Browsing: care transitions

CMSA Foundation
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The Pathway Home™ Program Revisited: Update on the Recipient of the 2019 CMSA Foundation Award for Case Management Practice Improvement

BY BARRY GRANEK, LMHC, PAMELA MATTEL, LCSW, AND GERALDO RAMOS, MSW, MPA
Pathway Home™ was launched in 2014 with a mission to provide essential care transition support to individuals navigating critical healthcare transitions. The Case Management Society of America Foundation is a non-profit organization advancing the practice of case management by promoting research and process improvement through grants and awards. The foundation has been making an impact on the practice of case management resulting in health improvements for individuals receiving services. In 2019, Pathway Home™ was honored with the 2019 Case Management Practice Improvement Award and accepted the honor in Las Vegas during the annual CMSA conference.

Transitions of Care
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A Road Less Traveled: Bridge to Home

BY JENNIFER CLINE, PT, DHSC, MS, AND SHONA METCALF, RN, BSN, MSN, CCM, IQCI
Carolinas Medical Center (CMC) in Charlotte, North Carolina, a facility of Advocate Health, has a Bridge to Home (BTH) program, which serves unfunded or underfunded patients by giving them two to three hours of therapy daily for approximately two weeks.

Social Determinants of Health
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CalAIM — A Lesson in Transition

BY SUSANE HAO, RN, MSN, CLCP, AND THERESA HERNANDEZ, CCM
Healthcare providers and case managers encounter patients who experience a combination of barriers related to social determinants of health (SDoH) that make it difficult for patients to manage their chronic medical conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes mellitus, hyperlipidemia, hypertension and depression.

Care Coordination
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Case Management Leads the Team in Transitions with Patients with Substance Abuse Disorder and Infective Endocarditis

BY BETSY STOVSKY, RN, MSN, AND MARY McLAUGHLIN DAVIS, DNP, NEA-BC, ACNS-BC, CCM
Patients with infective endocarditis (IE) due to opioid substance use disorder (SUD) and injection drug use (IDU) present to the acute care setting with a myriad of surgical, medical, psychiatric and social problems. The complexity of this patient population requires an experienced team of healthcare professionals to provide the care they need from admission to discharge. Case managers, as leaders in population health, patient advocacy and continuity of care, are important members of the multidisciplinary team to care for this patient population.

Care Corner
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Have You Heard About a Hospital at Home Program?

BY SANDRA ZAWALSKI, MSN Ed, RN, CRRN, CCM, ABDA, MSCC
A new level of care has emerged in the healthcare world called Hospital at Home, despite this level being used for several years. Hospital at Home (HaH), is a healthcare model designed to provide acute-level services in a home environment that clients would normally receive in a hospital setting.

COVID-19
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Covid Waivers 1135 in the Year 2023: Will They Continue?

BY JENNY QUIGLEY-STICKNEY, RN, MSN, MHA, MA, CCM, ACM-RN, CPHM, CMAC
CMS 1135 pandemic waivers give healthcare providers throughout the COVID pandemic the ability to relax legal standards for Conditions of Participation and transitions of care. Allowing the healthcare industry flexibility with current CMS Conditions of Participation rules for managing transitions of care has increased fluidity and speed of transition for patient care.

Telehealth
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Innovations in Telehealth for Care Teams

BY BARBARA ROBBINS, RN, BSN, MB
The COVID-19 pandemic led to great growth in virtual collaborative care teams with telehealth tools. In one study, the use of telehealth tools in February 2021 was found to be 38 times higher than pre-pandemic levels and a catalyst to home care.

Care Coordination
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COVID-19: Impacting Hospital Readmission With Focused Care Transition Calls

BY KATHLEEN (KATHY) PARRY, BSN, RN, CCM
The past 2 years have turned the healthcare industry upside down. The COVID-19 epidemic has impacted the industry in ways no one could have imagined. Rapid change in the healthcare environment meant switching from in-person work to remote work where case managers led the way by engaging patients as they transitioned through the delivery system from inpatient through the next level of care.