Overview:

Key to the development of care transitions programs is the understanding of the changes in reimbursement that led to their creation. We will briefly discuss this backdrop for the development of a care transitions program. A variety of care transitions models that have been piloted will be presented. The benefits that have been demonstrated through research will be reviewed. This leads us into an overview of the reasons for developing a collaborative care transitions program and a discussion of who should be involved in such an endeavor for it to be successful. Finally, a case study of a collaborative care transitions program will be used as an illustration.

Why should you attend: The continuing change in reimbursement models, as well as the increase in the use of pay for performance, necessitates assuring that patients are followed through the continuum of care. Understanding the models that have been developed to support a patient through their transition in levels of care is critical to the success of hospitals and post-acute care settings. In addition, the implementation of care transitions models enhances quality of care and improves healthcare outcomes. Collaboration between hospitals and post-acute settings in the development of care transitions programs is an effective method for addressing this gap in care.

Areas Covered in the Session:

• Reimbursement changes impacting the development of care transitions programs
• Description of various care transitions models
• Who should be involved in the development of a collaborative care transitions program
• Case study of a collaborative care transitions program

• Hospital CEO, COO, CNO
• Home Care CEO, COO, CNOs
• Discharge Planners, Utilization Review Nurses and Social Workers
• Skilled Nursing Facility Administrators and DONs
• Physicians
• Care Transitions Coordinators
• Community and Parish Nurses