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Coordinating
Care Transitions for
the Elderly and Dually Eligible:
Fostering
Self-Management and
Reducing Readmissions
When
the elderly
and dually eligible populations transition from one healthcare setting
to another, they frequently encounter gaps in care that negatively
impact their health, unnecessarily prolong hospital stays and specialty
care, and unduly increase the burden on caregivers and family. These
care gaps are most likely to occur during transitions from primary to
specialty care, from the emergency department to the surgical floor,
from hospital to home or from in-patient to long-term care.
Closing
care transition gaps for these populations is the focus of
"Coordinating Care Transitions for the Elderly and Dually Eligible:
Fostering Self-Management and Reducing Readmissions."
Contributing Authors
Throughout
this 65-page report, these respected thought leaders will share their
unique approaches to care transition management that positively impact
cost and engage the patient in their care decisions:
- Danielle
Butin, director,
northeast health services for Secure Horizons, United Healthcare;
- Diane
Flanders, director of
coordinated care systems at MassHealth, a unit that oversees the
state’s integrated Medicare-Medicaid managed care programs,
including Senior Care Options (SCO) and the Program of All-inclusive
Care for the Elderly (PACE;
- Sarah
Keenan, clinical
liaison with Medica; and
- Gregg
Lehman, PhD, president
and chief executive officer of INSPIRIS at time of contribution and
current president and CEO of Minneapolis-based Health Fitness Corp.
This
report is based on 2006 and 2007 audio conferences on the importance of
overseeing care transitions in the Medicare, Medicaid and dual-eligible
populations.
Table
of Contents
- Integrating
Health Coaching Into a
Comprehensive Health Management Effort
- Using
Health Coaching to Better Manage
Transitions and Improve Empowerment
- Implementing Health
Coaching Programs
- Results
of Health Caching in Managed Care
- Transition
Coach Program
- Advanced Illness and
Coordinated Care Program
(AICC)
- Polypharmacy Transitions
- Options
for Living Self-Management Programs
- Results
of Living Self-Management Programs
- Managing
Transitions for Medicare Patients to
Avoid Costly Inpatient Admissions
- The
Frail Elderly -- Growing Need, Growing
Problem
- The
Changing Role of Family Caregivers
- Ten
Most Common Reasons for Hospitalizations
Among the Elderly
- How
and When Breakdowns Occur
- Acute
Problem Management
- Physician
Relationship Management
- Utilization
and Cost Outcomes
- The
Dually Eligible Medicare and Medicaid
Population: A Care Coordination Perspective
- Program
Eligibility Criteria
- The
Provider Payment Method
- Defining
Care Coordination and Its Functions
- Working
with Elderly Waiver Services
- Transitions
to Care and Healthcare Directives
- Emergency
Care Plans Prevent Surprises
- Preventive
Care for Seniors
- Barriers
to Compliance
- Senior
Care Options (SCO): Bringing Medicare
and MassHealth Together
- Objectives
of the Senior Care Options Program
- SCO
Milestones
- Managing
a Merge of Medicaid and Medicare
Services
- SCO
Highlights
- How
the Payment System Works
- Senior
Care Organizations
- Q&A:
Ask the Experts
- Predicting
Inpatient Acute Utilization
- Managing
Fractures on an Outpatient Basis
- Criteria
for Identifying Pre-Hospice Patients
- Acute
Problem Management
- Geriatric
Depression Scale and Mini Mental
Status Exams
- Funding
& Reimbursement
- Interventions
for Self-Management Disease
Programs
- Health
Coaching in Pharmacy Outreach Programs
- Determining
the Frequency of Maintenance Visits
- Components
of the Home Visit
- Training
Transition Coaches
- Training
Nurse Practitioners
- Care
Transitions for the Dually Eligible
- Care
Transition Coordinator Caseload
- Coordination
Between Aging Programs
- Following
Geriatric Standards
- Methods
of Making Patient Contact
- Integrating
Utilization and Mental Health
Responsibilities
- The
Long-Term Care Consultation Form
- Recruiting
Beneficiaries When Enrollment Is
Voluntary
- Keeping
Nurse Case Managers Current
- Dissecting
the Central Enrollment Record
- Avoiding
Unnecessary ER Utilization
- Nurse
Care Managers and 24/7 Coverage
- Nurse
Case Manager Employment
- Glossary
- For
More Information
- About
the Authors
Publication
Date: April 2007
Number
of Pages: 65
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