Accreditation The American Medical Directors Association (AMDA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Designation Statement: The American Medical Directors Association designates this Internet Enduring Material for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
AMDCP Credit Designation: This session has been approved for a total of management 1.5 credit hours toward certification as a Certified Medical Director in Long Term Care (CMD).
Session Description: Hospital and skilled nursing facility (SNF) medical providers have begun to address transitions from acute care to SNF through clinical partnerships. In this session we present two models of Hospital-SNF partnership, the Johns Hopkins Community Health Partnership (J-CHiP), and the Partnership for Patients (PP) are presented. The former is a collaboration of the medical, nursing, and administrative leaders of an academically-affiliated SNF and those representing five community-based SNF partnering with the hospitalists of two large academic acute care hospitals- Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. The second is a partnership between the county Department of Human Services, a regional acute care hospital, regional nursing homes, and community health care providers in Sussex County, New Jersey & the Sussex County Transitional Care Program (TCP).
Describe two models of hospital-SNF partnership to reduce avoidable rehospitalizations and improve clinical outcomes.
Adapt collaborative practices, care coordination strategies, and disease-specific protocols to reduce avoidable hospitalizations.
Explain collaborative practices, care coordination strategies, and disease-specific protocols improve clinical outcomes in the skilled nursing facilities where they provide services.
Speaker(s): Michele F. Bellantoni, MD, CMD; John Loome, MD, CMD; Fatima Sheikh, MD; George Wang, MD, PhD
Reference(s): Ouslander JG, Maslow K.Geriatrics and the triple aim: defining preventable hospitalizations in the long-term care population. J Am Geriatr Soc. 2012 Dec;60(12):2313-8. doi: 10.1111/jgs.12002. Epub 2012 Nov 29. PMID:23194066 Tena-Nelson R, Santos K, Weingast E, Amrhein S, Ouslander J, Boockvar K. Reducing potentially preventable hospital transfers: results from a thirty nursing home collaborative. J Am Med Dir Assoc. 2012 Sep;13(7):651-6. doi: 10.1016/j.jamda.2012.06.011. Epub 2012 Jul 25. PMID:22835484 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-28.
Associate Professor, Department of Medicine,
Johns Hopkins University