Cross-Continuum Readmission Series
This five-part pre-recorded webinar course is designed to help you make specific, feasible, meaningful progress in aligning and coordinating your readmission reduction work with key partners across the continuum: hospitals, practices, community services and emergency departments. Join each session ready to examine your current readmission reduction efforts, learn about the efforts of your cross-continuum partners and identify specific opportunities to align or address gaps to help achieve your readmission reduction goals. This course, in its entirety, will take an estimated 5 hours to complete, but is set up in sessions and does not have to be completed all at once.
This pre-recorded webinar course was developed in support of the Hospital Improvement Innovation Network (HIIN) and Transforming Clinical Practice Initiative (TCPi) in 2018.
Transcripts are available upon request.
The Compass Hospital Improvement Innovation Network (HIIN) is supported by contract number HHSM 500 2016 00070C from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.
The Compass Practice Transformation Network is supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.
Care coordinators, health coaches, community health workers, nurse managers, care managers, population health and quality directors, community-based care coordinators.
All sessions presented by Amy Boutwell, MD, MPP, President, Collaborative Healthcare Strategies
- Discuss ways to make specific, meaningful progress in aligning and coordinating readmission reduction efforts with key partners across the continuum
- Examine your current readmission reduction efforts
- Discover the readmission reduction efforts of other providers and agencies in your community
- Identify specific opportunities to better align efforts with cross-continuum partners to optimize impact
Topics to be Covered
Who is Doing What For Whom and Why?
This webinar will provide a brief orientation to the AHRQ “ASPIRE Guide” (Designing and Delivering Whole-Person Transitional Care). Pre-requisites to effective collaboration will be reviewed including:
- Articulate your organization’s motivation and specific aim
- Define your specific target population(s)
- Describe the interventions you are implementing
- Identify gaps that could be addressed through collaboration
Working Smarter, Not Harder: Meeting Needs and Filling Gaps by Harnessing Available Resources
This webinar will describe resources available in the ASPIRE Guide, follow up on action steps from webinar one and discuss three strategies to “work smarter not harder.”
Practical, Feasible Lessons from ACOs (Accountable Care Organizations), Bundles and PCMHs (Patient-Centered Medical Homes)
This webinar will review additional resources from the ASPIRE Guide, follow up on action steps from webinars 1 and 2 and share four “practical, feasible strategies” learned from ACOs, bundles and PCMHs.
Practical, Feasible Lessons from the MVP (Multi-Visit Patient) Method
This webinar will follow up on action steps from webinars 1, 2 and 3, provide a brief primer on the “MVP Method” and highlight three “practical, feasible strategies” learned from MVP teams.
Practical, Feasible Lessons from HIIN (Hospital Improvement Innovation Network) Hospitals and TCPi (Transforming Clinical Practice Initiative) Practices
This webinar will review the specific recommended action steps from webinars 1, 2, 3 and 4, describe three “practical, feasible strategies” learned from HIIN, TCPI teams and a provide a series wrap up.
Amy Boutwell, MD, MPP
Dr. Amy Boutwell is the President of Collaborative Healthcare Strategies, a national thought leadership, strategic and technical advisory firm specializing in strategies to achieve high value care, improved whole-person care across settings and over time, focused primarily on reducing acute care utilization among the highest risk populations. Dr. Boutwell is a nationally recognized expert in the field of reducing readmissions and improving care for high utilizers, advising state wide initiatives to reduce readmissions and/or improve care for high utilizers in several states and nationally through the CMS Healthcare Improvement and Innovation Networks (HIINs). She co-developed the AHRQ Hospital Guide to Designing and Delivering Whole-Person Transitional Care (called the ASPIRE Guide). Dr. Boutwell is a graduate of Stanford University, Brown University School of Medicine and the Harvard Kennedy School of Government where she received the Robert F. Kennedy Award for Excellence in Public Service. She trained in internal medicine at Massachusetts General Hospital and practices hospital medicine.
No continuing education is provided for this course. The user will receive a certificate of completion upon completing the course.