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South County HealthWashington County Coalition established 1/2011
Lynne Driscoll RN, CCM,CPHMDirector of Case Management
South County Hospital
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Washington County – Dr. Bandola Medical Director and PCPDr. Drury Emergency Room PhysicianDr. Hao Huang- Medical Director SCNCDr. Rubenstein-Director of HospitalistsDr. William Sabina- Director, Medical Staff and Medical Director, Emergency room South County HospitalBright View CommonsSouth County Homecare Scallop ShellSouth County Nursing and RehabSouth Kingstown Nursing and RehabRoberts Health CentreApple ClipperBrookdale Assisted LivingWesterly Health CenterApple Watch Hill ManorThe Westerly HospitalHospice-Home and Hospice of RI &Gentiva HospiceCare Managers PCMHHealth centric Advisors
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Medicare Readmissions Data
Medicare Readmissions Data
Lowest readmission rate in the state
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Transfer of information
Pre-medication
Completeness of orders
Pharmacy completing admission and discharge medication reconciliation
Medication Management
Complete and accurate Nurse hand-off Fax prescription to SNF
pharmacy Business plan to SLT for
support of increasing pharmacy resources
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PharmD students completing medication reconciliation in the ED
Residency program set up to yearly projects PharmD student completing rotation with
homecare- joint visit with RN PharmD students rotation in SNFs
University of Rhode Island
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Started in the paper discharge Updated to electronic
Improved legibility Identified opportunity Faxed discharged to SNF, Homecare and PCP
prior to discharge Starting to share EMRs with SNF and Homecare
EMR
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Medication ManagementBehavioral Health Infectious disease
EducationInsurance Sharing IT
URI College of Pharmacy
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Bring people together Team- Multidisciplinary team of the hospital,
NCM of the PCMH, SNF, Homecare, Hospice, Community Health Team.
Communication and transparency is key to opportunity and improvement
Nurse Care Managers Patient Center Medical Home
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Examples: The Quahogger: 85 year-old gentleman who is a “Quahogger” with HF refused VNS at dischargeWhen readmitted, SCHHS used a systematic approach VNS created a reimbursement code to provide services to non-homebound patientsPatient was initially non-compliant with his own prioritiesPatient was a role model for HF self management