CARE+
What are the two types of CARE+ Programs
CARE+ Acute Care and CARE+ Primary Care
What does SCC stand for?
Supportive Care Clinic
What type of program is DM?
A. Intervention
B. Education
C. Care Management
D. Care Management and Education
B. Education
What are the 2 types of discharge dispositions we pursue for PDVs?
Discharge to Home
Discharge to Home with Home Health
True or False
Care+ teams do not address ATTs during visits
FALSE
Care+ teams address ATTs (typically on the 3rd visit)
True or False
SCC and Palliative Care the same
False
SCC is NOT Palliative Care
True or False
Patients in Disease Management Programs are enrolled in Health Enhancement Courses
TRUE
Disease management programs utilize condition-specific courses
What is the new acronym for APT?
ADK = Admissions per Thousand (K)
True or False
Patients in Care+ Acute Care will be disenrolled if they see their PCP while in the program
FALSE
Patients in Care+ Acute Care can still see their PCP. Patients in Care+ Primary Care will be disenrolled because it indicates they are well enough to be discharged.
What is the target population for SCC?
Adult patients with a serious illness and a prognosis of 12-18 months
Name 3 Disease Management Programs
Heart Failure, COPD, Renal Care Continuum Program
What is our Readmissions Goal and PDV Goal for the rest of the year?
Readmissions Rate Goal: 13.5% or lower
PDV Goal: 85% or higher
What are two patient criteria for CARE+ Primary Care?
Home/Wheelchair bound (active hospital DME) and no ambulatory visit in the last 6 months
What are the 3 visit types SCC does?
1. Clinic (Preferred)
2. Video/Telehealth
3. Home visits, if homebound
After patients complete the main program, what are the 2 types of Monitoring options for patients?
Monthly outreach by RN or Health Advocate
IVR (Interactive Voice Response) Calls
What is the PDV target date of a patient with a LACE <9 discharged from an Out-of-Area Hospital?
PDV Target Date is 7 days for any patient in an Out of Area Facility even if their LACE <9
Name 2 default patient criteria for CARE+ Acute Care
Default: Lace 12+, IPA or Covina Main Group, Not in SCC, recent admit
Name 2 Areas of Focus or Services SCC team provides
Serious illness conversations and goals of care discussions
Hospice transitions
Symptom management
Care coordination e.g., blood transfusions, procedures
Comprehensive medication review and optimize med mgmt for chronic diseases
Psychosocial support and community resources e.g., caregivers, IHSS
What are 2 support services the Renal Care Continuum program provides?
Health Enhancement Education
GFR Monitoring
Health Advocate Support for scheduling
Telephonic Check-Ins, if qualify
Escalation through NP
Who do we TigerText for Discharge Summaries from USC Arcadia or HMH?
Danielle Chipres