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Chronic Disease: 8 Change Concepts
How the Medical Home Enhances the Treatment of Patients with Chronic Disease
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Rate: $329 per location, includes access to CE portal and continuing education credits for up to five (5) users. Additional seats may be purchased at rate of $50.00. Special rate available for solo practitioners and the military. Please call 301-354-1769 for details.
Each registration comes with access to the archived version of the program and the materials until December 31, 2012.
Continuing Professional Education: This program is approved for 1.5 contact hour for nurses, social workers, and certified case managers.
There is widespread recognition that the U.S. healthcare system falls short in its efforts to effectively manage chronic conditions. Currently, 45 percent of the population has a chronic medical condition. Among the Medicare population the statistics are even worse: 83 percent have at least one chronic condition and almost a quarter have at least five co-morbidities.
To address this glaring need, the patient-centered medical home model is stepping up to transform how chronic care is managed and delivered.
The medical home transforms the traditional primary care practice into a model where the primary care physician works with a coordinated healthcare team to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives.
Join us on September 27, 2012 from 2:00-3:30 p.m. (ET) as we bring together three experts to share how payers and other organizations are designing programs to expand the transformation of the medical home in their states through collaboration, training and sharing of resources.
About the Webinar
The concept of improving chronic illness through a coordinated healthcare system is based on the idea that United States healthcare can do better. Over 145 million people – almost half of all Americans – suffer from asthma, depression and other chronic conditions. Over 8 percent of the U.S. population has been diagnosed with diabetes, and the majority of adults who live with chronic illness are managing more than one condition.
Providers who care for chronically ill patients can be better supported with evidence-based guidelines, specialty expertise, and information systems. Overall healthcare costs can be lowered through better care delivery.
To assist managed care organizations, hospitals, physicians groups, the military and others achieve a successful medical home model, the Commonwealth Fund in a report titled Guiding Transformation: How Medical Practices can become Patient-Centered Home listed eight characteristics – or change concepts – that can provide general directions for transforming a practice. The eight change concepts include:
Engaged Leadership. To become a PCMH, most practice organizations must undergo extensive cultural and system changes. This requires visible leadership that can help staff envision a better organization and improved care, establish a quality improvement apparatus and culture, and ensure that staff have the time and training to work on system change.
Quality Improvement Strategy. Effective leadership ensures that the organization embraces an effective improvement strategy that relies on routine performance measurement to identify opportunities for improvement and uses rapid-cycle change methods to test ideas for change. Information systems help support critical functions such as performance measurement, provider alerts and reminders, computerized order entry, and population management.
Empanelment. Considerable evidence has demonstrated that positive outcomes result from care provided by the same clinician and care team over time. A deliberate effort by the practice to link each patient or family with a specific provider – a process known as empanelment – facilitates continuity of relationship.
Continuous and Team-Based Healing Relationships. Robust and lasting clinician-patient relationships are at the heart of every medical home. The involvement of practice staff other than clinicians has been shown to improve care and outcomes.
Organized, Evidence-Based Care. Medical homes must be able to deliver high-quality care. Two critical components of the chronic care model are included in this change concept: planned care and decision support. Using information system tools like registries enables practices to identify gaps in care for patients before they visit, and decision support systems improve care by alerting providers when services are needed.
Patient-Centered Interactions. Patient-centered practices endeavor to increase their patients’ involvement in decision-making, care, and self-management. They see effective healthcare as being respectful of a patient’s needs, preferences, and values, and work to ensure patients understand what is being communicated to them.
Enhanced Access. Providing patients with the ability to contact their care team, or at least someone with access to their clinical information, both during and after office hours is an essential feature of a medical home. Ensuring access also means helping patients attain and understand health insurance.
Care Coordination. Many patients benefit from services outside the medical home, from medical or behavioral specialists, community service agencies, hospitals, and emergency rooms, for example. Effective care coordination involves helping patients find and access high-quality service providers, ensuring that appropriate information flows between the PCMH and the outside providers, and tracking and supporting patients through the process.
Join us as our faculty shares how they are using these concepts can help improve the delivery of care into an efficient system that addresses chronic medical conditions through a coordinated medical home model.
- Describe the importance of coordinating care efficiently for patients with chronic conditions in order to improve quality and decrease healthcare costs.
- Explain how payers, providers and academic organizations are building consensus among physicians and members of the care coordination team on the need to break down silos and work together to streamline the delivery of care.
- Outlines strategies that can be used educate and empower professionals and consumers to work together to improve health and wellness through effective care coordination.
Our Webinar Will Answer These Questions
- Why is now the time to transform to a patient medical home model?
- How will physicians and other members of the care coordination team be reimbursed?
- What data should be collected to demonstrate quality and outcomes is continued measurement needed once the program is in place?
- How are states, payers and providers working together to improve care for patients with chronic medical conditions?
- What systems are required to be in place when implementing these models of care?
- How do the patient and the family fit into these models of care?
Robert A. Gabbay, M.D., Ph.D. is Professor of Medicine, College of Medicine Division of Endocrinology, Diabetes and Metabolism and Director of the Penn State Institute for Diabetes and Obesity and Penn State Hershey Diabetes Institute.
His research program is focused on studying integrative approaches to Reinvent Diabetes Care. Much of his efforts are organized around improving diabetes care within the primary care setting where most patients with diabetes receive treatment. Dr. Gabbay is the PI of several ongoing projects which are described below that focus on care delivery and improving ways to improve clinical outcomes.
Dr. Gabbay helped to lead a unique, state-wide initiative aimed at transforming care in Pennsylvania to be aligned with the Chronic Care Model. The Chronic Care Model, developed by Dr. Ed Wager, is the best evidence-based approach to transform care from an acute and reactive system to a proactive, planned, and population-based system of care. To date, however, most implementation of the Chronic Care Model has been in large practice organizations due in part to unsupported reimbursement for chronic care elements and a mismatch between those who bear the implementation costs and those who potentially receive the financial benefits. The unique initiative in Pennsylvania aims to implement the Chronic Care Model across the Commonwealth leveraged by significant changes in reimbursement to cover implementation costs and reward quality improvement. Learning collaboratives were established across the state by Dr. Gabbay and supported by practice coaches with monthly data reporting, registry use, and practice reinvestment in needed services. Further, an evaluation of this three-year initiative across the Commonwealth that targets diabetes will include clinical outcomes, patient-centered outcomes and cost and utilization data. This unique undertaking merges, for the first time, changes in reimbursement with incentives for Chronic Care Model implementation. This initiative holds significant promise to transform healthcare in other regions and establishes a potential national model for systematic chronic disease management.
Dr. Gabbay, originally a native of New York City, completed his Bachelor’s Degree at McGill University. He then earned his Ph.D. in Biochemistry from the University of Wisconsin where he studied insulin signaling mechanisms. After an Internal Medicine Residency at Cornell University - New York Hospital, he had a Fellowship at Harvard Medical School - Beth Israel Deaconess Medical Center. He joined the Penn State Hershey College of Medicine in 1998. Dr. Gabbay is a tenured Professor of Medicine at the College of Medicine as well as the Department of Molecular Medicine. He also maintains an active endocrinology clinical practice.
Petrice Balkan, MediQHome Program Manager, Blue Cross Blue Shield North Dakota
Petrice Balkan joined Blue Cross Blue Shield of North Dakota in June of 2008 as the director of the MediQHome Quality Program. Under Petrice’s direction, a state-wide patient centered medical home was established. Today, the program has over 72% of BCBSND’s participating providers participating in the program and over 77% of BCBSND members assigned to a medical home. The MediQHome program has seen significant financial and clinical outcomes improvements and has also received national recognition by receiving The Case in Point Platinum award for the category of Utilization Management Program. Prior to her work at Blue Cross Blue Shield, Petrice was employed by Essentia Health (18 years) as a vice president of practice management and managed care. She was responsible for clinic and hospital revenue cycle management in addition to patient access, contracting, compliance and practice management.
Janis Coffin, DO, FAAFP, CMPE, Medical Director Department of Family Medicine Georgia Health Sciences University
Janis Coffin is a dedicated Family Medicine Physician who continually seeks to improve patient care, to advocate for patient involvement in health care, and to work closely with students and residents to teach them the importance of patient empowerment and appropriate patient care. Under Dr. Coffin’s leadership, the Family Medicine Clinic has been recently designated as a level 3 Patient Centered Medical Home by the National Committee for Quality Assurance. Since the designation award, Dr. Coffin has worked to implement the values and components of the Patient Centered Medical Home into the student and resident curriculum at both GHSU’s Family Medicine Clinic and at the various Family Medicine clerkship and residency teaching sites through activities associated with a recently awarded departmental Academic Administrative Unit Heath Resources Service Administration grant.
In her work with students, Dr. Coffin has served in the capacity of Director of the Women’s Free Health Clinic that is a student run clinic from 2005 to 2008, member of the Faculty Senate Student Promotions subcommittee since 2006, interviewer for the School of Medicine admission applicants since 2007, academic advisor for medical students since 2005, and 1st and 2nd year advisor since 2006. Her teaching roles have included Essentials of Clinical Medicine Physician Diagnosis Instructor since 2008, Essentials of Clinical Medicine Communications Lab preceptor since 2009, and Salvation Army Homeless Clinic preceptor since 2005. Dr. Coffin has received departmental teaching awards from 2007 to 2010 and was chosen as the recipient of the Medical Student Exemplary Teacher award in 2009 and 2010 and was inducted into the Alpha Omega Alpha Society in 2009.
Anne Llewellyn RN-BC, MS, BHSA, CCM, CRRN
Editor in Chief, Case Management Products
Dorland Health, a division of Access Intelligence
Who Should Attend
- Behavioral Health Counselors
- Case/Care Managers
- Clinical Nurses
- Disability management specialist
- Nurse Practitioners
- Managed Care Directors
- Medical Assistance
- Physician Assistances
- Practice Management Professionals
- Patient Centered Medical Home Consultants Social Workers
- $329 per location, unlimited viewing per location, limited to 5 eLearning accounts (a special rate is available for solo practitioners and the military. Please call 301-354-1769 for promo code for a price reduction if you qualify.
- Live Webinar Registration – $329 (per-site fee)
- Webinar Recording on CD-ROM – $329
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URAC has developed its Patient Centered Health Care Home (PCHCH) programs to educate and guide health care practices, and their sponsoring health plans, insurers and pilot programs through transformation into truly patient-centered health care homes. Learn more »
Continuing Professional Education
Nurses: This program is approved for 1.5 contact hours for nurses by Commonwealth Educational Seminars (CES). As an approved provider by the California Board of Registered Nursing (Provider Number CEP 15567), CES Programs are accepted by every State Board of Nursing with the exception of Delaware.
Certified Case Managers: This program is approved for 1.5 contact hours for case managers through the Commission for Case Manager Certification.
Social Workers: This program is approved for 1.5 CE hours for Social Workers. Commonwealth Educational Seminars (CES) is approved as a provider for Social Work Continuing Education (ACE Provider #1117) by the Association of Social Work Boards (ASWB, 400 South Ridge Parkway, Ste B, Culpepper, VA 22701) www.aswb.org. ASWB Approval Period: 10/6/09-10/5/12.
For questions regarding the Webinar or to register by phone, contact Hope Kabik at 301-354-1769.
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How Does the Webinar Work?
The live audio is delivered to your location over the telephone or your computer speakers. The Power-Point presentations are presented over the Internet and are available to print out before the program. This is like a talk-radio program with visuals on the Web. You and your team will be able to have a live Q&A with all the speakers.
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