7:45am – 8:45am Registration, Breakfast, Networking, Poster Session, & Vendors
8:45am – 9:15am Welcome
9:15am – 10:15am Keynote: Paying for Quality Healthcare Across the Continuum
This talk will review new CMS incentive and penalty programs as well as alternative payment models designed to reward physicians, long-term care providers and hospitals that work together to coordinate care for the patients that they share.
Kimberly J. Rask, MD PhD, Chief Data Officer, Alliant Health Solutions
10:15am – 11:15am Plenary Panel: Medication Sustainability Post-Discharge and the Important Role it Plays in Reducing Readmissions
Moderator: Jennifer Hodge, RN, MSBA, HIIN Quality Specialist, Alliant Quality
Shakeerah McCoy, MSN, RN, PCCN, Clinical Nurse Specialist, Transitional Care Program, Nash, UNC Health Care
Ouita Davis Gatton, RPh, Patient Care Coordinator, The Kroger Company
Gina Upchurch, RPh, MPH, Executive Director, Senior PharmAssist
Winnie Walker, RN, BSN, CCM, ACM, Emergency Room Case Manager, Duke Raleigh Hospital
Kathy Reese, RN, Case Manager, Community Care of the Lower Cape Fear
Christina Nunemacher, PharmD, Clinical Pharmacist, Realo Discount Drug
Michael Crooks, PharmD, Care Coordination Task Lead, Pharmacy Interventions Technical Lead, Alliant Quality
11:15am – 11:30am Break
11:30am – 12:30pm AM Breakout Sessions (Choose 1 Session)
Option 1: The North Carolina Way: Early Data from Faith Community and Health System Partnerships
This panel presentation presents findings from a learning collaborative of Wake Forest Baptist Medical Center and six other health systems who have partnered with faith communities to improve care for their vulnerable populations. This work, funded by The Duke Endowment, Kate B. Reynolds Charitable Trust and Northwest AHEC, has explored the impact of faith community partnerships on charity care costs and readmission times at seven hospitals located in both rural and urban parts of the state. Additionally, the project has tested partnership assumptions and characteristics thought to have been responsible for the success of the Memphis Model (a partnership of Methodist Le Bonheur Healthcare and over 600 mostly African-American churches), which was led by Rev. Dr. Gary Gunderson, who was recruited to WFBMC to adapt the model to NC.
Teresa Cutts, PhD, Asst. Research Professor, Wake Forest School of Medicine
Beata Debinski, MHS, Research Assistant, Wake Forest School of Medicine
Gary Gunderson, MDiv, DMin, VP of Faith Health, Wake Forest Baptist Medical Center
Jeremy Moseley, MPH, Director of Community Engagement, WFBMC
Rev. George Dean Carter, MDiv, Southeastern Regional Medical Center
Lisa Marisiddaiah, RN, Faith and Health Ministry Manager, CaroMont Health
Barry Morris, MDiv, BCC, Director of Spiritual Care and Community Integration, Randolph Hospital
Renee Rutherford, RN, FaithHealth and Readmissions Coordinator, Wilkes Regional Medical Center
Option 2: North Carolina State Health Plan Enhanced Transition of Care (TOC) Program
ActiveHealth Management (AHM) provides full population health management services, including transition of care services, to North Carolina State Health Plan (Plan) members who are active, COBRA, or pre-65 retirees. The population targeted for the Enhanced Transition of Care (Enhanced TOC) Program includes members that are at high risk for avoidable readmissions. The focus of our Summit presentation will be to discuss the purpose, implementation, and impact of the Plan’s Enhanced Transition of Care Program as well as continued efforts to achieve program goals. The goals of the Plan’s Enhanced TOC Program include improving member engagement, improving the overall member experience, coordinating care, reducing readmissions, and improving health outcomes. Through the Plan’s partnership with the North Carolina Hospital Association (NCHA) and ActiveHealth Management, strong relationships are being established with local hospitals across the state to integrate and coordinate care transition activities for identified Plan members. This partnership has provided us with an opportunity to receive real-time admissions and discharge feeds on Plan members admitted to participating facilities since January, 2015.
Keya Brooks, MBA/MHA – Network Manager, ActiveHealth Management
Kathryn Keogh, PhD, MSN, RN – Health Systems Clinical Coordinator, State Health Plan
Heema Sinanan, Project and Operations Manager North Carolina Hospital Association (NCHA) Strategic Partners
Option 3: The Healthy Aging NC Resource Center: A Vision of the Future
The Healthy Aging NC Resource Center is a project of the North Carolina Center for Health and Wellness (NCCHW) at UNC Asheville. Our mission is to be a leader and trusted partner in the state to help people meet the challenges of aging. We work with nonprofit organizations, government, clinicians, and businesses to provide innovative community programs and services that meet the needs of North Carolina Older Adults and Adults with Disability. Our current focus is on Evidenced Based Programs for Fall Prevention and Stanford’s Chronic Disease Self Management Programs. This presentation will be an overview of the Healthy Aging NC Resource Center, key partners, ways to become involved and create connectivity across the state. Explanation on how the Healthy Aging Resource center and Healthy Aging NC website can be implemented in the area of Care Transitions.
Jeanne Dairaghi, Chronic Disease Self Management Program Manager NCCHW’s Healthy Aging NC
Nicolle Miller, Director of State and Community Collaboration NCCHW’s Healthy Aging NC
Option 4: COPD Readmission Reduction Pilot
Why is it important? Starting October 2014, the hospitals had to pay a penalty for readmissions under HRRP for COPD readmissions. The HRRP is a reimbursement penalty approach for general acute care hospitals that have readmissions deemed “excess” by CMS. Beginning fiscal year 2013 (October 1, 2012). Reduction is capped at 1% in 2013, 2% in 2014 and 3% in 2015 and beyond. Reductions apply to total DRG reimbursement.
Sejal Patel, MD, Utilization Management Physician Advisor, New Hanover Regional Medical Center
Laura Warrick, RN, Manager of Clinical Services, New Hanover Regional Medical Center Home Care
Tony Bollhorst, RT, COPD Navigator, New Hanover Regional Medical Center
Pam Hagley, , RN, BSN, MSHA, ACM, Director, Clinical Resource Services, New Hanover Regional Medical Center
12:30pm – 1:30pm Lunch: Networking Session and Collaborative Breakout Sessions
Option 1: Networking Lunch
Option 2: Transitioning Home: Improving the Process for Individuals Needing Long-Term Supports
Join a facilitated conversation with fellow professionals passionate about person-centered transitions and quality transitions practices for individuals needing long-term services and supports. During this lunch session you will get an update on where the State of NC is on projects, initiatives, and policy specific to transitions work. You will also help us identify what’s missing and what shouldn’t be overlooked to ensure quality person-centered transitions are a reality in every transition. The NC Community Transitions Institute supported by the NC Department of Health and Human Services’ Money Follows the Person Demonstration Project is sponsoring this luncheon. Space is limited for this lunch session so if you wish to attend please reserve your space here.
Closed Session: The Duke Endowment Care Transitions Collaborative (closed to collaborative members only)
Closed Session: The Critical Access Hospital Quality Improvement and Care Transitions Collaborative (closed to collaborative members only)
1:30pm – 2:30pm PM Breakout Sessions (Choose 1 Session)
Option 1: Readmissions: Moving from Data to Patient Engagement
This program will overview changes in the health care environment, highlighting the shift from episodic care delivery of services to the current model involving linkages to community based partners. Common barriers to the achievement of patient centered care will be outlined with strategies to address them shared. The work of a readmission coordinator, operating in a transitional care model, including the analysis of data collected from patient interviews, will be discussed.
Carolyn Bowen, RN, BSN, Readmission Coordinator, Department of Care Coordination, Wake Forest Baptist Health
Linda Childers, MSW, LCSW, ACM, Manager, Department of Care Coordination, Wake Forest Baptist Health
Alisha T. DeTroye, MMS, PA-C, Director of Transitional and Supportive Care Director of PA Services, Wake Forest Baptist Health
Option 2: HOPE: Easing the Transition from Duke University Hospital to Skilled Nursing Facilities
At Duke University Hospital, geriatric patients being discharged to skilled nursing facilities (SNF) have been identified as high risk for readmission to the hospital. A program to improve post-discharge outcomes for this group is the Health Optimization Program for Elders (HOPE).
Heidi White, MD, MHS, MEd, Associate Professor of Medicine, Geriatrics Division, Duke University Department of Medicine, Medical Director of HOPE
Tammie Shepherd, MHA, BSN, RN, ACM, Director Case Management Department Duke University Hospital
William English, MBA, MSHA, Administrative Manager Duke Palliative Care, Administrator HOPE, Duke University Hospital
Option 3: Moving Forward Together: Partnering with Your Area Agency on Aging for Effective Care Transitions
Did you know there are 16 Area Agencies on Aging in North Carolina? Area Agencies on Aging (AAA) have been in existence for over 50 years and have long been established as the “go to” organization in the Aging Network for assistance and information, training, advocacy and direct services. This session will explore the ways that your local AAA can help to both collaborate and provide services such as Money Follows the Person, Chronic Disease Self-Management, Options Counseling, Home and Community-based Services, and community education. Learn about how strong community partnerships between your organization and your local AAA can be at the core of successfully transitioning the elderly client across the various levels of care and reduce the risk of readmission.
Sara Melton, AAA Director Southwest Commission Area Agency on Aging
Linda Miller, MA, Centralina Area Agency on Aging Director
Julie Wiggins, AAA Director High Country Area Agency on Aging
Option 4: Uniting Advance Care Planning Conversations between NC Healthcare Providers and the Community
The mission of the NC Partnership for Compassionate Care (NCPCC) is to ensure that patients’ end-of-life care choices are openly discussed, documented, and honored. In addition this collaboration aims to provide educational resources to the community and health care professionals to improve the quality of care at the end of life. Attendees will learn about current initiatives at the statewide level to promote greater utilization of the MOST and other advance directives. The Community Partnership for Compassionate Care and the Got Plans? training resources will also be shared as an example of community organizations and healthcare systems working in collaboration at a regional level to advance the understanding and acceptance of advance directives. Our aim will be to inform the attendees on the role of NCPCC in coordinating and disseminating information about the MOST and other advance directives, and to share examples of collaborative efforts.
Linda Darden, MHA, CPA, President & CEO Hospice & Palliative Care Center
Adam Koontz, MA LPC-S Corporate Manager of Advance Care Planning, Novant Health
2:30pm – 2:45pm Break
2:45pm – 3:45pm Plenary Panel: Behavioral Health
3:45pm – 4:00pm Closing