Best Practices In Transitions In Care For Case Managers, Nurses, And Physicians

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Transitions in care have become an important component in the treatment of patients. New and advanced payment methods such as bundled payments and accountable care organizations, as well as readmission reduction programs, have drawn more attention to this vital element of patient care delivery. Transitions occur when patients move from one level of care to another, whether within the acute care setting or beyond the walls of the hospital. During times of transition, information transfer is critical, yet handoff communication is sometimes neglected or performed as an afterthought. When this happens, care can be compromised, resulting in poor patient outcomes, readmissions, and higher costs.

This webinar will review best practices in transitioning patients, the pitfalls, communication streams, and the need to keep the patient at the center of the process. We will discuss the relationship between discharge planning and transitions and how these roles work together. Additionally, we will discuss hand-offs, what they are, and how to ensure that you are performing your handoffs in ways that will ensure the best transitions for your patients and their families. Each member of the interdisciplinary care team performs handoffs and has the responsibility of ensuring that they are thorough, complete, and timely.

Learning Objective:

• Understand the differences between discharge planning and transitions in care.
• Describe the best practices in hand-offs and the regulatory requirements associated with them.
• Discuss the risks and poor outcomes associated with inadequate transitions
• Discuss strategies for effective handoffs across the continuum.
• Review ways in which to ensure that your handoffs reflect best practice
• Learn how to engage patients and families in handoffs and transitions in care.
• Develop transitional care plans using best practices.

Areas Covered in the Session:

• Changes in discharge planning
• Moving from discharge to transitions
• Geography of transitions in care
• Definition of the continuum of care
• ACMA Transitions in Care Standards
• Goals of effective transitions
• Transitional planning process
• Transition challenges
• Handoff communication including best practices
• Influences on transition related to patients and families
• Influences related to physician practices
• Influences related to payers and regulations
• Influences related to internal hospital processes
• Influences related to case management
• Influences related to the next levels of care
• Adopting interventions to improve transitions
• Live Q&A Session

Suggested Attendees:

• RN Case Managers
• Social Workers
• Vice Presidents of Operations
• Director of Case Management
• Case Managers
• Directors and Vice Presidents of Nursing
• Directors of Patient Flow
• Director of Revenue Cycle
• Chief Financial Officers
• Chief Operations Officers
• Chief Medical Officer
• Hospitalists
• Director of Quality Management
• Nursing Home Directors
• Director of Home Care\
• Director of Finance
• Case Managers
• Social Workers
• Vice President of Case Management
• Hospitalists
• Physician Advisors
• Directors of Social Work

Presenter Biography:

Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating acute care and community case management models, provides education on case management and related topics, and on-site assistance to case management departments.

The author of nine books, and a frequently sought-after speaker, lecturer, and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.

Before her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. Before her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, at Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.

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