality and costs. According to the Centers for Medicare and Medicaid Services (CMS), the cost of poor care transitions of Medicare patients from acute care alone is $26 billion per year as of 2016.

This session will describe standards that will bring clarity to the practice of care transitions and assist providers, payers and all health care organizations in establishing processes for seamless coordination across the entire continuum of care, with the goal of achieving the best health outcomes.



Learning Objectives:
  1. Provide an overview of the opportunities to assure efficient, successful and cost- effective care transitions between settings and levels of care delivery
  2. Present and explain the ACMA Transition of Care standards developed by national health care leaders from all segments of care delivery
  3. Describe metrics associated with Transitions of Care and address opportunities for measurement to drive standardization across the care continuum

Session
2:45 PM - 3:45 PM

Abstract:



Session
2:45 PM - 3:45 PM

Abstract:



Closing Session: How to deal with fear in the creative process
4:00 PM - 5:00 PM

Erik C. Wahl

Abstract:

Back by popular demand, Erik Wahl will be joining us for this third ACMA Conference.
Wahl is an internationally recognized artist, TED speaker, and No. 1 bestselling author. His breakthrough experience as an artist and entrepreneur has translated into making him into one of the most sought-after corporate speaker.

In his presentation, Wahl will share with us that the awareness of fear is the key to controlling it, and he explains how to use fear in a healthy way.

Wahl will also be joining us at the Closing Party where he will be on hand to sign his book Unchain The Elephant.




Breakout Session F
Tuesday, April 16, 2019

10F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



11F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



1F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



2F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



3F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



4F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



5F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



6F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



7F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



8F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



9F - PLATINUM SESSION
9:30 AM - 10:30 AM

Abstract:



Breakout Session G
Tuesday, April 16, 2019

Session
2:45 PM - 3:45 PM

Abstract:



Session
2:45 PM - 3:45 PM

Abstract:



1G - Hospital and Health Plan Partnership for Discharge Planning and Transitions of Care
Practice Setting:  

2:45 PM - 3:45 PM

Stephanie Bowen, RN, MSN, ACM-RN

Yvonne Chan, RN, MSN, GCNS-BC, NE-BC, CCM

Abstract:

This session will detail a unique partnership between a community not-for-profit hospital and a local non-profit health plan for the care coordination of the managed Medicare and Medicaid patient population. The context and makeup of the partnership, keys to senior stakeholder involvement, model development and evolution will all be covered from both partners’ perspective. Pre-partnership and post-partnership results will be reviewed including avoidable days, readmission rate, length of stay and overall health care utilization, including Quality Measurement standards. Considerations and implications for replicating the model for complex patients will be discussed.



Learning Objectives:
  1. Describe the approach and methodologies used in creation of the partnership
  2. Explain the roles and purpose of each transitions of care program outlined
  3. Identify opportunities and strategies for applying the model

2G - Physician Advisor Workflow and Metrics
Practice Setting:  

2:45 PM - 3:45 PM

Yvette Coronado-Castellanos, BSN, RN, ACM-RN

Leah Low, MD

Abstract:

To remain financially secure in an ever-changing environment, an understanding of regulatory guidelines governing medical necessity and how payers define medical necessity is critical. Care management plays an instrumental role in this process, and their performance influences the revenue stream of an institution. This presentation will present a case study of UTMB Galveston’s experience responding to the need to improve. The foundation of the change was a new physician advisor program and a reorganization of care management. Barriers, challenges and strategies for success will be discussed. Attendees will learn ways to develop and implement a physician advisor program at a large, multi-center, academic, state institution serving a resource-poor region. Our improved workflows, processes and care management reorganization will be highlighted.



Learning Objectives:
  1. Identify the steps to design and implement a Physician Advisor Program at a large, academic institution
  2. Formulate new workflows and processes that improve measurable outcomes and engage physicians in care management
  3. Construct and implement strategies to engage hospital leadership, physicians, and staff to successfully complete a transformational change across an organization

3G - Providing Culturally Competent Care to LGBTQ Patients
Practice Setting:  

2:45 PM - 3:45 PM

Susan Guthrie, MSN, RN, ACM-RN

Stacy Wright, LCSW, MHA, MBA, ACM-SW

Abstract:

Healthcare systems, including post-acute care agencies, are not all equipped to provide culturally competent care for lesbian, gay, bisexual, transgender and queer (LGBTQ) patients. The LGBTQ community is growing and its members have unique needs often unmet by healthcare systems. The personal story of one transgender patient will demonstrate how one healthcare system creates a sense of dignity and respect for patients during an acute care stay and how collaboration with post-acute providers, such as home health and skilled nursing facilities is critical to doing so.



Learning Objectives:
  1. Better understand specificIdentify specific needs of LGBTQ patients, including the complex needs of these patients when exploring post-acute care options needs of LGBTQ patients
  2. Determine ways in which hospitals and post-acute care services treat the LGBTQ community with improved inclusion, respect and dignity
  3. Recognize potential ethical dilemmas that may arise when providing culturally competent care to LGBTQ community patients

4G - Applying Technology and Tools to Enhance Utilization Management
Practice Setting:  

2:45 PM - 3:45 PM

Patricia Resnik, MJ, MBA, RRT, CPHQ, CHC, FACHE

Janine Jordan, M.D.

Abstract:

In this session, presenters will review utilization management processes in a large, integrated delivery system and how they leveraged technology to improve efficiency and effectiveness. The leadership team’s journey to operationalize a collaborative, interdisciplinary team approach to utilization management engaging with colleagues from patient financial services, compliance, information technology and health information management services will be discussed. Attendees will gain insight to develop proactive monitoring processes including hard stop alerts for short stay admissions and will utilize data dashboards to drive operational improvements.



Learning Objectives:
  1. Identify processes to proactively manage short inpatient admissions
  2. Describe how to leverage technology to enhance utilization management processes
  3. Identify methods for engaging physician advisors in daily utilization management

5G - Screening Pediatric Patients for Readmission Risk
Practice Setting:  

2:45 PM - 3:45 PM

Sarah Bradshaw, RN, MSN, CPN, ACM-RN

Blair Buenning, RN, BSN, CPN, ACM-RN

Abstract:

Readmission reduction is a vital component of case management programs. At the core of readmission reduction is the identification of high-risk patients who may require more focused intervention by case managers. There are several risk assessment tools available to evaluate the adult population, but pediatric assessment
tools are less common. During this presentation, the High Acuity Readmission Risk Pediatric Screening (HARPS) tool and research findings will be reviewed.



Learning Objectives:
  1. Identify how quality improvement and research projects can be used together to produce statistically significant high-quality outcomes
  2. Describe an evidence-based pediatric readmission tool
  3. Develop an action plan to apply the HARPS tool within your organization

6G - Medically Complex Population Management: Implementing a Complete Program Utilizing Inpatient and Outpatient Healthy Planet Workflows
Practice Setting:  

2:45 PM - 3:45 PM

Edwin Ray, RN, MS

Abstract:

Organizations face a daunting challenge to understand which subsets of their patient population present the greatest need for care management to mitigate risk. Instead of focusing on individual populations defined by disease process, patient cohorts consisting of multiple comorbidities are identified and their needs are evaluated as a whole. Using EPIC’s Healthy Planet, Longitudinal Plan of Care and MyChart workflows provide information to providers and patients. Outcome monitoring occurs via workbench reports and RADAR dashboards. This approach has demonstrated a decrease in both 30- and 90-day readmission rates.



Learning Objectives:
  1. Identify the most “at risk” cohort of patients
  2. Determine commonalities required to treat a mixed disease population and how to design a program that addresses the needs of all
  3. Implement an integrated program using multiple aspects of Epic functionality for inpatients, outpatients and aspects outside of an encounter

None
Wednesday, April 17, 2019

ACM™ Certification Review: Case Management Process and Practice
8:00 AM - 3:30 PM

Debbie Blevins, MSN-HCM, RN, ACM-RN

Pat Kramer, Ed. S, CCM, NCC, CSW, ACM-SW

Abstract:
Part 1:
Abstract:
The scope of services and standards of practice provide social worker and nurse case managers with a guide by which they can engage in the practice of case management.  Understanding the parameters within which the case manager practices assures a uniformity of services delivered to patients in need and assists the case manager in performing the duties required within health care delivery systems.
This session is designed to provide the practicing case manager with a review of case management practice standards in accordance with American Case Management Association guidelines and ACM certification It will provide intensives for focused review in domains of case management practice including screening and assessment, planning and care coordination/intervention/transitions.

Part 2:
Abstract:
The scope of services and standards of practice provide social worker and nurse case managers with a guide by which they can engage in the practice of case management.  
This session is designed to provide the practicing case manager with a review of case management practice standards which can be applied to case scenarios.  It will provide intensives for focused review of the evaluation domain of case management practice. The session will include case management scenarios presented in an interactive format allowing attendees to apply information gathering, assessment, decision-making and problem-solving skills.


Learning Objectives:
  1. Describe the three domains of practice utilized by the Health Delivery System Case Manager
  2. Apply the essential job functions to the role of a Health Delivery System Case Manager
  3. Describe clinical and psychosocial assessment and intervention methods used in case management

American Case Management Association
11701 W. 36th St.
Little Rock, Arkansas 72211
Phone: 501-907-ACMA (2262)
Fax: 501-227-4247
Contact Us

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