ACUTE CARE TEAM UDATE
By Annie Deaver, LMSW, Acute Care Project Manager; and Janet Stoeckl RN, CCM, Clinical Director
As DSRIP Q3 turns the page, Millennium’s Acute Care Team has been keenly focused on supporting our hospital partners as they complete deliverables due in March.
Our hospital acute care partners include:
- Brooks Memorial Hospital – Dunkirk, NY
- Cuba Memorial Hospital – Cuba, NY
- Eastern Niagara Hospital – Lockport, NY
- Erie County Medical Center – Buffalo, NY
- Kaleida Health – Buffalo, NY
- Niagara Falls Memorial Medical Center – Niagara Falls, NY
- Olean General Hospital – Olean, NY
- TLC Health Network – Irving, NY
The Acute Care Team has expanded our supportive reach throughout Erie, Niagara, Chautauqua and Cattaraugus counties.
As a team, we are excited that our reach continues to grow as we provide needed support to our attributed Medicaid patients — we understand this population needs additional supports to have better overall health outcomes. To this end, we have developed an “Inclusive Acute Care Strategy” that will enable our team to provide optimal support to our acute care partners. Because each hospital serves a different population of patients (i.e. urban, suburban and rural), we have an overall strategy which considers the differing counties in which the site may serve.
The “Inclusive Acute Care Strategy” includes facilitating a monthly acute care workgroup where our partnering hospitals can be supported through the Performing Provider System (PPS) as they share best practices with one another. To date, Olean General Hospital has shared elements of improving transitions of care and reducing 30-day hospital readmissions with other partners.
Additional topics that have been discussed include “Population Wide Bed Reduction Plan”; “Workforce strategy”; and “Learning Management” application for required project trainings. The workgroup also provides the occasion for sites to learn how Millennium can provide support through the remainder of DY2 and beyond.
Upcoming acute care workgroup meetings are at 8 AM on Feb. 16 and March 16, 2017. We encourage all of our hospitals to participate in these meetings!
The “Inclusive Acute Care Strategy” also includes developing quality improvement approaches to help hospitals focus on high performing measures; effective care coordination and effective transitions of care.
We have identified that some of our acute care partners need support helping patients transition from the hospital to the next level of care.
Areas of focus include:
- HEALTHeLINK training on patient queries.
- Care Continuity Documents (CCD), an electronic document exchange standard for sharing patient summary information.
- Health Home integration… by educating and connecting our hospital partners with health homes will support Medicaid patients who are high need/high cost stay healthy and stay out of the Emergency Department and hospital.
Millennium’s Acute Care Team is providing support through regular touch points with each hospital as they see fit. Our ongoing objective is to support our hospital partners and ensure their success in reaching DSRIP deliverables.