2023 Session Descriptions
Friday, October 13
Are You Ready for Value-Based Contracting? (VBC)
As the country transitions to value-based care – through VBID, ACO REACH, MSSP, and other innovative payment models – post-acute and home-based care providers must find their place in this new healthcare landscape. This presentation will dive into clinical and administrative criteria that will determine how to best enter this arena and who the best partners will be. We will help providers learn how to get their seat at the table before they are left behind.
The State of the Science of home-based medical care: What do we need to know for success? (Clinical Practice)
Presenters will provide updates to their prior AAHCM “State of the Science” sessions by synthesizing recent evidence related to HBMC, identifying key research themes in the field, and examining gaps in our knowledge as we care for the homebound in the community. Presenters will survey new HBMC research to describe where research in home-based care has grown and identify areas where evidence has not caught up to current practice.
Addressing Microaggressions in the Home (Education)
Microaggressions are indirect, often subtle but harmful acts that reinforce stereotypes and discriminate against members of marginalized groups. Microaggressions are common in medicine and disproportionately affect women and health care professionals who are traditionally underrepresented in medicine. In this session we will share and have the opportunity to practice effective strategies and frameworks designed to combat microaggressions from patients and caregivers and apply them to scenarios in the home.
Hospital at Home 101 (H@H)
Hospital at Home (HAH) 101 session will describe HaH basics. We will review history of HAH model, the recent HAH waiver and legislation, staffing models of HAH, the types of patients cared for,, and considerations regarding developing a program. We will break into small groups and review clinical cases with group discussion on HAH care. We will leave ample time for participant questions.
Leveraging data to improve performance (Public Policy)
Details to come.
Non-pharmacologic interventions for behavioral symptoms of dementia: Implementing the DICE Approach and the Tailored Activity Program (TAP) (Clinical Practice)
This session will focus on non-pharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD). We will discuss multiple approaches but focus on two evidence-based, patient-centered programs: the DICE Approach and the Tailored Activity Program (TAP). We will describe quality improvement work to implement these at our institutions, discuss complex real-life cases, and engage session attendees in generating creative interventions for caregivers to try. Finally, we will invite attendees to share their own successful approaches.
Meeting patients where they are: engaging patients in challenging living situations (Clinical Practice)
Some patients live in conditions that can adversely affect their health, and may even pose potential harms to providers. Home-based providers may encounter hoarding, squalid conditions and infestations. Such situations may be from isolation, poverty, or even choice of home over institutionalized settings. Providers may have to make difficult decisions about how to support patients, and at what point such support seems unsustainable in terms of provider safety, resources spent, and patient health.
Building a Care Process Model and Medication Formulary for Hospital at Home using Infusion Pharmacy Services (HaH)
Many hospital at home programs utilize daily medication dispensing models from inpatient pharmacy. Our hospital at home program is active in 14 hospitals across a 350-mile radius in the state of Utah. In order to deliver medications to patients throughout a large geographical area, a homecare infusion pharmacy is utilized to fulfill prescription orders and provide clinical support. We have found logistical and clinical efficiencies by creating a
unique care process model and medication formulary that allows for sending multiple doses of medications, reducing the number of daily infusions needed, and simplifying the treatment options within given drug classes. Learn how our care team has worked together to simplify patient care, decrease costs, and transform hospital at home into a value-based program.
Theory and Practice of Longitudinal Home Care Medicine for High Need, Complex Populations in Value-Based Payment Models (VBC)
Details to come.
Meeting patients where they are: engaging patients in challenging living situations (Clinical Practice)
Some patients live in conditions that can adversely affect their health, and may even pose potential harms to providers. Home-based providers may encounter hoarding, squalid conditions and infestations. Such situations may be from isolation, poverty, or even choice of home over institutionalized settings. Providers may have to make difficult decisions about how to support patients, and at what point such support seems unsustainable in
terms of provider safety, resources spent, and patient health.
Transforming a Home-Based Primary Care Practice to Value-Based Care: Our Experience with ACO REACH (VBC)
ConcertoCare has had a presence in Washington State for over 10 years as a value-based care practice, but the acquisition of a larger, fee-for-service practice in 2021 compelled our growing practice to reorient our business model, clinical operations, population health, and clinical strategies towards an integrated risk based practice. Medicare’s ACO REACH was a primary focus of this transition. In this session we will share our narrative,
learnings, and recommendations for other practices.
Preparing our Healthcare Workforce for the expansion of medical care in the home: Home Based Primary Care & Hospital at Home Training Opportunities (Education)
Details to come.
Beyond the Screening: A Home-Based Multidisciplinary Team Approach to Addressing SDOH (Clinical Practice)
Success in addressing SDOH is reliant on a multidisciplinary approach and strong partnerships with Community Based Organizations. During this presentation, participants will learn from the social workers from a Home-Based Primary Care multidisciplinary team from UW Health. This team has successfully developed comprehensive workflows to screen for and to address SDOH barriers for all patients receiving care in their program. Participants will learn strategies for how to overcome barriers to care coordination, and how this process fits within the organizational strategy for addressing SDOH.
Tech-enabled Hospital at Home: Leveraging 21st Century Innovation to Achieve Scale (H@H)
Technology is one of the key drivers to effectively delivering a hospital-level care at scale. Together we will explore opportunities to embed technologies, such as remote patient monitoring (RPM) and telemedicine, to achieve high quality hospital at home care at scale. We will also discuss how to achieve techquity and ensure robust patient engagement and reliable device connectivity across diverse populations and locales.
Understanding pain in Homebound Older Adults (Clinical Practice)
Details to come.
Buprenorphine for Pain Management (Clinical Practice)
Details to come.
Public Policy Update
Details to come.
Expanding the Team: The Key Role Community Paramedics Play in Hospital@Home (H@H)
Hospital@Home is an innovative model of care providing acute, inpatient hospital care in a patient’s home instead of an inpatient hospital bed. EMS in an integral part of a safe Hospital@Home program. Community Paramedics can provide a wide scope of care to patients including antibiotics, diuretics, and high dose steroids while partnering directly with hospitalists via telemedicine in the care of acutely ill patients. Community Paramedics can play a key role in safe Hospital@Home care.
Saturday, October 14
Fresh Food Rx: A Community Engaged Approach to Addressing Food Insecurity for Older Adults (Population Health)
Details to come.
The National Home-Based Primary Care Learning Network 1-Minute Survey Greatest Hits (Clinical Practice)
National Home-Based Primary Care (HBPC) Learning Network (LN) Leaders will: 1) provide LN overview and importance of quality improvement and continuous learning for HBPC; 2) describe monthly “1-Minute Survey” of key topics in HBPC conducted for each LN Workshop; 3) present “3 Greatest Hits” chosen by LN members: 1) deprescribing; 2) chronic pain management; 3) social isolation/loneliness – each “Greatest Hit” will include real-time audience polling and brief evidence-based didactic on each Hit.
Life after Onboarding – Precepting and Continued Education for our Home-Based Medical Care Workforce (Education)
As the specialty of home-based medical care expands to meet the needs of our aging population, there is a growing need to thoughtfully provide education and preceptorship to a workforce that is eager albeit inexperienced in this developing field of medicine. Additionally, the home setting, as opposed to a clinic or hospital setting, offers many unique nuances and challenges when it comes to precepting and “bedside” education. This session will focus on discussing our preceptorship program for our advance practice providers (APPs) and identify strengths and further opportunities. The presenters will then facilitate a discussion with audience members to better understand and share models of preceptorship at other institutions and organizations.
Remembering Our "Why": The Voice of Patients and Caregivers in a Hospital at Home Model (H@H)
A fireside chat with clinical leaders, patients, and caregivers to share their unique experiences of the hospital at home model. In collaboration with our partners, we will share how our model is dedicated to involving patients and support person to embed their perspectives at the forefront of our strategy to improve experience, quality and safety of hospital at home. Patient stories drive our mission forward. They remind us why we deliver care in the home.
Building for the Future: Making Room for Innovations in HBMC (Practice Mgmt)
The goal of this session is to emphasize, through case examples and (if 90 min workshop format) facilitated problem-solving, the importance of innovation and continuous improvement in existing HBMC practices given the rapidly changing practice environment, need to improve effectiveness and experience of the team as well as clinical and operational outcomes, and great opportunity for HBMC providers and teammates to be active participants in the evolution and professionalization of this field.
Designing an Age-Friendly Health System (Clinical Practice)
There is a critical need to redesign all healthcare settings to provide more effective and tailored care to older adults. The Age-Friendly Health System 4Ms framework (Mobility, Medication, Mentation, What Matters) offers a guide to health systems to improve care for this vulnerable population. This session will review the components of an Age-Friendly Health system, the current national movement, and how one early adopter health system became Age-Friendly specifically in its inpatient, emergency department and home-base primary care settings. We will review common barriers and challenges to Age-Friendly clinical program implementation as well as step-wise path to early successes. Areas of opportunities will be highlighted in particular around patient-centered transitions of care through multiple sites of care.
House Calls Approach to Evaluation and Management of COPD
Details to come.
Helping the Penguins on the Melting Iceberg: Change Management for Broader System Adoption in Launching and Scaling Home Hospital Programs (H@H)
Launching and scaling a Hospital at Home program involves varied challenges, a primary one being encouraging colleagues to embrace this care model. No less than a culture change, this is essential for growth. Similarly, engaging patients to increase awareness of the model allows for self-advocacy. This workshop will 1) highlight best practices in spurring change across your organization for rapid adoption and 2) bring ideas for how to message directly to patients.
Opportunities and Challenges for Strong Care Transitions Across Home-Based Services (Pop. Health)
This workshop focuses on care transitions of patients across different home-based services. Presenters knowledgeable about home-based models ranging from acute provision (hospital at home) to post-acute (rehabilitation/palliative care at home) and chronic care (home-based primary care) will describe case studies that support efficient and patient-centered transitions as well as existing gaps and the patient, organizational, and systems-level factors influencing them. We will also discuss promising research efforts to support improved systems of care.
Dementia 101: Detection, Diagnosis, Disclosure, and Management of Behavioral Disturbances (Clinical Practice)
Details to come.
Structural interventions in the Elderly (Clinical Practice)
Details to come.
Age-Friendly Care & Hospital-In-Home: Implementations in the VA Health Care System (H@H)
The Department of Veterans Affairs (VA) Hospital-In-Home (HIH) program delivers patient-centered, acute-level hospital care at home within a single-payer integrated health care system. As of 2022, there were eleven HIH sites across the VA, evidence of modest adoption. This session presents findings from the first year of a 4-year project conducting an in-depth inquiry into the most effective ways to implement, adapt and sustain HIH across the VA, delivering care congruent with Age-Friendly principles.
Lessons Learned Utilizing a Risk Stratification Tool to Assist in Complex Care Management (VBC)
Our team has developed and implemented a risk stratificaton tool focusing on healthcare utilization, medical conditions, medications, mental health, and socioeconomic conditions with the goal of recognizing high risk patients that may benefit from more intense outreach and case management. The outreach attempts to decrease overall healthcare utilization and help improve patient satisfaction rates. This talk will discuss the development and implantation of our tool as well as our results and lessons learned.
Session #30 Integrated, Whole-person Care for Home Based Seniors with Complex Condition (Clinical Practice)
This session will outline how Landmark Health leveraged behavioral health collaborative care in a home-based geriatric medical practice to improve access to behavioral health care applying a treat to target approach that included brief behavioral health interventions, care management and medication management when clinically indicated leveraging a robust interdisciplinary team working together to achieve improved outcomes for patients with complex health care needs.
Integrated, Whole-person Care for Home Based Seniors with Complex Condition (Clinical Practice)
This session will outline how Landmark Health leveraged behavioral health collaborative care in a home-based geriatric medical practice to improve access to behavioral health care applying a treat to target approach that included brief behavioral health interventions, care management and medication management when clinically indicated leveraging a robust interdisciplinary team working together to achieve improved outcomes for patients with complex health care needs
Home Care Coordination (HCC): Post acute care for high risk patients (Clinical Practice)
Details to come.
Identifying and enrolling HaH patients: from the Command Center or from the front lines (H@H)
Identifying and enrolling appropriate HaH patients can be onerous. As more HaH programs launch with a centralized command center serving multiple sites, teams may struggle with who is best positioned for this important work. This session highlights a quality improvement initiative to decentralize patient enrollment from a health system-wide command center to a local site within a virtual hybrid HaH program. We will emphasize lessons learned and alternatives for optimizing enrollment at your HaH program.
Closing Session
Details to come.
|
