Strategies to Improve Transitions of Care
Expires February 23, 2024
This training will review case studies and examples of successful care transitions implemented by organizations in multiple settings including rural and urban, large organizations and solo practices.
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About this Training
Implementing Strategies to Improve Transitions of Care OnDemand
A fundamental tenet of the medical home is coordination of care across the landscape of a patient’s care journey–this is particularly critical during transition between sites of care, such as from hospital to home. PCMHs excel at building clear and open communication among patients and families, the medical home and members of the broader care team (https://pcmh.ahrq.gov/page/defining-pcmh). They also focus on the exchange of information between providers and between the practice and other care settings, for patient safety and to ensure that clear communication processes are in place so patient needs are addressed promptly and efficiently. Avoiding duplication of services with comprehensive, coordinated patient care moves the practice in the direction of the high-quality, cost-effective outcomes sought by patients and payers alike.
Join NCQA faculty and an NCQA 2020-2021 CCE Quality Award Winner for a review of key strategies that can improve transitions of care and a discussion of NCQA’s PCMH Care Coordination standards, causes of ineffective care transitions and best practices for building a care transitions program and improving overall care management.. This OnDemand will also review case studies and examples of successful care transitions implemented by organizations in multiple settings including rural and urban, large organizations and solo practices.
What You Will Learn
At the conclusion of this course, participants will be able to:
- Describe the Intent Behind the Transition of Care Criteria.
- Answer Common FAQs for CC 14-19
- Understand Transitions of Care from a Deep Dive Study.
Who Should Attend
- Primary Care Teams.
- Practice Managers.
- Health Plans.
Jennifer Anglin, MS, CHES, PCMH CCE
Jennifer Anglin is a Manager of Recognition Policy at NCQA. Her responsibilities include creation and maintenance of PCMH resources and providing support to practices going through transformation or annual review. Prior to NCQA, Jennifer worked for Purdue University by assisting practices throughout the state of Indiana on quality improvement and research projects as well as supporting them to meet Medicaid’s Promoting Interoperability program and Medicare’s MIPS program. Jennifer’s professional interests include health policy,, research, and education. She has a particular interest in social determinants of health and the behavioral health aspect of Patient-Centered Medical Homes.
Jennifer holds a BA in secondary education from Valparaiso University and a master’s degree in health science from Indiana State University. Jennifer is a Certified Health Education Specialist and has been an NCQA Patient-Centered Medical Home Certified Content Expert (PCMH CCE) since 2013.
Bonni Brownlee, PCMH CCE, MHA CPHQ
Ms. Bonni Brownlee is a healthcare management professional with over 25 years of experience in health program development, clinical operations, and performance improvement. For the past 14 years, Bonni has focused her attention on clinical practice transformation, providing expertise in practice redesign and evolution towards the Patient-Centered Medical Home (PCMH) model of care to countless primary care associations, clinical practices, health systems and health plans. Bonni was a member of the TransforMED faculty for the first documented medical home initiative (the National Demonstration Project), coaching 18 family practice teams on practice redesign strategies to improve access, efficiency, and quality. Bonni directed The Commonwealth Fund’s Safety Net Medical Home Initiative in its first two years, then served as advisor to the Qualis Health leadership team as well as a field consultant to the 65 participating clinics on their journey towards becoming high functioning medical homes. In addition to her work in clinical practice transformation, Bonni provides clinic operations expertise to HIT strategic planning, EHR system selection and implementation, electronic referral systems, telemedicine programs, and community-wide health information exchange initiatives.
Ms. Brownlee has supported over 250 primary care practices in their applications for NCQA PCMH recognition; she is also an NCQA-contracted PCMH application evaluator. She served on the advisory panel for The Joint Commission in the development of their Primary Care Home (PCH) standards which accompany the Ambulatory Care accreditation package and has trained many FQHCs on Joint Commission standards for ambulatory and laboratory services. Bonni has additionally served on multiple task forces and advisory panels in applied research on primary care quality improvement methodologies, including practice coaching.
Bonni currently supports hospitals and health systems in clinical transformation through the national Medicaid redesign program known as DSRIP – Delivery System Redesign Improvement Program. In addition, her consulting role supports strategic planning, program development, integrated care design and implementation. She is leading several regional collaboratives on care transitions, synthesizing inpatient and outpatient care to provide seamless, high quality care to patients as they transition between care environments.
Ms. Brownlee has a master’s degree in healthcare administration from the University of San Francisco and carries the CPHQ (Certified Professional in Healthcare Quality) credential. She has earned the PCMH CCE (Certified Content Expert) credential from the National Association for Quality Assurance (NCQA). She has a clinical background in medical technology. Ms. Brownlee is a 2020-2021 PCMH CCE Quality Award Winner.
In support of improving patient care, the National Committee for Quality Assurance is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), the American Nurses Credentialing Center (ANCC) to provide Interprofessional Continuing Education for the healthcare team.
This activity was planned by and for the healthcare team, and learners will receive 1.0 Interprofessional Continuing Education (IPCE) credit for learning and change.
This educational activity is approved for: 1.0 AMA PRA Category 1 CreditTM.
This educational activity is approved for 1.0 nursing contact hours.*
This live course grants 2.0 required Continuing Education Unit (CEU) points for PCMH Certified Content Experts.
* Please note – You must attend the entire program to be eligible for total number of contact hours.
ATTENTION: Effective February 1, 2022, this on-demand (enduring material) activity no longer offers credits for the American Academy of Physician Assistants (AAPA), the American Psychological Association (APA), or the Association of Social Work Boards (ASWB). Only applicable professionals who fully completed this on-demand activity prior to February 1, 2022, are eligible for AAPA, APA, or ASWB credits. No other CEUs are impacted by this change.
Disclosure of Relevant Financial Relationships
The National Committee for Quality Assurance (NCQA) endorses the Standards of the Accreditation Council for Continuing Medical Education which specify that sponsors of continuing medical education activities and presenters at and planners for these activities disclose any relevant financial relationships either party might have with commercial companies whose products or services are discussed in educational presentations.
For sponsors, relevant financial relationships include large research grants, institutional agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution. For presenters or planning committee members, relevant financial relationships include the receipt of research grants from a commercial company, consultancies, honoraria, travel, or other benefits, or having a self-managed equity interest in a company; or having an immediate family member or partner with such a relationship.
Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.
Relevant financial relationships exist with the following companies/organizations:
Jennifer Anglin: None
Bonnie Brownlee: None
Additional Planning Committee Member:
Caroline Blaum: None
Tracelyn Thigpen: None
Ashley Turner: None
This program was developed in part by NCQA staff.
This program received no commercial support.
- Self Paced
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