Implementation Plan
The solution proposed by this author includes, the use of risk assessment and implementation of interventions based on risk stratification to prevent readmissions. Interventions include, care coordination, home health care and remote monitoring as needed. Three presentations will be engaging senior leadership and associates to ensure an effective implementation. Initially, the recommended process will be presented during a one to one meeting with the Senior Vice President of Health Partner Services with the assistance of a power point presentation, supplemental handouts including the LACE index tool (Appendix A), as well as the proposed policy and procedure (Appendix E). The Senior Vice President of Health Partner Services …show more content…
The first group is high risk patients who are identified by frequent emergency department (ED) visits more than 12 times in six months and those who have an extended or complicated hospitalization typically requiring complex needs after discharge. The second manner of identification is through Diagnosis Related Groups (DRG) 291-293 found on paid claims data. DRG ‘s established through the inpatient prospective payment system are part the methodology of reimbursement created by the Centers of Medicare and Medicaid Services as a provision of the Social Security Act of 1886. (Centers of Medicare and Medicaid Services, …show more content…
Once the LACE score is determined, the paper record will be uploaded in to the into the acute inpatient authorization within Clinical Care Advance. The score will also be documented in the Case Management Model progress notes. The LACES score will then be compared to a risk stratification outlining one of three sets of clinical interventions. All three risk stratification levels will include basic discharge planning comprised of coordination of care with primary care physician, arranging for a discharge follow up appointment within 14 days of leaving the inpatient setting. The nurse will coordinate home needs such as oxygen or other durable medical equipment. Post discharge interventions will follow the guidelines outlined with in the three levels of risk stratification.
Level 1-LACE < 10
CS Health Plan will assign a nurse case manager to reach out to the patient within 48 hours of discharge. Initial contact with the patient will occur telephonically and the care coordinator will:
• Utilize motivational interviewing techniques to assess the patient’s knowledge of the disease, assess for additional needs and set mutually agreed self-care goals.
• Confirm the patients the date and time of the follow up appointment as well as any transportation concerns.
• Confirm the patient has a home scale and understands the need for daily weights and when to call their
The solution proposed by this author includes, the use of risk assessment and implementation of interventions based on risk stratification to prevent readmissions. Interventions include, care coordination, home health care and remote monitoring as needed. Three presentations will be engaging senior leadership and associates to ensure an effective implementation. Initially, the recommended process will be presented during a one to one meeting with the Senior Vice President of Health Partner Services with the assistance of a power point presentation, supplemental handouts including the LACE index tool (Appendix A), as well as the proposed policy and procedure (Appendix E). The Senior Vice President of Health Partner Services …show more content…
The first group is high risk patients who are identified by frequent emergency department (ED) visits more than 12 times in six months and those who have an extended or complicated hospitalization typically requiring complex needs after discharge. The second manner of identification is through Diagnosis Related Groups (DRG) 291-293 found on paid claims data. DRG ‘s established through the inpatient prospective payment system are part the methodology of reimbursement created by the Centers of Medicare and Medicaid Services as a provision of the Social Security Act of 1886. (Centers of Medicare and Medicaid Services, …show more content…
Once the LACE score is determined, the paper record will be uploaded in to the into the acute inpatient authorization within Clinical Care Advance. The score will also be documented in the Case Management Model progress notes. The LACES score will then be compared to a risk stratification outlining one of three sets of clinical interventions. All three risk stratification levels will include basic discharge planning comprised of coordination of care with primary care physician, arranging for a discharge follow up appointment within 14 days of leaving the inpatient setting. The nurse will coordinate home needs such as oxygen or other durable medical equipment. Post discharge interventions will follow the guidelines outlined with in the three levels of risk stratification.
Level 1-LACE < 10
CS Health Plan will assign a nurse case manager to reach out to the patient within 48 hours of discharge. Initial contact with the patient will occur telephonically and the care coordinator will:
• Utilize motivational interviewing techniques to assess the patient’s knowledge of the disease, assess for additional needs and set mutually agreed self-care goals.
• Confirm the patients the date and time of the follow up appointment as well as any transportation concerns.
• Confirm the patient has a home scale and understands the need for daily weights and when to call their