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Managed Care Academy Boot Camp 2: Transitional Care within Population Health - Integration, Process, Performance and Finances
posted 02.03.2016
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Managed Care Academy Boot Camp 2: Transitional Care within Population Health - Integration, Process, Performance and Finances

Tuesday, March 22, 2016
9:00 AM - 10:30 AM

Room: Thurgood Marshall North

CEU Credits: 1.5

Jessica Grabowski, LCSW, Director of Social Services at Aging Care Connections, oversees all of the social services departments including The Bridge Model of Transitional Care which is located at the Adventist La Grange Memorial Hospital and 6 surrounding skilled nursing facilities. She is involved in program quality improvement including data collection and evaluation, and readmission reviews with the partner hospital. She received her MSW from University of Chicago and BA from Indiana University.              

Walter Rosenberg, MSW, LCSW, Manager of Transitional Care at Rush University Medical Center, supervises a team of clinical social workers, oversees financial and operational planning for the department, conducts program development and evaluation, and provides clinical services. He serves on the hospital-wide Readmission Oversight and Adults with Intellectual and Development Disabilities committees, and leads the Impact and Innovation group.  He is a lead trainer for its Bridge Model of transitional care and serves on the advisory board of the Dominican University Graduate School of Social Work. He received his MSW and BA from the University of Illinois at Chicago.

Sharon Post, Director of Long Term Care Reform at Health & Medicine Policy Research Group, which provides operational support for the Bridge Model, as well as contributing policy analysis on transitional care, readmissions, long-term services and supports, and Medicaid/Medicare.  Sharon also leads the Center’s Behavioral Health-Primary Care Integration Learning Collaborative and directs its policy research in the areas of aging, disability, and managed care. She received a BA in Social and Historical Inquiry from Eugene Lang College, the New School for Liberal Arts. 

Walter, Jessica, and Sharon are Program Managers at the Bridge Model National Office, heading its model development, quality improvement, and community partnership efforts.

Why this topic?

Over 50 sites across the country currently replicate The Bridge Model, a social work-based transitional care intervention designed for older adults discharged from the hospital back to the community. For six sites that implemented Bridge as part of a single Medicare Community-based Care Transitions Program (CCTP) in 2012-2014, the Bridge Model consistently decreased 30-day readmissions and mortality, increased physician follow-up, and decreased patient and caregiver stress. Recent data shows readmission decreases between 20-40% (depending on the target population). In addition to impacting utilization and patient satisfaction outcomes, the Bridge Model National Office has focused its efforts on lean processes and flexible integration of transitional care into inpatient, outpatient and community-based settings, developing a standardized performance dashboard for monitoring quality and fidelity.

As health care across the country continues to move in the value-based direction, population health and care coordination strategies are increasingly gaining momentum. On-the-ground clinical experience in concordance with research has shown us that patient engagement and self-efficacy are important tools to build upon when integrating person-centered transitional care into population health strategies.  Increasingly, payers are recognizing the need to link clinical and community-based service providers to address inter-related medical and social needs in order to achieve population health goals and manage costs. Social work is uniquely poised to serve a critical role in this environment due to the person-centered approach, psychosocial therapeutic techniques, and the comprehensive lens it brings to patient assessment and intervention. We will specifically discuss the Bridge Model of transitional care, and highlight its approach to key elements of population health, including quality improvement, hospital-community collaboration, operations, and financial sustainability. 

What you will gain from this session?

People who attend our session will gain a meaningful understanding of national population health efforts on a conceptual and practical level. Policy and financial background will be provided for further context. The role of psychosocial and social determinant of health issues in population health, as well as how to approach sustainability for programs addressing them will be explored within the transitional care model. By the end of the session, our goal is for people to understand what population health approaches are most appropriate to their specific agency or organization, and the process and financial data they would need to become part of these efforts.                 

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