Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research

1. Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research

2. Patient Care Transition • Care transition paths funnel through primary care physician • Common risk stratification method • Common care planning and patient action plan techniques • Common method of measurement tracking for results • Lean process improvement methods used to develop processes and improve access Inpatient ER Community Screenings

3. Patient Care Transition • Pre-Discharge Orders • Risk Analysis for Readmission • Project Red • Scheduled PCP Appointment • Post Discharge Phone Call • Readmission Data and Analysis Team • Lean Kaizen to Improve Process Inpatient Discharge Planning

4. Patient Care Transition • Pre-Discharge Orders • Risk Analysis for Readmission • Project Red • Scheduled PCP Appointment • Post Discharge Phone Call • Readmission Data and Analysis Team • Lean Kaizen to Improve Process Inpatient Discharge Planning EMR Medical Home • Missouri Medicaid Collaborative and PCMH • High Risk Identification • Pre-visit Planning • Care Plans • Patient Involvement • Standing Orders • Templates • Data Collection for Outcomes • Lean Tools Used to Improve Patient Flow

5. Patient Care Transition EMR Medical Home ER Care Continuity Software • Missouri Medicaid Collaborative and PCMH • High Risk Identification • Pre-visit Planning • Care Plans • Patient Involvement • Standing Orders • Templates • Data Collection for Outcomes • Lean Tools Used to Improve Patient Flow • Patient Stratification • Patient PCP Identified • No PCP Patient Referral • Kaizen to Develop Processes

6. Patient Care Transition EMR Medical Home Care Continuity Software • Missouri Medicaid Collaborative and PCMH • High Risk Identification • Pre-visit Planning • Care Plans • Patient Involvement • Standing Orders • Templates • Data Collection for Outcomes • Lean Tools Used to Improve Patient Flow Community Screenings • Patient Stratification • Patient PCP Identified • No PCP Patient Referral • Kaizen to Develop Processes • Community Health Needs Assessment • Community Collaborative • Risk Identification • Community Needs Mapping

7. Patient Care Transition • Pre-Discharge Orders • Risk Analysis for Readmission • Project Red • Scheduled PCP Appointment • Post Discharge Phone Call • Readmission Data and Analysis Team • Lean Kaizen to Improve Process Inpatient Discharge Planning EMR Medical Home ER Care Continuity • Missouri Medicaid Collaborative and PCMH • High Risk Identification • Pre-visit Planning • Care Plans • Patient Involvement • Standing Orders • Templates • Data Collection for Outcomes • Lean Tools Used to Improve Patient Flow Community Screenings • Patient Stratification • Patient PCP Identified • No PCP Patient Referral • Kaizen to Develop Processes • Community Health Needs Assessment • Community Collaborative • Risk Identification • Community Needs Mapping

8. Thank you