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Survivors of TBI and their families each process the occurrence of a TBI through 6 unique stages using “grief theory” as a framework. There are key factors in the rehabilitation and recovery process that impact their level of acceptance, coping, and adjustment following a TBI. Understanding these stages by professionals, families, and survivors can directly enhance the success of their rehabilitation program and assist in achieving maximized successful outcomes. The case manager’s role in assisting patients who have sustained TBI can be greatly enhanced through an understanding of these stages, as readiness of the survivor and family to engage and participate in the case management process is dependent on the current stage of acceptance and coping being experienced. The case manager, as the conduit of information and communication, is in the unique position to support the interdisciplinary team with a thorough understanding of the family and survivor’s stages in the rehabilitation and recovery process.

Presented by

Deborah Gutteridge, MS, CBIST,
Clinical Evaluator

Ms. Gutteridge currently functions in the capacity of Regional Manager of Marketing and Business Development for NeuroRestorative, a national organization providing multiple levels of post-acute supports and services for persons with Acquired Brain Injury. Ms. Gutteridge possesses a Master’s of Science Degree in Counseling Psychology and is a Certified Brain Injury Specialist Trainer. She has recently served 3 years as President of the Board of Directors of the Brain Injury Association of Kansas and Greater Kansas City. She has served in the capacities of Director, Secretary, and President for the Case Management Society of America-KC Chapter, and has held several positions on the National Board of Directors of the Case Management Society of America. She was CMSA’s 2014 recipient of the Award of Service Excellence and most recently served as the President of the CMSA Foundation. She has worked in the field of brain injury for over 30 years. She is in her 22nd year of service with NeuroRestorative, and is a regular presenter for both local and national venues.

NTOCC CALL TO ACTION!!

This year the National Transitions of Care Coalition (NTOCC) convened a special task force to review and provide recommendation/revision enhancements to the NTOCC Care Transition Bundle: 7 Essential Intervention Categories.  The Care Transitions Bundle was first developed and launched in 2011 to support individuals and organizations with essential interventions for improving transitions of care for providers, patients and their identified family caregiver.

We would like to invite providers, patients and caregivers to review the suggested revisions and provide comments or thoughts about the proposed changes. There are seven (7) individual sections to review and you do not have to review all 7 but it is encouraged. The public comment period will be open for 30 days, ending on December 31, 2021.  

Feel free to share this link with your colleagues, patients and caregivers or other organizations as everyone is encouraged to review and provide comments.  https://nowcomment.com/blogs/29631

Please follow the instructions below for the "Now Comment" platform, in order to begin the process of reviewing the NTOCC Care Transitions Bundle: Seven Essential Intervention Categories. 

Link to all 7 of the the care transition bundle documents:

https://nowcomment.com/blogs/296311

In order to include your comments on the proposed revisions to 2011 NTOCC Care Transitions Bundle 7 Essential Elements document, you must set up a new account , on the Now Comment platform, which will only take about 60 seconds.

NTOCC is looking forward to recieving your comments regarding the proposed revisions to the Care Transition Bundle: 7 Essential Intervention Categories. As always if you have any questions regarding this Press release, please contact me anytime by phone at (501)712-8686 or by emailing me at valemmons@gmail.com.

Kindest Regards,
Val Emmons
NTOCC, VP Communications & Govt. Affairs

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Presented by:

Rebecca Perez, MSN RN CCM – Sr. Manager of Education and Strategic Partnerships &

CMSA Foundation Executive Director

Case Management Society of America

Abstract

Care transitions are a priority for all health care stakeholders and much work has been done in recent years to develop processes, incentives, disincentives, and metrics to improve transitions and prevent readmissions. Much has been published about transition management, and organizations are very focused on the process, so why are readmissions still a concern.

Approaching a transition as part of a continuum of care rather than a focused episode is a strategy that has resulted in reduced readmissions. Engaging case/care management with the care transition team will demonstrate improved outcomes, and in many cases, improved quality of life. This presentation will demonstrate the value of case/care management when included as part of care transitions, especially for those with multiple chronic conditions.

Objectives

As a result of this program, the participant will:

1. Analyze the causes of readmission regardless of transition process.

2. Comprehend the integral role of case/care management support of a transition process.

3. Discover the value and return on investment of case/care manager supported transitions.

Bio

Rebecca is an experienced Registered Nurse with a Master’s Degree in Nursing, is a Certified Case Manager, and a member of the Gamma Omega Chapter of Sigma Theta Tau International Nursing Honor Society. She is the author of numerous professional articles, a co-author of CMSA’s Integrated Case Management: A manual for case managers by case managers, developer of the Integrated Case Management Training Program, and Maser Trainer. She recently joined Parthenon Management Group as the Senior Manager of Education and Strategic Partnerships for the Case Management Society of America.

PRESENTED BY:

ELLEN FINK-SAMNICK

MSW, ACSW, LCSW, CCM, CCTP, CHMIMP, CRP, DBH(S)

SEP 21, 2021

12:00 PM CDT

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Abstract:

Few topics are more intimate and ethically complex for case managers than engaging with patients around end of life processes. The importance of this issue has been highlighted by evolving issues, from legislation and reimbursement, to the latest dimensions of the COVID-19 pandemic. Organizational mandates intersect with professional ethical codes yielding a fresh generation of ethical dilemmas for case managers to reconcile.

Citing the latest industry literature, regulations, ethical codes, and practice guidelines this unique presentation will provide attendees a comprehensive view of the evolving end of life care landscape. Emphasis will also be on a template to guide assessment of, and intervention with end of life situations across the developmental life span

Behavioral Learning Objectives are:

1. Discuss four (4) issues to influence the evolution of end of life care

2. Identify legal documentation associated with care decision-making

3. Identify related cultural implications across populations

4. Explore the ethical implications of EOL care amid the COVID-19 pandemic

5. Discuss how end of life care can pose ethical pitfalls for case managers

6. Implement the Intergenerational Spectrum toward patient (family) engagement during EOL care

7. Align EOL care to case management’s professionals ethical standards of practice and codes

BIO:

Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CCTP, CHMIMP, CRP, DBH(s)

Ellen Fink-Samnick is an award-winning industry thought leader who empowers healthcare's transdisciplinary workforce. She is subject matter expert on the Social Determinants of Health and Mental Health, Workplace Bullying and Violence, Professional Ethics, Professional Case Management Practice, and Wholistic Case Management™.

Her latest books include, The Essential Guide to Interprofessional Ethics for

Healthcare Case Management, The Social Determinants of Health: Case Management's Next

Frontier, End of Life Care for Case Management, and upcoming Social Determinants of Mental

Health: Advancing Wholistic Practice Excellence. Ellen is a panelist for Monitor Mondays, plus

contributor to RAC Monitor and ICD 10 Monitor. She serves as moderator of Ellen’s Ethical

Lens TM on LinkedIn, consultant for the Case Management Institute and moderator of their Case

Managers Community. Ellen is also Lead for Rise Association’s Social Determinants of Health

Community.

Ellen is a Licensed Clinical Social Worker, Board-certified Case Manager, Certified Clinical

Trauma Professional, Certified Mental Health Integrative Medicine Provider, and Certified

Rehabilitation Provider. She is a subject matter expert for Western Governors University, lead

clinical supervision trainer for NASW of Virginia, and adjunct faculty for University of Buffalo’s

School of Social Work, and George Mason University’s Department of Social Work. Ellen is also

a Doctor in Behavioral Health candidate at Cummings Graduate Institute of Behavioral Health

Studies.

Ellen’s passion is evident across her varied roles as professional speaker, industry consultant,

educator, continuing education content developer, accreditation specialist, clinical social work

supervisor and professional mentor to the case management community. Her contributions

transverse the industry’s professional associations and credentialing organizations. A past

commissioner for the Commission for Case Manager Certification, and Chair of their Ethics and

Professional Conduct Committee, member of the Board of Directors for the Case Management

Society of America, Ellen serves on the editorial boards for the Professional Case Management

Journal, Case Management Monthly, and RAC Monitor. More detailed information is available on

her LinkedIn Profile.

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PRESENTED BY

MELISSA CARDINE, MSN, RN, BCPA

There is a rapidly growing demand by patients and their families for access to independent patient advocates. Navigating the complexities of the current healthcare system has only become more challenging with the global pandemic. Patients were not allowed to have a loved one with them during a most vulnerable time moving from one level of care to another. This presentation will talk about the role a patient advocate can have in improving transitions of care.

 Learning Objectives:

After our session, those in attendance will be able to:

1. Discuss why health advocacy is needed
2. Define the role and scope of practice for a patient advocate
3. Describe how a patient advocate can improve transitions of care

Bio:

Melissa Cardine has been a nurse for over 20 years. Her passion is advocacy. In October of 2015, after more than 15 years at the bedside Melissa took this passion and the ideas she developed in her master’s program and founded The Bridge RN Patient Advocates. She enjoys listening to patients, families, and caregivers along with collaborating with healthcare professionals. Melissa was selected to be a Board Member of the Patient Advocate Certification Board (PACB) in November 2019 and currently is the President. Her passion for advocacy is evident in her daily interactions with all those she meets. 

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the National Transitions of Care Coalition (NTOCC).  ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Please join NTOCC at 12pm CDT/1pm EDT for an in depth overview on:

 Reclaiming the Time Between Visits:

Using Free Technology to Build Relationships, Efficacy, an Improve Outcomes
Presented by
Geri Lynn Baumblatt, MA, Chief Engagement Officer at Docola
Eran Kabakov, PT, CEO and Founder of Docola,

Abstract: 

Time with patients and families is always limited. Even when we use communication and health literacy best practices to educate patients and families, they still struggle to remember what to do and how to do it, so they can successfully transition to home or a new care setting. Research shows that leveraging the time before and after conversations through asynchronous care communication, like ePrescribing, patient education and resources, can improve understanding, self-efficacy, health outcomes, reduce readmissions, clinic and ER visits, length of stay. There are also benefits for clinicians and organizations such as: improved conversations and relationships, new insights, and operational efficiencies. And there are now free, high quality resources and platforms that make it easier than ever to prescribe knowledge and communicate care.

Objectives: 3-4 Learning Objectives 

1. Describe asynchronous care communication and e-prescribing information to patients and families (information therapy)

2. Explain the benefits of asynchronous communication for patients and families to improve care transitions

3. Describe how e-prescribing resources can help build relationships, create operational efficiencies, and improve the provider experience

BIO’s:

Geri Lynn Baumblatt, MA has worked in patient communication, education, and engagement for over 20 years. She created of a large library of multimedia resources at Emmi and partnered on research to understand how they impacted patient understanding, shared decision making, and improve outcomes. As Chief Engagement Officer at Docola she is creating a patient education content clearinghouse. She’s also the co-founder the Difference Collaborative, serves on the editorial board for the Journal of Patient Experience, on the Patient Experience Policy Forum, and writes a column on patient engagement on Healthcare IT Today. @GeriLynn @DiffCollab 

Eran Kabakov, PT is CEO and Founder of Docola, a care communication platform where providers can find and e-prescribe information to patients and build relationships. Eran has been a clinician for over 30 years, and is a volunteer at the Aurora Project, and a member the Society for Participatory Medicine. @docolainc

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the National Transitions of Care Coalition (NTOCC).  ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hours through the Florida Board of Nursing, Provider # 50-94.

REGISTER HERE FOR APRIL 20

Presented by
James Lett, MD, NTOCC President
Cheri Lattimer, RN, BSN, NTOCC Executive Director

Abstract: The COVID-19 pandemic has brought about unprecedented challenges for healthcare providers and their patients, highlighting the need for smooth transitions and care coordination.  This session will look at the issues that the COVID-19 pandemic has presented to the healthcare community.  Using the newly developed COVID-19 Pathway the speakers will describe the pathway, tools and resources that enable multidisciplinary transitions of care across health care settings.  

Objectives:

1. Review the epidemiology of the COVID-19 virus 
2. Identify the critical gaps in care transitions and coordination of patients with COVID-19
3. Assess interprofessional strategies that support effective care coordination 
4. Define a comprehensive hospital transition plan that supports patient and family caregiver factors
5. Apply interprofessional strategies and resource for enhanced communication with patients and their family caregivers

Bio's:
Dr. James Lett II, MD is a geriatric medicine specialist in Rockville, MD and has been practicing for 42 years. He graduated from University of Kentucky, College Of Medicine in 1974 and specializes in geriatric medicine.  He has more than forty years of medical practice that has included office, hospital, sub-acute and long-term care settings, and been a nursing facility medical director for more than 20 years. Dr. Lett has long been active in medical organizations, having served as president of such organizations on local, state, and national levels including as President of AMDA. He has written and spoken for a number of years about various long-term care subjects and the care of frail elders.  He was a founding member of the National Transitions of Care Coalition and currently serves as the Coalition’s President.

Cheri Lattimer, RN, BSN, is Executive Director for the National Transitions of Care Coalition (NTOCC) and President/CEO of Integrity Advocacy & Management. Her leadership in quality improvement, case management, care coordination, and transitions of care is known on the national and international landscape. She is affiliated with various professional organizations and maintains active roles on several national boards and committees including URAC’s Health Standards Committee, CMS Caregiver Workgroup, CMS Advisory Committee for Education and Outreach, ACHIEVE, ABQAURP CME Committee, and American Nurses Association.

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the National Transitions of Care Coalition (NTOCC).  ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hours through the Florida Board of Nursing, Provider # 50-94.

REGISTER HERE FOR APRIL 6

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Summary: This presentation will present a multidisciplinary approach to transitions of care with an emphasis on incorporating the role of a pharmacist. The discussion will include assisting transitioning patients and residents from hospital to home, hospital to nursing facilities, and nursing facilities to the home. Medication changes are frequent within each setting and unfortunately, changes are often lost in transition. Pharmacists can provide a skill set that helps ensure an optimal medication regimen. The current pandemic has brought special challenges to identifying medication concerns and techniques to work in this environment will also be discussed.

Objectives:

1. Review a model for Transition of Care incorporated in one hospital system and its evolution over time.

2. Discuss the benefits of an interdisciplinary team including nurses, social workers, community health workers, dieticians, pharmacists, and pharmacy technicians in providing care through transitioning to different settings.

3. Describe intervention settings and benefits of each including telephonic, hospital visit, attend physician visit, and home visits.

4. List obstacles encountered in ensuring optimal medication management and ways to tackle such obstacles.

5. Detail challenges encountered with recent pandemic and tools and skills incorporated to ensure the optimal impact on patient care.

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the National Transitions of Care Coalition (NTOCC).  ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hours through the Florida Board of Nursing, Provider # 50-94.

BIO: Tricia resides in Frederick County, Maryland, and is currently employed with Frederick Regional Health System as a pharmacist with community physicians and other providers through the Frederick Integrated Health Network. She received her Bachelors of Science in Pharmacy and her Doctor of Pharmacy from Purdue University and is a Certified Geriatric Pharmacist as well as Certified Care Professional. Her experience includes many years working in the long term care environment as well as working in a federal funded community health center, retail and hospital practice.

*This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the National Transitions of Care Coalition (NTOCC).  ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hours through the Florida Board of Nursing, Provider # 50-94.

CMS BI-MONTHLY FORUM; HEAR IMPORTANT

UPDATES TO CMS QUALITY PROGRAMS

The Centers for Medicare & Medicaid Services (CMS) Quality Programs Bi-Monthly Forum will be held on Tuesday, January 26, from 2:30 – 3:30 p.m. ET. During this webinar, attendees will learn important updates relevant to CMS’s Quality Measurement and Value-Based Incentives Group (QMVIG). The forum will also provide stakeholders with the opportunity to ask CMS subject matter experts questions on quality reporting programs and initiatives that directly impact their organizations.

This forum will include the following topics:

• Medicare Promoting Interoperability Program Updates

• CMS QRDA I and III Implementation Guide Updates

• eCQI Resource Center Improvements

• Quality Payment Program Updates

• Care Compare Updates

Participation Information

Please use the link below to register for the January 26 forum. You will not be able to share your participant information because it will be unique to you. Please check your spam filter if you do not receive an email confirmation. You can also use the link below to share this event with your colleagues.                               

• Registration URL: https://register.gotowebinar.com/register/7277077437102865936

• Webinar ID: 803-908-283

Please note that registration for this webinar is limited, but the forum’s slide deck will be posted to the Promoting Interoperability Events webpage in the weeks following the webinar.

For More Information

If you have questions regarding registration, know of others who would like to be included in future communications regarding the forum, or prefer not to receive these communications, please email CMSQualityTeam@ketchum.com.

The Quality Measurement and Value-Based Incentives Group (QMVIG) is part of the CMS Center for Clinical Standards and Quality. QMVIG brings you programs on meaningful measure development, health information technology, quality compare programs (etc.).

Join CMS on January 21st for the CHART Model Community Transformation Track Payment Webinar

The Centers for Medicare & Medicaid Services (CMS) will host a webinar on January 21, 2021 to provide an overview of the Community Health Access and Rural Transformation (CHART) Model Community Transformation Track payment policies.

The CHART Model Community Transformation Track will test whether upfront investments, predictable capitated payments, and operational and regulatory flexibilities will enable rural health care providers to improve access to high quality care while reducing health care costs.

During the session, the CHART Model team will discuss the Community Transformation Track payment policies and provide additional guidance on how payments are calculated throughout the duration of the model. The forum will also provide an opportunity for attendees to ask the CHART Model team questions regarding these topics.

Session information and registration link are included below. Please feel free to submit questions in advance to our team using the field at the end of the registration form or by emailing CHARTModel@cms.hhs.gov

CHART Payment Webinar:

Thursday, January 21, 3:00-4:30pm ET

Register to attend here:

https://deloitte.zoom.us/webinar/register/WN_KhEZumzWTaOG92cMFkHubg

Feel free to forward this event to colleagues who may be interested in learning more about the CHART Model. Following the events, presentation materials will be available on the CHART Model webpage (https://innovation.cms.gov/innovation-models/chart-model).

You may contact the CHART Help Desk at CHARTModel@cms.hhs.gov with questions. To stay up to date on upcoming model announcements, events, and resources, join our CHART Listserv by visiting the CHART Model webpage at https://innovation.cms.gov/innovation-models/chart-model.

Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page.