11:15 AM – 12:00 PM

| Tuesday November 6 |

Design of An Effective Discharge Outreach Program

Cynthia Hallam, BSN, MBA, Divisional Director of Clinical Operations
BlueCross BlueShield of Louisiana

Objectives

  1. List and discuss key steps that can be taken to design a discharge outreach program
  2. Explain several reasons why adverse events happen and what can be done to minimize their occurrence
  3. Identify how Milliman Care Guidelines® can be used in the delivery of a discharge outreach program

Discharge outreach programs have traditionally focused on pain management, understanding of discharge instructions, medication adherence, wound care and follow-up appointments. This presentation will outline how the Care Guidelines were used in a discharge outreach program to assess a broader scope of needs, to improve transition of care across settings, and to reduce readmissions for patients discharged with a medical cardiac or respiratory condition.

Using CareWebQISM as a Case Management Documentation Tool

Rebecca Perez, RN, CCM, CPUR, CPUM, Health Services Coordinator
Carpenters' Health & Welfare Trust Fund of St. Louis
Lynn Nemiccolo, RN, Director of Business Product Development
Milliman Care Guidelines

Objectives

  1. Introduce alternative use of CareWebQI
  2. Discover how a case management plan is devised using the Care Guidelines
  3. Observe how the product is used to monitor outcomes and return on investment

In this session the attendee will see how a moderate-sized, self-insured, self-administered health plan for Union workers and their families aggressively provides care management services. A challenge for many years: how to standardize the CM process and documentation? The attendee will see how this fund utilizes CareWebQI to achieve these goals.

Guideline Application When Evidence is Uncertain: Panel Discussion

John Schaller, MD, MPH, Medical Director
Schaller Anderson of Arizona, Inc.
David Evans, MD, Medical Director
ActiveHealth Management, Inc.
Helen Blumen, MD, MBA, Editor
Milliman Care Guidelines

(Repeat Session)

Objectives

  1. Increase understanding of the application of evidence-based medicine to the evaluation of new and emerging technologies
  2. Describe current health care payor approaches to technology assessment
  3. Improve decision-making regarding clinical use of new and emerging technologies when evidence base is incomplete

Kicked off by the co-presenters' description of how they manage areas of medicine where the evidence is uncertain, this session would like to engage the audience in a dialogue that explores the challenges and may lead to take-away strategies or solutions.

1:30 PM – 2:20 PM

| Tuesday November 6 |

How We Implemented Care Guidelines 11th Edition In 60 Days

Kathleen Vinson, RN, BSN, Program Manager Clinical Resources
Melissa Vaughn, Medical Policy Specialist
LaShonda Swoope, RN, Health Care Services Coordinator
Anthony Watts, BS, System Analyst
BCBS of Tennessee

Objectives

  1. Understand the review process when comparing the modified Care Guidelines and the 11th Edition Care Guidelines
  2. Understand the systems and education training process involved with the implementation of the 11th Edition Care Guidelines
  3. Understand the process involved with implementing the 11th edition Care Guidelines software and changes involved--nothing works without this piece

This presentation will provide a description of the planning process and steps taken to implement the new edition of Care Guidelines into the BCBST systems and operations within a two-month timeframe. There are three systems involved and they had to become operational simultaneously.

Care Guidelines 12th Edition Preview

James Schibanoff, MD, Editor-in-Chief and the Care Guidelines Editors
Milliman Care Guidelines

Objectives

  1. Inform the user of the pertinent clinical changes in Ambulatory Care in the 12th Edition
  2. Inform the user of the pertinent clinical changes in Inpatient and Surgical Care in the 12th Edition
  3. Inform the user of the pertinent clinical changes in Chronic Care Guidelines in the 12th Edition

Translating Evidence into Practice: An Australian Experience

Giselle Caron, BHSC, Team Leader
Mater Health Services

  1. Inform the audience of developing models of care based on evidence
  2. Explain Mater Health Services' methodology and results
  3. Discuss challenges, benefits and future directions

More than 50 pioneering, innovative and patient-centered models of care have been implemented at Mater Health Services following an initial pilot in 2003 within the Mater Private Hospital Orthopedic Unit. Surgical, Medical, Oncology, Pediatric and Obstetric models of care have been implemented effectively across our seven hospital facilities. Our models of care aim to improve patient outcomes, facilitate standardized care, and decrease length-of-stay. This has been achieved via the utilization of international evidence-based best practice guidelines (Care Guidelines), and an integrated delivery system on health outcomes. The Care Guidelines incorporate and advocate pre-admission and strong home care support, with a decreased hospital length of stay. The Care Guidelines are focused on the patient achieving Recovery Milestones and moving through the continuum of care accordingly. The patient’s progress is based on the achievement of pre-determined clinical milestones, rather than the effluxion of time (days). Any variations in care or outcomes are recorded on the carepath, and are analyzed and reported to the doctor and clinical team for evaluation. Our Models of Care, through the utilization of carepaths, focus on the involvement and coordination of multi-disciplinary teams and coordinated discharge planning. Extending patient care to outside the hospital campus, early engagement and ongoing education of patients throughout the continuum of care, and streamlining documentation are also key aspects of our program. Improved patient outcomes, standardization of care, decreased length-of-stay, along with increased patient and staff satisfaction are all benefits being achieved daily through the implementation and integration of the Exceptional Models of Care at Mater.

2:50 PM – 3:45 PM

| Tuesday November 6 |

Using Care Guidelines in a DRG Setting

James H. T. Tan, MD, MPH, MBA, CPE SVP, National Medical Director
AMERIGROUP Corporation

Objectives

  1. Explain the difference between DRG and Per Diem Reimbursement Methodology
  2. Explore Opposing Issues between Hospitals and Health Plans in a DRG setting
  3. Discuss how the Care Guidelines facilitate a common goal for hospitals, health plans and physicians

With DRG methodology as a driving force in reimbursement, hospitals are under pressure to improve efficiency. Can the Care Guidelines facilitate a common platform for hospitals, physicians and health plans?

If You Never Ate Häagen Dazs®, Would You Know What You Were Missing?

Nancy Skinner, RN, CCM, Director, Board of Directors
Case Management Society of America

(Session Repeats)

Objectives

  1. Identify issues and barriers to transitions across the continuum of care
  2. Discuss available technologies, evidence-based guidelines, medication reconciliation strategies and adherence gaps that impact the patient's movement through the healthcare continuum
  3. Understand tools, guidelines and pathways that facilitate effective communication between patients

Healthcare today is sometimes fragmented and is not consistently associated with an efficient transition of patient care. Patients can be challenged by an inability to comprehensively understand their diagnosis, implement all aspects of the continuing care plan, or even realize which provider will guide their care as they transition through the healthcare continuum.

This presentation will discuss the future of transition and coordination of care, and demonstrate how a partnership between case/care managers and patients can contribute to advancing desired healthcare outcomes. Provided information will be based on tools developed by the National Transitions of Care Coalition (NTOCC). NTOCC has brought together more than 30 associations and organizations representing stakeholders from various practice settings to address improving care coordination and communication as patients leave one healthcare setting and move to another. NTOCC seeks to be an influential stakeholder in public awareness, education, and health policy so that our health care system will focus efforts on improving the coordination of care among the various health care settings impacting quality of care, reduction of medication errors and enhancing clinical outcomes.

Interrater Reliability (IRR): Increasing Your Organization’s Quality and Consistency

Vikki Choate, RN, CCM, RN-BC, CCP, Director of Training
Bob Conrad, RN, Product Manager
Milliman Care Guidelines

Objectives

  1. Recall the definition of IRR
  2. Define the goals of performing IRR
  3. Describe the desired outcomes of performing IRR
  4. List the various ways in which IRR can be conducted

Healthcare today can be fraught with litigious activity. In addition, regulatory and certification requirements have heightened the need to ensure the consistency of medical management decision-making. These issues have fast become of paramount importance to payors and providers alike. Care management best practice is supported by the use of evidence-based clinical decision support tools and the performance of regular interrater reliability assessments on the use of these tools.

This session will define interrater reliability, establish its importance to care management, and identify the goals for performing these assessments. This session will also demonstrate the use of Milliman Care Guidelines’s Interrater Reliability Tool as one of the ways which these vital assessments can be performed.