the tahoe carson valley transitions in care collaborative n.
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The Tahoe/Carson Valley Transitions in Care Collaborative

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  1. The Tahoe/Carson Valley Transitions in Care Collaborative “A Solution for Improved Care Management in Rural Environments”

  2. CMS GOAL: Proactively manage 10% of the 50% (CMS 2009 Hospital Referral Region Data) Cost Per Medicare Beneficiary

  3. Our High Risk Populations • Congestive Heart Failure * • Pneumonia * • Chronic Obstructive Pulmonary Disease • Diabetes • Elderly patients with co-morbidities * (No Medicare Payment for 30 Day Readmission Effective October 2012)

  4. The Transitions in Care Option

  5. The Four Pillars Dynamic Patient-Centered Approach Medication Self-Management Physician Follow-up RedFlags http://www.caretransitions.org/structure.asp

  6. A Regional Concept Epic

  7. Nurse Remote Care Center Broadband T.I.C. Provider Nurse Remote Call Center

  8. A Regional Concept T.I.C. Home Monitoring T.I.C. T.I.C. Epic

  9. “Prevent the Financial Bleed” Just “one” chronic disease preventable readmission per month can impact your bottom line Averaging government and commercial payors from actual Barton Health cases shows: $11,859.50*/month = $142,314annual impact(*not a fully loaded cost) We must control the bleed to demonstrate efficiency while improving quality in care

  10. Integrated Delivery Through Rural ACO Model ACOs…groups of doctors, hospitals, and other health care providers coordinating high quality care for patients. Care coordination leading to service duplication prevention and error avoidance. Success equals high-quality care and efficient spending of health care dollars.

  11. Benefits for Rural Health Communities • Lowering our cost of care, offsetting expected potential inpatient revenue losses due to reimbursement changes. • Achieving savings from CMS, through providing Medicare beneficiaries quality and patient satisfaction. • Gives all of us alternative options for survival other than becoming part of a larger established health system entity. (http://www.cms.gov/affordable-care-act-in-action-at-cms.html)

  12. Rural Provider Survival