Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. For Eligible Beneficiaries Who are Enrolled in Part a and Part B, Part a Finances Post-institutional Home Health Services Furnished During a Home Health Spell of Illness for up to 100 Visits During a Spell of Illness. Part a Finances up to 100 Visits Furn

10/29/2013

  • Advancement of a Consolidated, Patient-Centered Care and Treatment Plan. EMHS has a number of care managers and care management programs particularly for high-risk/high cost patients. Each establish individual treatment plans and frequently coordinate with other program managers. There could be significant value to a comprehensive patient-centered POC that is maintained on a community site (like HIN) when population care management and payment models are used (e.g., accountable care). The care coordinators are trying to get the individualized treatment plans on HIN which could be a first step toward a patient-centered community care plan.

  • Focusing on Medication Reconciliation Challenges. Reconciling medications on admission is a challenge for EMHC. It is a labor-intensive process for the home health nurse to determine what medications a person was on prior to hospitalization and what they should be on after their hospitalization. Engagement of the Primary Care Manager has been helpful, but only applies to limited cases when they are a participant in the PCMH. As HIN and EMHS evaluates processes for continued improvements in efficiency, medication reconciliation could be prioritized.

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