And now I would like to introduce our speaker to get us started with part four this morning. Dr. Tony Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. Thank you so much for being back here with us this morning, Dr. Sesta, and we invite you to go ahead and kick off part four for us. Thanks, Lindsay. Welcome back, everybody. I can't believe it. We made it to part four. You guys are doing great. Not easy, I know, particularly on a busy day. So I do thank you for your ongoing attendance with our boot camp series, and today it's all about transitions in care. But what I did was I dovetailed transitions in care with the continuum of care, lots of care words here today, case management and the continuum and transitions. And, you know, it also all bumps up with discharge planning and also with utilization management. And as you start to see how these pieces fit together, as we take it beyond our basics, you begin to see how the silos really don't work because all of these pieces, they're like puzzle pieces. They kind of have to, you know, fit together in order to work optimally. So let's get started then, and I'm going to start talking a little bit about the continuum of care. And I have that infinity symbol in the middle there because when you do think about the continuum, and you're going to think about it essentially during two times. One would be during your planning for discharge, and the other one would be during that transition. And so we're going to look at many more specific examples. But patients, you know, they move in and out of these different levels of care at any point in time, and therefore, you know, you can't say it starts here or it starts there. Okay. I also wanted to give you some definitions because I like to level the playing field a little bit and say, what is this thing, the continuum of care? So in medicine, it describes the delivery of health care over a period of time. In patients with a disease, this covers all phases of illness from diagnosis to the end of life. So delivery of health care from, you know, there was an old expression, cradle to grave, womb to tomb, you know, if you remember those from back in the day. But essentially, the continuum does that. It's a concept involving an integrated system of care that guides and tracks patients over time through a comprehensive array of health services spanning all levels of intensity of care. So that one to me kind of says a little bit better, you know, it's an integrated system because all these pieces have to, again, fit together, and patients move in and out of them at different points in time. So it guides and tracks patients over time through physical health, mental health, and social services spanning all levels of intensity. We did a webinar series a couple of years ago for an integrated mental health program. Well, it was a bunch of hospitals, mental health hospitals through the South. And you know, as I did my research, I saw how integral mental health is to physical health. And we all kind of know that, but I think, you know, it becomes more obvious when you start to think about this continuum. And then, of course, social services and CMS, Centers for Medicare and Medicaid, and Medicare in particular is pushing us toward more of these social determinants to get us to think more about the social services side of the equation. So when you're thinking about your patients, particularly across the continuum, you want to think about those three things, physical, mental health, and social services. The continuum includes those services, but also the integration of those services. And case management is the chief integrating mechanism. So you can have all of these services, and all of these services can kind of be disparate, standalone from each other. But when you really want to talk about a true continuum of care, you have to have a way to bring those pieces together to integrate them, and that's the role of case management. So I kind of thought about it for a while. What would I put down on the continuum of care service list? And this is what I came up with, but you know what? We're going to look at an even more intense list than this in a few minutes. But when you look at this list, I think I hit, you know, a good number of the more commonly used services that you're going to hit on that continuum of care, but, you know, it's a lot. We have so many opportunities today. So what are the goals of the continuum of care? It depends on where you're looking at it from, where your vantage point is. For those of us in the hospital, of course, and even post-acute, we want to reduce costs, and we want to do that by reducing length of stay, reducing inappropriate admissions, and readmissions. So those are your really, you know, fundamental ways of reducing costs. Improving quality of care, of course. Now capturing market share and managing risk fall more into, well, market share is something every hospital wants to do, because if you really think about it, you know, the idea is to hold patients, to keep patients in your continuum, whatever that might be, and manage risk at the same time. So if you're going to have patients bopping in and out of these different services across the continuum, then you want to make sure, you know, that you're managing them as best as you can. Product lines, you know, you want to have a lot of product lines in your continuum, and you want to recruit and retain staff by providing an environment that's more, you know, conducive to feeling good about the work that you do. So now let's look at the continuum from a cost basis. So we have lower-cost services here, so we have self-directed, so the patient is under their own control and they're managing themselves. And then you might have prevention through social determinants of health management. So by helping folks manage their social determinants, maybe it's food insecurity, it's transportation, it's medications, by addressing those kind of things, you can help to keep a patient self-directed and not have their cost of care go up, basically. And then you have primary care, and you have physicians and allied health also under primary care. Moderate cost. Now why do we go through these costs? Because when you're doing a discharge plan, as we've talked about in other webinars, when you're doing that, what you want to do is you want to think about all these different services, but you also want to think about the service that will meet that patient's need at the lowest cost possible. So that combination, that thought process, is what kicks in when you need to have a comprehensive understanding of all these different services available to the patient. And have that crucial discussion with your physician when you need to consider some other level of care. So under the moderate cost, you have secondary, subacute care, specialists, outpatient clinics, and home care. So any one of these can be higher cost, but generally speaking, those fall into the moderate cost. The other thing to always consider is the cost always relates to the frequency of use of the particular service or the duration of use of the particular service. So again, these are aggregates. And then we have higher cost. Of course, tertiary care, hospitals, emergency departments, and centers of excellence fall higher cost as does acute rehab. And those behavioral health institutions. Now some of you may work in a quaternary hospital or health system. What is that? That's a tertiary. You take tertiary and then you add on advanced trauma, subspecialty services, organ transplants, and long-term services. And so that's where you get that quaternary. And then you've got your nursing homes, which also can be higher cost, again, depending on the situation. And then, of course, your outpatient side. On the acute side, ambulatory surgery centers. Oh, my gosh. I mean, how much surgery? That used to be a long hospital stay are now doing ambulatory. It's unbelievable. Emergency departments and urgent care centers all can be acute and all outpatient. And then, of course, rehab. So for rehab on the outpatient side, of course, you have to think about your physical therapy, your occupational therapy, your speech and swallow, and home physical therapy, occupational therapy, speech and swallow, and PT. So you might be going to a rehab place, or you might be getting your rehab at home. Restorative, so what does restorative care mean? And it's also something for you to think about on that outpatient side. So restorative follows rehab. What does it mean? It's kind of not what it sounds like. Restorative simply means once that patient reaches the best level of functionality that they can, that you maintain that level. And that can be done with home therapy or outpatient therapy or other services, perhaps, that that patient might need. So restorative is like if patients hit their baseline, but we don't want them to deteriorate. You can think of it almost as maintenance. Skilled, falls under outpatient, of course. Home care, hospice, infusion dialysis centers, and then your custodial services. Now you may remember if you participated in our discharge planning webinar, CMS, Medicare, is now expecting us not only to provide the clinical services a patient might need after discharge, but also to consider other non-clinical services that that patient might need. So it could be some of these custodial things, homemaker services, home-delivered meals, daycare, other primary care or family care services out in the community. So you've got to think about those non-clinical issues that the patient may be addressing and make sure you document those. I always say, for the most part, case management is episodic. What do I mean? Well, I mean that, you know, we're going to treat a patient as an individual case manager for an episode of care, and then we're going to transition our patient to somebody else. So when you're treating a patient as a case manager in the hospital, that's obviously episodic. Home care is episodic, even rehab is episodic. The only time in which, and we're going to talk about this, you want to think about case management as not episodic is in the community. If I'm a community case manager, maybe working in a patient-centered medical home, for example, well, I'm going to follow that patient. They may go in the hospital and come back out or get home care, but I still have overall responsibility for that patient. So case management is an across-the-continuum solution, and it really is what you're going to need in order to be sure that patients are getting the right level of care across that continuum and any other services that they might need. So it's really the glue that holds the continuum of care together. I may have mentioned a couple of times ago that some of the early bundled payment programs and accountable care organizations didn't do well because they didn't have that strong case management component. Maybe they gave it short shrift, maybe they didn't understand it, but those were many of the orgs that didn't fare well with these new payment models. You cannot have integrated care without somebody managing those transitions, somebody managing what's happening and when that transition needs to take place, and so therefore it's important really in a truly integrated continuum of care that we have case managers at all of those transition points. We do and we don't. We don't have them everywhere yet, but things have gotten better and better all the time. So we link across all those settings and all those providers. We are that glue. This is a graphic from Healthy Transitions Colorado. They call it the Geography of Transitions of Care, and again, it's kind of like my earlier one with the infinity symbol in the middle. In this case, they've put the patient in the middle, and that's absolutely right, and you can see the back and forth arrows, as I said, so our patients go in and out and back and forth and all around. Now we want to keep those transitions to a minimum as best we can, but that's just the way it is. So where do we, case management, fit into all of this? These next couple of slides are from the ACMA, the American Case Management Association. You may remember I mentioned them as one of the two accrediting bodies for case managers, and they only accredit case managers working in hospitals and health systems. So they listed the case manager's responsibility, advocacy and education, ensuring the patient has an advocate for needed services and any needed education, meaning us. Clinical care coordination and facilitation, of course, and we've talked a lot about coordination of care, coordinating multiple aspects of care to ensure that the patient progresses. Advocacy and transition management, transitioning the patient to the appropriate level of care needed. Utilization and financial management, managing resource utilization and reimbursement for services. Performance and outcomes management, monitoring and, if needed, intervening to achieve desired goals and outcomes for both the patient and the hospital. And next week, we're going to talk about outcomes because, you know, we have this kind of funny, if you will, place that we sit between managing the needs of our patients and also managing the goals of your hospital. And so, you know, we find ourselves kind of in the middle of that. Social management, assessing and addressing psychosocial needs that would include the individual, the family, and the environment. Research and practice development, so as case managers, we have an obligation, a professional obligation to identify any potential practice improvements and use evidence-based data to influence how we do our work. So by attending webinars, that's exactly what you're doing. You're staying up to date on things, but, you know, you're also looking, oh, can I incorporate this or that into my daily practice? So when we think about the continuum and these delivery systems, you know, what we're essentially doing is we're removing these silos. And silos, you know, were around and still are around to some extent, but if you look at this entire list here, you see how in an integrated continuum of care modality that you've got all these different things that integrate or should integrate with each other. So on top we have inpatient hospital visits and all the services and and techniques that we use there as case managers. We have outpatient planned visits based on guidelines. So we'll talk more about that today. How do we case manage patients in the community? Continuity from inpatient to outpatient. You know again those transitions in care. And then follow-up. Who follows up? How do they follow up? When do they follow up? Do we have patient navigators in the community? Community health outreach workers. Lots of titles for those roles. We'll talk about those too. So some of the generic things that we do as case managers. First and foremost we're always part of a multidisciplinary team. And if we're working on the ambulatory side, outpatient side, we're going to risk assess our patients. We're going to develop guidelines and we're going to coordinate their care. Whether you're working with a patient in the hospital or whether you're working with them on the outpatient side, you're always trying to move them to some level of self-management. And that's not always easy with every patient. Obviously some patients are able to self-manage and some patients will never be able to self-manage. So you've got to understand each patient's level of ability to do that. You have to discuss the importance of this. You have to refer them for education or other kinds of programs. And then if they are clinically complex, then they need clinical case management services. And whatever you're doing, you're doing it within a framework that respects their cultural background and allows their cultural background to be part of their care. So what we're doing here is we're really just, you know, respecting our patients. So transitions of care are the platform really for linking across the continuum. So it's the tool. If we're the case manager linking, then the transitions of care are the platform that we use in which to do this. If you do all the things that are listed here, you're really going to improve your transitions regardless of what setting you're in or what setting the patient is going to be going to. So you must have good alignment with the post-acute world. You have to have timely identification of a plan and a good communication with your patients, families, and stakeholders. Integrated electronic records are becoming more and more a thing so that the data that starts maybe with a patient in the hospital moves and is available to somebody taking care of that patient post-acute. Appropriate staffing, appropriate roles, which we talk a lot about, clear and effective policies, and then ensuring appropriate transitions through leadership, mentoring, and auditing. So leaders, we're going to talk about the best ways to transition patients, but you've also got to make sure you audit those transitions so that you know the staff are following a standard that you want them to follow. Okay. Again, here we have some more stuff from the American Case Management Association. They came out with transitions of care standards. So they say, identify patients at risk for poor transitions, complete a comprehensive transition assessment, perform and communicate a medication reconciliation, establish a dynamic care management plan that addresses all settings through the continuum. You know, this can be very difficult to do. One of the things that we did when my department was inpatient case management and outpatient case management was we anticipated where the patient might go. So for example, you might send them to acute rehab, but you know that from acute rehab they're more than likely to be going either to a subacute rehab or even home rehab, and so you can kind of plan that out. You don't have to put every detail, but if you tell the next level of care provider that you're anticipating this patient will eventually be going to subacute rehab from acute, well then you've got a more across-the-continuum look, long-term look at what's going to be happening with your patient. And of course, you want to communicate essential care transition information as that patient transitions or moves, and I'm going to talk about what that means shortly. So what is the planning process for transitioning? Now you're going to start to see now how transitions and discharge planning bump into each other, but they are different, and I think what's happened is that this terminology has become, you know, synonymous one with the other. Some people say transitions, some people say discharge planning. So if you can think of it this way, planning for discharge. Planning for discharge is exactly that. You're planning for the discharge destination for the patient. So you're thinking about and determining based on your patient assessment where that patient is going to go, next level of care, and then the transition itself is the actual movement of that patient from one place to another. So they do bump into each other, they relate to each other, but they are different. So to get to that, you first have to, of course, assess your patient's condition and risks and needs. And so as ACMA said, you might want to look for those high-risk patients. If you have patients that you know aren't going to fare well in the community, well that's the patient you're going to try to get those extra resources for. Development of the discharge plan, including the goals of treatment and disposition. So now I'm working on getting that right destination determined. Implement that plan, maybe make a referral at some point. Monitoring the plan or modifying the plan as things go on in the course of the hospital stay. As we know, sometimes plans change. Confirmation of and final prep for the patient's transition. Now we get to the transition itself, where we transition the patient to that other level of care or to home, and then that follow-up with the patient after that transition takes place. And that's in another important part of transitional planning because, you know, patient leaves the hospital. Well, we don't want to just close the door and say thank you. We really do want to have that follow-up and we'll talk about that. So I thought this was interesting. ACMA put this out. They said that, well actually it came from CMS, but put out by ACMA. Twenty-six billion dollars spent on poor transitions of acute care Medicare patients by CMS per year. Poor transitions, and we're going to talk about what those are. And transitions to not be poor, they're dependent on effective handoffs. So just a couple of interesting comments here. The top one on the right is from the Joint Commission Sentinel event alert. Transfer and acceptance of patient care responsibility achieved through effective communication. That's their definition of a handoff. So it's a transfer and acceptance of the responsibility for that patient. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient's care. I know that's a lot, but that's, you know, all of that really defines really nicely what a handoff is. And the Agency for Healthcare Research and Policy said clinical handoffs, also known as sign-out, shift report, handovers occur in many places along the healthcare value chain. It involves the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person or professional group on a temporary or permanent basis. So when you transfer your patient to somebody else, you are transferring your professional responsibility for that patient to that somebody else. And so when you do that, you want to make sure that you've given them all the information that they need to do that well, to take responsibility and accountability for that patient. So that means good communication during those care transitions. I've got three types of communication here. So we have verbal, and what you want to have with verbal communication during a transition is a systemized method for making sure that the person who's currently taking care of the patient speaks directly to the person who will be the next provider or caretaker. Now in the real world, that's not always possible, and it's not always necessary. But again, if you're doing, if you're identifying higher risk patients who aren't going to fare as well, you want to make sure you've got a really good handoff of information. And then electronically you can do it as well. You can use checklists, making sure that you're accounting for everything that you want to say and send to the next provider. Even timeout forms. Discharge timeout is, you know, a time where you make sure everything has been done. When a patient gets admitted to the hospital, we are very diligent about getting all the correct paperwork done, making sure the patient, you know, the patient's care is transitioned as received, excuse me, as comprehensively as possible. On the opposite end of the spectrum, when the patient is discharged, we're not always quite as diligent. So timeout forms where you essentially make sure everything's done for transition can also be a good tool. And then there's the transitional minimum data set. Minimum data sets can be used in a number of different ways, but they do help to improve communication. And what it means is it's kind of like that timeout form. It's the minimum amount of information that you want to be sure that you communicate, that you don't neglect to include something. So if we always just kind of do it catch as catch can, then, you know, we're likely to forget something in the rush of the day. So it gives you that consistent baseline of information. It can also help to avoid unnecessary admissions or readmissions because you're improving all that communication. And that would really apply to all three of these. Now what's going to happen sometimes, particularly with your higher risk patients, is you're probably going to wind up with a combination of all three of these, or at least two of these. So you really want to think through your transition in terms of what will best suit that particular patient. I can't believe it's back, it was back in 2010, that the Joint Commission mandated standardized handoff protocol. So they basically said what I just said, and that's you want to do it in a standardized, regimented fashion. And they said the transition of care, as well as the transfer of patient specific information by one health care professional to another, with the purpose of providing a patient with safe continuous care. We saw that in the Sentinel event statement as well. This can only be achieved by effective communication, verbal and or written. And I agree with that. And then this, I thought was fascinating, a typical teaching hospital may perform 4,000 handoffs every day. Now that's not just obviously discharges, but oh my goodness, you know, that's a lot of opportunity for things to fall through the cracks for sure. Ineffective handoffs can mean more errors. So as health care is evolved and things are more specialized, there's so many more people involved on a patient's team. And then patients are exposed to more of those handoffs. So it's not just us handing off to ourselves, to each other. Well, the patient gets mixed up in those handoffs sometimes as well. And so that can be confusing for the patient. Ineffective handoffs can contribute to gaps in patient care and breaches or failures in patient safety, including med errors, wrong site surgery, and patient death. So, you know, we see gaps in communication that can result in very negative outcomes. On the other hand, they can, you know, handoffs can be difficult. I mean, yeah, it sounds all really good, right? But it can be hard to do. And we have a very complex environment that we work in. It's dynamic. It's always changing. And so it can be very difficult to communicate. And that's why our first webinar in this series was about walking or bedside rounds. Why? Well, because bedside rounds gives us an opportunity to even handoff and certainly pass information and have the team together without, you know, kind of chasing after people, as we're going to talk about in a second. Some nursing units may transfer or discharge 40 to 70 percent of their patients every day, thereby increasing the frequency of handoffs encountered daily and the number of possible breaches at each transition point. Absolutely. You know, there's been studies done on patients just transferring within the hospital. It's gone down, I'm very happy to say, but I remember at one point they were estimating that one patient might move bed five times, six times, seven times, you know, while they're in the hospital. That's gotten better as lengths of stay have also gotten shorter. But just a imagine, and that it's confusing for the patient too, as well as the health care team, not great. So what contributes to these fumbled handoffs? Well, a lot of safety problems. One study reported by surgeons found that communication breakdowns are a contributing factor in 43 percent of incidents and two-thirds of these communication issues were related to handoff issues. The use of sign-out sheets for communication between physicians is a common practice, yet one study found errors in 67 percent of the sheets. Yeah, that's physicians, but think about it. How is your handoff communication? The errors included missing allergies and weights and correct medication information. Another study focused on near misses and adverse events involving novice nurses. The nurses identified handoffs as a concern particularly related to incomplete or missing information. So ask yourself, would your own handoffs, the way you today do handoffs, would they make the grade? Would you be addressing some of the things that we're talking about here? Are you able to have a standardized approach to your own handoff? And then, you know, I've been talking about chasing after team members for years. I've talked about chasing after team members as one of the big reasons for walking into disciplinary rounds, you know, but there that and to me, you know, that's one of the biggest, but you know, it's a waste of time. We're organizationally complex and so you may have trouble getting to that health care provider. You may have difficulty getting a chance to communicate. Patients will have lots of specialties and clinicians of all sorts. Sometimes you don't even know who they are when you're taking care of a particular patient. It may take time just to figure that out. One study found that only 42% of nurses could identify the physician responsible for the patient in their care. This study highlights the potential gaps in communication among health care providers transferring information about care and treatment. So there's a thought. When you have a standardized handoff protocol, be sure to include who the primary care provider and specialists are. Okay, just a little sip here. Okay, so some implementation expectations for effective handoffs. Well, I say the first one I call right environment. So you want to have interactive communication, so it's not a one-way-I'm-just-talking-at-you. You want to have an opportunity for give and take of information. Second one, right information. So the information you do communicate should be up to date and including the patient's care and treatment and services, conditions, any recent changes, anything of that nature. And then lastly, the right process. So you want to have a process for verification of the received information, repeat back, read back, however you think you need to do it, but you want to make sure that everybody understands what's being said. And rounds, again, is a great way to do that. Other implementation expectations for effective handoffs. So an opportunity for the receiver of the information to review relevant patient historical data, which may include previous care, treatments, and services. Now, interruptions during handoffs are limited to minimize the possibility that information would fail to be conveyed or would be forgotten. So when you're having that conversation, maybe it's a telephone conversation with, you know, the case manager at the rehab facility. You know, you want to do that in a quiet place where you're not going to get interrupted, and you want to give your full attention to that handoff. So we have discharge, and then we have the transition itself. So you want to understand the influences on that particular patient's transition as you go through. So patient, family, and or caregiver, what are the influences on them, especially if the family and caregiver are going to be involved? What are your case management processes that they can influence the transition? If you're not doing a timeout at the point of discharge, if you're not using standardized handoff tools, any of those things are going to influence the transition. Hospital and post-acute processes, how are they related to each other? And physicians can have an influence on the transition, not always positively. Understand which patients are part of alternative payment models and how to collaborate with those case managers, sure. So I mentioned earlier bundled payments and accountable care organizations, and you also have patient-centered medical homes. Now these are, you know, in your what used to be called clinics, and there are case managers in your patient-centered medical home. And, you know, you want to communicate with those folks when you transition a patient who seems to not be able to self-manage particularly well. And then develop strategies for your department during staffing challenges. You know, when you are short-staffed, that's when, you know, you're likely to have an issue with discharge and transition. So leaders, you should always have some kind of a new approach to the work when you need to during a staffing challenge. And as we looked at earlier, we really do need to have case managers at all patient touch points, as I call them. So we've talked about the admission and ED case managers, peri-op case manager for that continuum from presurgical testing right through to the PACU. Inpatient case manager, obviously, and then community case manager. So, again, they might be in a patient-centered medical home, home care, long-term care. We're seeing them more and more across the continuum, and that's the person you want to seek out when you're doing that transition. And then the transitions case manager, which I just wanted to talk about again since we are talking about transitions. So we saw earlier that sometimes, you know, when your patient leaves, you need to follow them because you're concerned about their ability to manage on their own or even with a family member in the community, particularly if they did go home. So you can call these high-risk patients, high-risk for not faring well when they leave the hospital. So the transitions case manager follows them, you know, typically for 30 days after discharge. I've seen some hospitals, you know, do it up to 90 days. That's up to you. Thirty days is the average. They usually follow telephonically, and if there is that community case manager available, they're going to interface with them. So it's not that if, okay, if the patient is being followed by a case manager in the patient-centered medical home, that means that I, you know, I, the transitions case manager, don't need to follow them anymore. Conversely, you just want to keep communicating with them, with the patient, but you also want to interface with the case manager. You want to assess your patients for what will be high risk. So it could be frequent readmissions. So if you have a patient who's in and out of the hospital, in and out of the ED maybe, you know, that's going to be somebody who the transitions case manager is probably going to want to follow. And sometimes you may have specific diagnoses, particularly chronic conditions. Patients with chronic conditions are sometimes, you know, do need that extra support as they transition back out into the community. And then let's just talk now for a few minutes about your internal transfers or transitions, and that's, you know, during the acute care continuum. So we have input, transition component number one. So you have transfers coming in, and when they do, did anybody get some kind of a good handle? Patients coming in from long-term care settings. Patients waiting for admission. So you've got those three buckets or types of transfers that are going to be coming into the hospital or admissions, I should say, they're going to be coming into the hospital. And so when we talked about the admitting case manager, you know, this is like where are we? Where are we in this process? Where do we fit in in terms of doing an initial assessment for the correct level of care? And then we have intra-hospital transfers. So ED to a scheduled unit for admission. Medical-surgical unit. Patient might then go to a higher level of care. They might go to telemetry or an intermediate area, and then they might go to a higher or lower level of care, like critical care, and then they might go to a lower level of care, like the PACU. And then they might start off in a holding area, such as an express unit or a discharge unit, and then go to the next level of care. So, you know, even within the hospital, and like I said, you know, there's been studies done, you know, five, six, seven transfers. You can see how that can happen pretty easily, particularly with a more complex patient. And then, of course, output. So you have basically four different ways a patient's going to go. They're going to transfer to another acute hospital. They're going to discharge to a next level of care facility, or they're going to discharge to a next level of care service, or just home, not just home, but home without any additional services, which would include, hopefully, primary care. So when you're transitioning, the reason I mention this is because when you're transitioning to one of these, your approach might be a little bit different. Is that patient going home in some ways at higher risk than that patient going to another hospital? Sure, because they're not going home with any support system, even if they're going home with home care or just DME. Patients going to another acute hospital or another level of care facility are moving to another support system. So I always think about it in terms of those patients who are kind of going home, and that's, to me, much riskier in a way. Of course, like any process, we do have some challenges that present themselves when we try to do this as effectively as we can. All those multiple providers, again, when that patient is transitioning out to the community, make sure that you communicate with their primary care provider and possibly with a specialist. So that would be your medical patients. Obviously, patient going home after surgery, you may need to communicate with the surgeon's office. You may not. So, again, it depends on the situation. Patient, family, or caregiver decision-making could be a transition challenge, particularly if you're getting a delay from them and they're not, you know, I don't want to say cooperating, but they're not participating as timely, perhaps, as they should. Pay or reimbursement variation also can be a transition challenge, particularly when you have inadequate funding for those next levels of care. You know, those are patients who sometimes wind up staying in the hospital longer than they should. Avoidable days or delays, avoidable delays, can certainly be a transition challenge for you. Readmitted patients, well, what the heck happened? Why is this patient readmitted? If it was a preventable readmission, you really do want to get to that root cause, as we've talked about. Physician practice patterns, you know, oh, let's just let them stay another day. Communication across the continuum and coordination of care, all the things. You might want to make sure you have a good plan with goals. And in the post-acute provider world, you know, we call it compromised care. So you might have a nursing home, a skilled nursing facility with a lot of readmissions or higher cost and length of stay. You want to have some awareness of that when you look at that data with your patient. Or they also might be not too quick in accepting patients. You know, these are quality of care issues that you want to have an awareness of so that, you know, you kind of talk to the patient about that. Lots of influences on the patient's transition. So we're going to go through each one of these influences. Let's start with patient and family, as we just saw. Having done some studies on avoidable delays, I think I've mentioned that one of the biggest that pops up, I mean, first pops up, you know, your internal hospital delay stuff. But the next that often pops up are the patient delays. Excuse me, I should have said family, family delays. Depending on the dynamics within the family, the location of the family, lots of different reasons why you can have some difficulties. But some of the common stuff is whether or not they agree with the plan. Hopefully they do. That's an expectation now of Medicare that the patient agrees with the plan, it meets their goals. The word discharge might turn them off. You know, it sounds so finite. Maybe you want to use the word transition, particularly if they're going to a new provider, you know, a facility or home care. You might want to say, we're transitioning you, and that might sound less finite, less of an endpoint than discharge. Timeliness and decisions, as I was saying, you know, that seems to be one of the big ones, or, you know, bringing in paperwork and things like that. End-of-life decisions, other really difficult decisions that might have to be made that will slow things down, and, you know, you don't want to push patients' families too much on some of these things. Family dynamics, as I said, and geography. So when you've got family who's away or out of town or lives in another state, and you're doing everything by telephone, well, that also can take additional time. As I've been alluding to, these transitions can be difficult for patients and families. So now they've gotten used to one level of care. Now we're going to disrupt that and send them somewhere else. That might be confusing to them. With new providers, new rules, different financial requirements and a new care plan, and so, yeah, I mean, you can see how it can be troubling for them, and so you want to keep that in mind when those transitions are happening. Provide good education, reinforcement, take away some of the mystique, maybe, if they're very nervous about going. So physicians can be our greatest asset when it comes to transitions, and sometimes they can be a barrier. How well have they planned with you for the transition? The word discharge for the physician can sometimes be iffy, ticklish. What are their critical thinking skills around discharge planning? We still work in an environment in which there are financial incentives for medical doctors not to discharge patients. I hate to have to say it, but it's still the truth. So your surgeons get a lump-sum payment for the stay, regardless of how long the patient stays, but your medical doctors bill for each bedside visit. And so if they are a community-based physician, not a hospitalist, then that's potentially a problem. That end-of-life communication, you've got the family trying to make decisions on one end, and maybe you've got the physician on the other end who is dragging their feet a little bit to have that conversation. Delays in getting consults, hospitalist impact can be really good. Hopefully it is. And then are they invested in a post-acute care facility or provider? And then you've got your payers and your rules and your regulations. So on the managed care side, you know, there's a lot of things. Choices. Choices of vendors for next level of care, delays, timeliness, you know, getting all these different approvals that we have to get. And then you might have a self-pay or a flat rate gone bad, or choice delays, you know, patient or payer. On the regulatory side, as we've talked about, there are so many more regulations relating to us, relating to case management than, you know, there had been even just 10 years ago. And so we've got the Balanced Budget Act of, I can't believe that, 1999. Is that right? Oh, my Lord. So we must inform the patient of their right to choose among participating Medicare providers of post-hospital services, respecting their preferences when they are expressed. So, you know, that could be a bit of a delay there. The Medicare Discharge Notification Appeal, one- and two-day stays for observation. So, you know, we have to follow the regulations. We have to be sensitive to our patients' needs and concerns. And so, you know, And try to, you know, move things along as quickly as we can. And then those hospital issues. So patients' transitions, whether it's in the acute care continuum or whether the patient is going to transition to the next level of care, getting everything done. And a lot of this, you know, dovetails with the avoidable delays. These are your internal hospital service delays. And these are things, you know, that we're familiar with. But it also could be a hospital-acquired condition, a safety event. Maybe the patient had a fall. And then all the other tools of the trade, like we've talked about, huddles and care conferences and team conferences. And then when people don't document completely, that can be problematic. And your own departments, your own departmental processes, including those delays that might come. And I mentioned before, what do you do when you've got a horrible staffing shortage? You know, six people got the flu or whatever it is. You know, you've got to consider all of that. What's your staffing model and gender? What does the nurse do? What does the social worker do? What is the relationship between the two? What are their critical thinking skills, their sense of urgency? I should say your. Your case management intelligence and your workload, we don't want to overload you so you can't do anything particularly well. You know, there's that term, let me see if I can get it right, when you have too much work to do, you're going to go a mile wide and an inch deep because you're just barely touching on a hundred different things. Whereas if you have a proper workload, you can go an inch wide and a mile deep. You're going to get deep into the different things that you're doing. And that, of course, is where we want you to be. And so, you know, workload is, to me, a big issue. And then your leadership and are they outcomes focused, data driven? And then that lack of integration across the continuum. And then you've got your next level of care issues. Different use of the next level of care. So you want to make sure you're using all the services available to that patient. And when you're looking at those next level of care providers, look at their use of SNF days. Do they accept patients on the weekend? Is home health delayed in seeing a patient? Is DME delivered on time? Small things to consider that are going to impact on your transition. And so we want to make sure we are aligned across the continuum, as we've been talking about. And I just here, you know, typically I will put the patient and family in the center. But here I just wanted to demonstrate that case management really is holding up all of this. Pre-admission, admission, post-discharge, and community. So we want to align all of that with the patient and family in mind. And so, you know, we have some external solutions to these transitional issues. And while most of you I believe work in hospitals, I think it's important that you have an understanding of what's happening on the community side, so that you can be sensitive to where that patient goes, what that external person needs to know from you, and how that will support you if and when that patient needs to come back to the hospital. So we're thinking about the continuum. So we're not just thinking about inside the hospital, but we're thinking beyond the walls of the hospital. So we have community case management. Now these programs can take place through your hospital, your facility. So if you had a clinic that you're, or a patient-centered medical home that you're now going to develop a community case management program for, well that's owned and operated by your hospital. You might do it in partnership with some community providers where they're creating a case management program. Parish nurse programs, believe it or not, there's a lot of these where volunteers from a particular parish will actually work as community-based case managers. And then you have Medicaid case management programs. Many states have these. The last time I checked, I think about 17 states had some kind of a case management program through the Medicaid program. And this is a very vulnerable population, so to me that makes a lot of sense. So the goal is to empower the patient and family so they know how to access the health system and receive the care they need, providing them education for a healthier lifestyle, decrease costs, and decrease readmissions. So a lot of the goals you're going to see on the community case management side are consistent with the goals that we have on the hospital side. Some of you may be familiar with the website I have on the bottom, Partnership for Patients. And the Partnership for Patients, some of the things that they recommended would include community-based organizations working with local hospitals and other health care and social service providers to support Medicare patients who are at high risk of being readmitted to the hospital while transitioning from the hospital setting. And so that, again, you know, you find your high-risk patient, you transition your patient to a community-based organization, and then they assist patients in staying in contact with their physician. You know, so a lot of times, as we know, patients will leave the hospital and they just kind of fall into a black hole. They don't see the physician, they don't make any follow-up appointments, and so, you know, they're going to get lost out there. So we should have interdisciplinary teams that are involved in risk assessing, developing guidelines for patients, coordinating care, and providing that self-management support. We would discuss the importance of self-management and refer to educators and programs where that might be necessary. So our quick, you know, education with the patient might not be enough. You may need a more formal educational session or a program. Those really complex, clinically complex patients should have a clinical case manager and make sure everything fits into their cultural background, as we talked about earlier. Now what's interesting about community case management is it's not just hospitals that are doing this. Health plans are doing it to some extent. This was anticipated to be a bigger deal than it became when, you know, when we were looking at different types of payment methods. Employers and then providers, employers, big companies. I've consulted with some major, well, in one case it was a company that makes bread, you can figure that out, but, you know, hundreds of employees, maybe 1,000 employees, and it behooves the employer to provide them with some kind of case management so that the employees, you know, continue to work. I mean, let's face it, that's what it's about. So, you know, they have somebody, if they've got diabetes or heart failure or something like that, they've got a case manager to help them manage that and stay as well as possible and continue to work. Sorry. It's true. So, community-based providers, as we've been discussing today, home care, those patient-centered medical homes, rehab, skilled nursing, and MD offices, all fall on the community side. So they want to reduce high-cost and high-volume patients. So it could be measured by length of stay or number of visits. So you see how things kind of dovetail. Improved quality of care and improved patient satisfaction with care. And then which patients do I look for? So if I'm in a patient-centered medical home and we have, you know, I don't know, a thousand patients in my patient-centered medical home, well, I don't think all a thousand patients are necessarily going to need to have intensive case management. So I have to figure out a way to, you know, triage those patients to figure out who needs the most case management services. So you might want to identify your high-risk, high-cost, high-volume groups. It could be a Medicare population, chronic conditions, Medicaid population, underinsured, uninsured, or some other combination thereof that works best for you. Sometimes I've seen community-based providers simply go for patients that have the highest expenditures for a period of time. So they could be in the ED, have been admitted a couple of times, you know, just accessing a lot of services. So you have risk intervention, risk identification, evidence-based interventions, and then managing that patient's outcomes. Risk identification, again, identify people who are at greatest risk for adverse outcomes, and then you stratify into high-risk for case management interventions, and then you refer to the appropriate service. So if they're high clinical risk, they're going to get referred to the RN case manager, and if they're high psychosocial risk, they're going to get referred to the social worker. No matter what, the nurse case manager and the social worker have to work together, collaboratively. The nurse case manager is looking more at high-risk, clinically complex patients, providing clinical education. The social worker is focusing on psychosocial and financial issues and providing brief counseling in some instances. Now, doesn't that look very similar to what we do in the hospital? Very similar idea, stratifying the work between the RN case manager and the social worker based on clinical needs versus psychosocial needs. And then both would coordinate referrals for transition. I thought this was kind of interesting. This is not current, but I think it's still appropriate. This was from Patient Advocate back in 2007, I can't even believe it. Even Christopher Columbus would have had a tough time navigating the waters of the complicated U.S. healthcare system, and most people, especially when ill, aren't the best navigators. Enter patient advocates. They help ensure that the patient gets to see the desired specialist. They do internet research so the patient is more informed when talking to the doctor. They educate family members on how to support the patient during a hospital stay, for example, ensuring that the pills really are meant for her. And they sort through the mountains of bills and, if necessary, negotiate fees with the healthcare provider, insurance company, or other payer. So patient advocates, and they can be lay people, people specially trained to be advocates, but this is another integral role to how patients will transition and transition well. And then the patient navigator, and do remember, as I've said with many other topics, titles are not important. It's what the person actually does. So this was in Parade, a lay publication. Patient navigators guide us through the medical maze. So here's another title, really. As the healthcare system grows more complicated, many people need help handling it. So a new specialty has emerged, that of the patient navigator. The role may involve coordinating doctor's visits, maintaining telephone contact between patients and physicians, arranging rides to and from the hospital, helping with insurance forms and even suggesting what to ask at your next appointment. So if you look at all that list, that's all about transitions. And so if you have an opportunity to identify somebody like this, wow, you know, and you've got a patient who needs that kind of support, then, you know, you should hopefully have somebody in your system on the community side who can do something like that for you. So this is actually, this slide came from some work I had done, and one of our stages was stratification, as you can see. So if you look at the yellow box, low and moderate risk on the left there, who's going to manage, you know, again, going back to our 1,000 patients, you're going to have some that are low risk, some that are moderate risk. Some moderate risk and low risk can be managed by your staff nurse in the clinic. Sometimes they may need an RN or social work case manager. On the red box, you've got moderate risk and high risk. There'll be a staff RN role there, but also a case manager role, RN, and or social worker, particularly on those high risk patients. And then, you know, these are very approximate percentages. You know, if you're looking at 1,000 patients and you're going to risk stratify them, well, you know, again, in the aggregate, and it really does depend on the patient population, but also how you're defining risk. You may have low risk, 70 percent, moderate risk, 20 percent, and then high risk, 10 percent. So, you're going to hit those high risk patients first, and from there, you're going to go down to your moderate risk, if you've got enough resources to do that. So, the staffing ratios are very different on the community side than they have been on the hospital side. We have high risk, and I should mention rising risk patients. These are patients who would score moderate risk, but have risk factors and potential for high risk, if not case managed. So, you know, when you are handing off your patients to a community case management program like this, you want to give them all those potential risk factors, because that's going to play into how, well, how they're going to assess that patient's risk level and how they're going to deploy resources accordingly. So, the staffing ratios, 50 for Medicare patients, 75 patients for Medicaid, and for commercial patients, you and I, 100 to 150 patients, because these patients are more likely to be able to self-manage, whereas your Medicare population, again, in the aggregate, are more likely to need some help, because they probably have multiple problems. And then there's lots of tools for decision support, and, you know, you can use some of these in the hospital, too, so guidelines, get with the guidelines, some of you may remember that, triggers for high risk, or print it on forms, you know, any of that kind of thing. Medical mechanisms for specialty services or interactions, provider and staff education, they have wonderful pocket cards, I remember the first pocket card I did was for heart failure, you know, if you gain this much weight, you know, some of you may still have those, if you fall red, you call the doctor, you know, and really a great way so patients don't panic and just automatically call the doctor all the time, or go to the emergency department, and you teach them how to weigh themselves, and then, you know, depending on how much weight they gain. So little tools like that, that's actually a big tool that can help patients out of the hospital, wallet cards, patient maps, any kind of thing like that can be a really good thing. And then there's a lot of electronic health records, there's registries, I like the registries that will notify the provider when the patient is due for blood work, let's say, or an appointment, or anything of that sort, and they have disease management registries, so specific protocols for diabetics or heart failure, again, you know, any of the chronic conditions. And then Google and Microsoft both have personal health records where you can keep your own information. As I mentioned, patient subgroups, you know, with ways to trigger staff for what that patient needs at a specific point in time. And then a care plan with the patient, working, you know, with an educator to come up with a good plan. So when you want to pull your patient into some community resource, so when you're transitioning your patient to the community, you want to look for these community resources that are going to help you help that patient manage most effectively. So we've talked about some of these, but there's other services, there might be a health department resource or a health plan resource that you can tap into, and you need to discuss those, obviously, with the patient. You always, always want to try to encourage your patient to be as self-managing as possible. You want to emphasize their role in their care. You don't want them to be passive participants. You really do want them to take control of their care. So you can download the assessment from the website and go over the patient's self-management readiness, so you can figure out where they are in terms of their ability to self-manage. Your staff should receive training on how to do this, it's not just something you kind of just do, and then care planning and problem solving, all kinds of techniques and templates to help you to do that. Under self-management, there's basically three things, health literacy, compliance versus adherence, and self-efficacy, or the patient's level of confidence. So health literacy is really, it's stunning when I tell you what I'm going to tell you now, and that is that only about, and it depends on where you're reading it, but only about 17% of the population of the United States has a usable level of health literacy. What does that mean? That means a person's ability to read, understand, and act on health information. I have some very highly educated friends and relatives who really don't get it. They really, really don't get it, or they think they know better than the doctor. So they can read something, they don't necessarily understand it, and if they do they still may not be able to act on it. So that's the vast majority of the population of the United States, and it has nothing to do with education or socioeconomic level. For some reason, this is something folks really struggle with. So when you are doing education on your patients, be it clinical or be it discharge, planning, education, you want to make sure you're getting it through to them, and that may not even be completely possible, but you want to repeat, repeat, repeat, speak at a level hopefully they can understand, don't use jargon, because poor health literacy leads to medication and treatment errors and ineffective health care interactions. If that patient doesn't understand what anybody's talking about, well they're not going to really be able to ask the right questions or, as I said, use that information effectively. And then we have adherence and compliance, two terms that folks interchange also all the time. I do it myself sometimes. They're used synonymously, but they're actually different. So adherence, adherence refers to the patient adhering to the proper practices. Compliance is when the patient follows the instructions. Adherence empowers the patient, thereby becoming a co-equal to the care providers. Compliance is believed to be, is believed to promote a paternalistic and condescending attitude toward health care. So, you know, when a doctor just wants the patient to, you know, follow the directions, do what I'm telling you to do, or when the patient can't think beyond that, kind of just blindly does what the doctor says, well that's compliance. Adherence means I'm becoming actively involved, and I can't do that very well if I'm not, if I don't have any health literacy. I can't participate effectively in my own care if I don't really understand what it is that I'm supposed to be doing. So you just want to keep that in mind, you know, you don't want people to feel like, all right, I'll just do it, because at the end of the day they're not going to get anywhere near as far as the person who's actively engaged and participating. And then self-efficacy, which is the extent or strength of one's belief and one's own ability to complete tasks and reach goals. So those are your things to keep in mind. If a patient doesn't think they're going to do well, well they're probably not going to do well. I did a study on that too, and the patients who had a positive outlook on how well they were going to do, did better than those that had a negative outlook. So to the extent that you can promote positivity, also another good way to keep patients from transitioning all over the place. All right, so some tips now for interventions that may improve your transitions. Post-discharge follow-up calls. So you're going to have a subset of patients who are going to be followed by that transitions case manager, but then you're also going to have some other patients that aren't high risk enough for that, but they should still get a post-discharge follow-up call. And usually, you know, the two groups you want to focus on are your patients going home with no services and or your patients going home with services. So some of those may be followed by that transitions person, but the others should get a follow-up phone call because that's where you're hopefully going to identify any potential problems. Make sure the patient is connected to a primary care provider if they don't already have one, because again, if they're lost in space, not seeing a doctor, they're going to wind up back in the ED. Be sure that essential discharge information is transmitted to the next provider of care and caregiver as we've been discussing today. Make sure you get that right information there, verbal and or written communication. Standardize your process, maybe that checkoff list, that discharge timeout, and that would include off hours and weekends. Actively engage patients and families to realistically assess the discharge potential. Participate in discharge planning and achieve successful care continuity when they return home. Now this is a tip, but it's actually a requirement from CMS. So they have to actively participate in discharge planning. They have to agree to the discharge plan, discharge destination, and then we want to make sure they have a successful transition and that has to do with educating them about what's going to happen when they get home and making sure that there's a good continuity for them. Identify end-of-life issues earlier during an inpatient admission. Yes, absolutely, if you can, and address them prior to discharge, including connecting patients to community end-of-life services. Connect patients who require complex care to a medical home or other program that can provide support and resources to patients and their caregivers seven days a week, 24 hours a day. So a lot of these patients and in medical homes or even the case manager in the medical home is available around, someone is available around the clock. So your complex patients should be connected and they should be taught that that's their first call to make before they come back to the hospital. Implement ED case management with both case managers and social workers who coordinate the patient's return to the nursing home or other post-acute service. So that can be another way, you know, let's not forget we can transition patients out of the ED as well. And so sometimes they go back to that nursing home or other post-acute service and not need to be admitted to the hospital. Work with local primary care providers, nursing homes, and other providers to discuss and develop strategies to prevent avoidable readmissions and contributing factors. So have a team set up, whether it's your local PCPs, but certainly your nursing homes and other, you know, home cares, other providers in the community to talk about what the barriers are for them. That means that they have to send a patient back to the ED. Those teams are really good. I've done a quite, I've done a few of those teams myself and they can be pretty amazing when you hear what their issues are versus what our issues are. And a lot of stuff, you know, it's like low-hanging fruit. It can be, it can be fixed. And so, you know, you don't know until you sit down together. So that's one of your first questions, you know, when your readmitted patient returns from the hospital, do you have a primary care physician or provider? They may, but just, you know, don't want to access them or maybe they don't. Improve timeliness of discharge summaries to the physician regarding continuing care and diagnostic testing and results. That's a big, that can result in huge errors and problems. Patient has a test for the end of the stay, the results are not back before discharge. Patient discharges to the community. Nobody knows that test was done and it had an actionable test result that nobody knew about. Really scary stuff. So make sure that information is also transitioned. You want to make sure that the next provider knows this test was done. Develop standard actions for transitions from hospital to next level of care, including in the office. So like I said, you want to have some kind of a minimum data set or some other tool that's going to help you to make sure you don't forget anything when you transition information. Okay, we've got the discharge process duplicate there. Improve the delivery of discharge instructions to patients, especially those who don't speak English or have low literacy rates. You know, we can talk all day, but if the patients don't understand us, you know, we have to go that extra mile to make sure we're communicating as best as we can. Make sure you have a good med rec process. So I like to think of our future case management world as an across-the- continuum model, not just, you know, case management in the hospital and then case management here, but really again to get those silos removed. So you want to create one seamless department that includes inpatient and community. Have one director for each level who report to the same person in the same department. So let me use my example. So I was the vice president. I had inpatient case management and I had community case management. I had a director for the hospital side and I had a director for the community side and they both reported to me. Consider inpatient as episodic. So again, the acute care case management model is, you know, that short continuum of care and then that transition of those most high-risk patients to a community case manager and then they would manage them from the community. Provide handoffs as patients transition across the continuum and create one single database for all the patients. We're getting there. I think we're closer to this sort of perfect world than we ever have been and I think the key really is to bring the two departments together if you have the luxury of doing that. It's not always possible if you have home care case management or some other level of care. It's not going to be completely possible, but to the extent that it is possible, it's great. I would bring together the hospital and community staff case managers to talk about specific patients. We solve so many problems that way. I mean, it was just really great. So I just like to share some success stories and that was one of mine. So our goals across the continuum include reducing readmissions or visits, reducing cost of care or resource consumption, improving clinical outcomes, and improving quality of life and patient satisfaction. And again, these apply regardless of where you're case managing across the continuum. These are the standard goals that we should all have. So what is the future of case management? Well, I think we'll continue to have acute care case managers. Hopefully we'll have payer case management that's more involved, you know, really involved. We'll have more community case managers, electronic communication across the continuum, and I do believe we're getting closer to that. Some of you have that already. Health homes for all patients and a case management delivery system without walls. Now today, we have a load of resources for you. If this is your area of interest, we've got plenty of reading here. I would turn your attention to United Hospital Fund here on slide 85, the United Hospital Fund, Always on Call when Illness Turns Families into Caregivers. If you're interested in learning more about family caregivers, that's a really good one. Okay, well, Lindsay, I'm going to turn it back to you and see if anybody has a question. Perfect. Thank you so much, Dr. Sesta. We do have a few questions that have come in, and so if anybody has any that you are typing, go ahead and place those into the Q&A option found there at the bottom of your Zoom window, or if you don't see that option, you can, of course, type your questions into the chat so we can make sure to address your questions here as well. Okay, so this first one asks if you have any recommendations for a case management policy and procedure manual that can be edited to fit our needs. Well, as a, I mean, I'll just be honest, as a consultant, that's what I do for a living. I create those for hospitals, so I don't personally have any, but you may have a colleague, maybe there's somebody listening today who would be willing to share theirs. If so, maybe, Lindsay, they could email you or text you, Lindsay, and and, yeah, so if anybody's willing to share with this person, is that okay? Yeah, okay, yeah, maybe somebody out there, a colleague, wants to share that. Perfect, so if anybody does have any information they'd like to share, you can always send that to education at gha.org, and then I'd be happy to get that out to the requester as well. So this next question asks, what is community case management? Is it considered part of population health? Well, population health can be an adjunct to community case management. It's a little bit different, and again, there's so many variations on the theme from what I've seen from population health, but it's, I'm trying to think of an analogy, it's really, as you know, focusing on some of the things that we It's really, as you know, focusing on specific populations of patients, and it is a form of community case management, and if you've got, let's say, community case management in your patient-centered home, which I've seen hospitals that also have a POP health program, you just want to make sure you're communicating between the two so you're not overlapping on the types of patients that you're focusing on. You know, that I would stress. If you have, if you only have POP health and you don't have that issue, obviously, but it's different, it's a little bit different, but with some commonality. Perfect. So I hope that helped. Yeah, absolutely. And then there's a couple more questions similarly asking if you have examples. So this person asks if you know where to possibly find a generic example of a case management plan, and we kind of talked about that just a moment ago, and then any risk stratification tool examples. Yeah, if both of those people, were those the same person or two different people? It is the same person, yes. Can you forward that to me? Sure. I'd have to get those. I don't have them top of my head, so. Yep. Alicia, I see this question came from you, and probably the best thing to do, if you wouldn't mind, if you'll send an email to education at gha.org, and if you just want to include your couple of questions in that email, then we'll make sure that gets over to Dr. Sesta and she can follow back up with that information as well. And that goes to anybody else who may have a more detailed question that may apply to your organization that you may not want to ask here, feel comfortable asking in this format, you can always send those questions over to education at gha.org, and we'll be happy to get those over to Dr. Sesta. I don't see any other pending questions at this time. Let me go ahead and post just some information there for you all in the chat. So you should see that note there now in the chat section that is just a reminder that you will receive that email tomorrow morning. So for those of you who have joined us for the full series, I hope that you have become familiar with this process, but you will receive an email and it'll come from educationnoreplyatzoom.us. And so because it does come from that Zoom email, those tend to get caught up in spam, quarantine, junk folders, that kind of thing. So if you don't see it in your inbox in the morning, I would encourage you just to go check those additional folders. And then if it's still not there, and you would like to access the recording, we do record these as on demand, meaning that you can use that same Zoom link to access both the live session from today, and then also the recording. And then just remember that the recording is available for 60 days from today's date. And then we do have that additional security measure in place of manually approving each of your recording access requests. So when you click on the Zoom link, it will prompt you to enter your information, and then that will send an email to us to approve. And we do approve those very quickly. And then again, you will have 60 days from today's date to access that recording. And then also included in that email tomorrow morning will be a link to the slides that Dr. Sesta presented today. But I did go ahead and provide that link to the slides there for you in the chat to have as a resource now as well. And then again, as we mentioned earlier, if you do have any follow up questions that you just didn't have a chance to type in today, please don't hesitate to send those to education at gha.org. And I will type that email address here in the chat for you as well. Okay, I don't see any other pending questions, Dr. Sesta. So thank you all so much for joining us today. And then we will just look forward to seeing you all back here for part five next week to wrap up this series. And we just thank you so much all for joining us. And always thank you, Dr. Sesta, for your time and information. And we look forward to seeing you all back with us next week and hope you have a wonderful rest of this week and weekend. Thank you so much. Bye.

Dr. Tony Sesta

seamless transitions in care

case management

discharge planning

patient outcomes

reduce costs

effective handoffs

standardized protocols

minimizing errors

enhancing communication

high-risk patients

post-discharge follow-up

care coordination

decision-making