The Role of Home Health in Reducing The Role of Home Health in Reducing Acute Care Hospitalizations: Acute Care Hospitalizations:

An Agency Case StudyAn Agency Case Study

Care Transitions . . .Care Transitions . . .

The movement patients make The movement patients make between health care practitioners between health care practitioners and settings as their condition and and settings as their condition and care needs change during the care needs change during the course of a chronic or acute illness.course of a chronic or acute illness.

Care Transitions InterventionSM , Eric Coleman, MD, MPH

““Care transitions is a team Care transitions is a team sport, and yet all too often sport, and yet all too often

we don’t know who our we don’t know who our teammates are, or how they teammates are, or how they

can help.”can help.”

-Eric Coleman, MD, MPH-Eric Coleman, MD, MPH

Home Health is on Home Health is on your team!your team!

CUTE

ARE

OSPITALIZATION

Acute Care Acute Care Hospitalizations . . .Hospitalizations . . . Cost about $ 3506 per dayCost about $ 3506 per day Have an average LOS of 5.9 daysHave an average LOS of 5.9 days Occur much more frequently for Occur much more frequently for

patients with chronic conditionspatients with chronic conditions Occur in 1 out of 4 home health Occur in 1 out of 4 home health

pt. episodes pt. episodes

Medicare Readmissions: Medicare Readmissions: WE ARE BEING WATCHED . . .WE ARE BEING WATCHED . . .

Medicare Payment Advisory Commission (MedPAC) 19.6% or 1/5 of 12 million Medicare

beneficiaries in 2003 or 2004 were re-hospitalized within 30 days of discharge from the hospital

Up to 76 % of these readmissions may be preventable

64% of those readmitted, received NO post-acute care between discharge & readmission – home health underutilized

* MedPAC June 2007 report to Congress

A New England Journal of Medicine study . . .

Found that in 2003-2004, 1/3 or 34% of discharged patients were rehospitalized within 90 days

Shocking news . . .

Of all of the patients in the NEJM study who were re-hospitalized, only

9% were homecare patients!

FACT:HOME HEALTH CARE CAN MOST

DEFINITELY HELP DECREASE HOSPITAL RE-ADMISSIONS

MedPac study 2007 MedPac study 2007 discovered . . .discovered . . .

““Patients’ adherence to discharge Patients’ adherence to discharge instructions also affects hospitals’ instructions also affects hospitals’ readmission rates”readmission rates”

We need to make sure that We need to make sure that knowledge sharing between knowledge sharing between

clinicians and patients and their clinicians and patients and their families is maximized – families is maximized –

IMPROVED COMMUNICATION!!IMPROVED COMMUNICATION!!

AVOIDABLE HOSPITAL AVOIDABLE HOSPITAL RE-ADMISSIONS ARE . . RE-ADMISSIONS ARE . . ..

A QUALITY PROBLEMA QUALITY PROBLEM A SAFETY PROBLEMA SAFETY PROBLEM THE MOST IMMEDIATELY THE MOST IMMEDIATELY

ACTIONABLE DRIVER OF ACTIONABLE DRIVER OF EXCESSIVE COSTSEXCESSIVE COSTS

Common reasons people Common reasons people return to the hospital after return to the hospital after discharge:discharge:PROBLEMSPROBLEMS1) Problems with medicines1) Problems with medicines

2) Not getting a timely follow-2) Not getting a timely follow-up visit with physicianup visit with physician

3) Not recognizing early signs 3) Not recognizing early signs of trouble OR of trouble OR RED FLAGS!RED FLAGS!

Home Health can intervene Home Health can intervene and help to resolve all of and help to resolve all of these issues!these issues!

HOME HEALTH CANHOME HEALTH CAN

1) Reconcile meds and 1) Reconcile meds and communicate with communicate with physician’s officephysician’s office

2)Encourage pt. to keep 2)Encourage pt. to keep appt. and help appt. and help arrange transportationarrange transportation

3) Teach pt. 3) Teach pt. RED FLAGS RED FLAGS & communicate & communicate immediately with immediately with physician’s office or physician’s office or Care Manager Care Manager

FACTS:FACTS:Through the use of best practices and home care, these hospitalizations and expenses may have been avoided

Increased hospitalizations for patients can translate into decreased reimbursement for physicians (Medicare and private insurances)

FACT:FACT:

Best Practices:Best Practices:

Evidence-based practicetechniques or methodologies that, through experience and research, has been proven to reliably lead to a desired result. (ie. good health outcome)

WHAT WORKS!

Best Practice Intervention Package (BPIP) - Home Health Quality Campaign, Quality Insights

The WINNING EQUATION . . .

Current State of Post-Acute Current State of Post-Acute Care- Care- Fragmentation and Practice Variation are Fragmentation and Practice Variation are Barriers to Quality & EfficiencyBarriers to Quality & Efficiency

ACUTE CARE

POST-ACUTE CARE

ONGOING CHRONIC

CARE

POST ACUTE

AT HOME

VALUE

The missing The missing puzzle piece . . .puzzle piece . . .

Teaching the patient HOW to get Teaching the patient HOW to get well well

and stay well!and stay well!

(SELF-MANAGEMENT (SELF-MANAGEMENT

SKILLS)SKILLS)

Do Home Care Interventions Reduce Do Home Care Interventions Reduce Readmissions?Readmissions?REFERENCES:REFERENCES:

Phillips CO et al.”Comprehensive discharge planning with Phillips CO et al.”Comprehensive discharge planning with postdischarge support for older patients with congestive heart postdischarge support for older patients with congestive heart failure: a meta-analysis.” JAMA.2004 Mar17:291(11):1358-67.failure: a meta-analysis.” JAMA.2004 Mar17:291(11):1358-67.

DESCRIPTION:DESCRIPTION:

Pooled analysis of 18 randomized controlled clinical trialsPooled analysis of 18 randomized controlled clinical trials

RELEVANCE TO HOME CARE:RELEVANCE TO HOME CARE:

11 OF 18 TRIALS INCLUDED HOME VISITATION11 OF 18 TRIALS INCLUDED HOME VISITATION

RESULTS:

After mean follow-up of 8 months with home visit intervention had lower readmission rates - 35% vs 43% Subgroup of trials with home visit performed better

adequately checks the patient's health condition at each visit to detect problems early. assesses the patient's ability to eat, drink, and take medication, and to live safely in their home.coordinates the patient's care by regularly communicating with patients, informal caregivers, doctors, and other care providers.

Acute care hospitalization may be avoided if the home health nurse. . .

Home Health Care Home Health Care can…can… Provide skilled physical assessmentProvide skilled physical assessment Teach the patient and/or their family daily skills Teach the patient and/or their family daily skills

to manage their disease (1:1) SELF-CAREto manage their disease (1:1) SELF-CARE Communicate with the Medical Home worker to Communicate with the Medical Home worker to

alert them of potential problems –alert them of potential problems –RED FLAGSRED FLAGS Provide resolution for the identified problem and Provide resolution for the identified problem and

prevent hospitalizationprevent hospitalization Provide medication reconciliation Provide medication reconciliation (make sure (make sure

the patient is taking the right meds)the patient is taking the right meds) Set up pre-filled med boxes/syringes with Set up pre-filled med boxes/syringes with

pharmacypharmacy

Medicare covers home Medicare covers home health if . . .health if . . . There is an intermittent skilled need There is an intermittent skilled need

(wound, IV, diabetes skills, Med (wound, IV, diabetes skills, Med management, unstable physical management, unstable physical status, ambulation dysfunction)status, ambulation dysfunction)

There is a doctor’s orderThere is a doctor’s order The patient is homebound – The patient is homebound – (def) pt (def) pt

does not leave home frequently or for does not leave home frequently or for long periods and has difficulty leaving long periods and has difficulty leaving the homethe home

Homebound means. . .Homebound means. . .

there is a normal inability to there is a normal inability to leave home and, therefore, leave home and, therefore, leaving home requires a leaving home requires a considerable and taxing effort.considerable and taxing effort.

Pt may be SOB, have poor Pt may be SOB, have poor endurance, or have endurance, or have ambulation/movement difficulties ambulation/movement difficulties

-”Coverage Guide for Home Health Agencies”, Medicare Reference Guide, August 2006,CMS Pub. 100-2, Ch.7 , §30.1

Homebound Criteria 1Homebound Criteria 1

Patient’s medical condition Patient’s medical condition restricts the ability to leave home restricts the ability to leave home without the assistance of another without the assistance of another individual or without the individual or without the assistance of a supportive device assistance of a supportive device (cane, walker, wheelchair)(cane, walker, wheelchair)

-”Coverage Guide for Home Health Agencies”, Medicare Reference Guide, August 2006,CMS Pub. 100-2, Ch.7 , 30.1

Homebound Criteria 2Homebound Criteria 2

Patient leaves home only to Patient leaves home only to receive medical treatment that receive medical treatment that generally cannot be provided in generally cannot be provided in the home OR leaves the home the home OR leaves the home infrequently; for short periods for infrequently; for short periods for non-medical purposes or to non-medical purposes or to attend a religious service or attend a religious service or unique event.unique event.

-”Coverage Guide for Home Health Agencies”, Medicare Reference Guide, August 2006,CMS Pub. 100-2, Ch.7 , 30.1

Patient is still considered Patient is still considered to be homebound if to be homebound if he/she. . he/she. . .. goes to adult day-caregoes to adult day-care goes to religious servicesgoes to religious services goes to get their hair done goes to get their hair done

infrequentlyinfrequently goes to unique events such as goes to unique events such as

family reunion, funeral or family reunion, funeral or graduation as long as absences graduation as long as absences are of short durationare of short duration

Patient is Patient is notnot homebound if he/she:homebound if he/she: goes to workgoes to work goes to a Senior Centergoes to a Senior Center goes out to eat every daygoes out to eat every day goes on trips, bingo or to the casinogoes on trips, bingo or to the casino

THESE PATIENTS WOULD NOT BE COVERED UNDER THE HOME HEALTH MEDICARE BENEFIT

Care Managers can:Care Managers can:

Check patient post-discharge for signs Check patient post-discharge for signs of non-compliance or lack of of non-compliance or lack of knowledge about their care /meds and knowledge about their care /meds and for insufficient support for self- for insufficient support for self- management in the home.management in the home.

Intervene Intervene immediatelyimmediately,, if necessary if necessary Set up F/U appt with physician within Set up F/U appt with physician within

1 week and refer to 1 week and refer to HOME HEALTH HOME HEALTH if if needed.needed.

Individuals with at least one of the Individuals with at least one of the following should be considered for home following should be considered for home care:care:

Cognitive ImpairmentCognitive Impairment COPDCOPD DiabetesDiabetes Frequent Hospitalization for any causeFrequent Hospitalization for any cause History of depressionHistory of depression Low Output state (classic CHF symptoms)Low Output state (classic CHF symptoms) Multiple Active co-morbiditiesMultiple Active co-morbidities Persistent New York Heart Association Classification III or IV Persistent New York Heart Association Classification III or IV

symptomssymptoms Persistent non-adherence to treatment regimensPersistent non-adherence to treatment regimens Renal insufficiencyRenal insufficiency

*Excerpted from Iowa Health System standardized protocols for patients with heart *Excerpted from Iowa Health System standardized protocols for patients with heart failurefailure

Medical Home Medical Home GuidelinesGuidelines RIGHT CARERIGHT CARE RIGHT PATIENTRIGHT PATIENT RIGHT SETTINGRIGHT SETTING RIGHT INSTRUCTIONSRIGHT INSTRUCTIONS Physician is the “Quarterback” of Physician is the “Quarterback” of

the teamthe team Medical Home Worker / Care Medical Home Worker / Care

Manager is the coordinator of care Manager is the coordinator of care “ “ the communicator / organizer”the communicator / organizer”

Medical Home Model Medical Home Model Provides . . .Provides . . .

Better quality of care at a Better quality of care at a

lower costlower costDecreased ACHDecreased ACHMore preventative care More preventative care Better coordination of careBetter coordination of care

Medical Home Medical Home GuidelinesGuidelines

Identify those discharged patients who Identify those discharged patients who are at a greater risk for re-hospitalizationare at a greater risk for re-hospitalization

Make 1Make 1stst contact with pt post D/C within contact with pt post D/C within 48 hours -48 hours -did the pt. pick up their meds? are there did the pt. pick up their meds? are there signs of non-compliance? are they confused about their signs of non-compliance? are they confused about their meds ? assess if pt needs and is agreeable to home health meds ? assess if pt needs and is agreeable to home health

Make f/u Physician appt. within the week Make f/u Physician appt. within the week if possibleif possible

Maintain ongoing communication & Maintain ongoing communication & follow-up re: patient (verbal vs. electronic follow-up re: patient (verbal vs. electronic or both)or both)

Our Challenge- working together we can . . .Decrease healthcare

spending by decreasing volume and utilization of services, specifically ACH, while achieving positive patient outcomes.

Complete Home Care :Complete Home Care :A Case Study of Care Coordination and A Case Study of Care Coordination and Decreasing Acute Care HospitalizationsDecreasing Acute Care Hospitalizations

Our Success:Our Success:

ACH Rate

by 41% !!

Complete Home Care Complete Home Care

We have been extremely involved We have been extremely involved in implementing our own ACH in implementing our own ACH Program, in conjunction with Quality Program, in conjunction with Quality Insights of PA (QIO) since 2004 Insights of PA (QIO) since 2004

In 2005, we were 1 of 3 agencies in In 2005, we were 1 of 3 agencies in PA chosen to participate in a pilot PA chosen to participate in a pilot program using telehealth to program using telehealth to decrease ACHdecrease ACH

Complete Home CareComplete Home CareACH Telehealth ACH Telehealth ProgramProgram

Identifies patients at risk on admissionIdentifies patients at risk on admission

by completion of our self-designedby completion of our self-designed Hospital Risk Assessment FormHospital Risk Assessment Form SEE APPENDIX ASEE APPENDIX A

Risk factors were derived from actual Risk factors were derived from actual agency patient population statisticsagency patient population statistics

Score obtained from this assessment Score obtained from this assessment determines telehealth eligibilitydetermines telehealth eligibility

Our patients are more likely to be rehospitalized if they: Are poor and live alone Came to home care from an inpatient

facility Had higher functional deficits in ADL’s Had difficulty managing meds Experienced difficulty breathing Had more than 2 secondary diagnoses Were admitted to home care with Dx of

diabetes, cardiac or chronic skin ulcers without a self-care management plan in place

* Based on a case study of Complete Home Care patients (2006)

Patients Identified at Patients Identified at Risk for ACH and Eligible Risk for ACH and Eligible for Telehealth for Telehealth Receive front loaded home health Receive front loaded home health

visits in the first 2 weeks after visits in the first 2 weeks after admissionadmission

Receive telephone monitoring Receive telephone monitoring calls from home health nurses on calls from home health nurses on designated days in-between when designated days in-between when nursing visits not made, including nursing visits not made, including weekendsweekends

Receive individualized teaching, Receive individualized teaching, counseling and tele-triage, if counseling and tele-triage, if necessary during the telephone necessary during the telephone monitoring callmonitoring call

Receive a PRN nursing visit, if Receive a PRN nursing visit, if warranted, or physician may be warranted, or physician may be notified of any adverse condition notified of any adverse condition identified during the callidentified during the call

Emergency ProceduresEmergency Procedures

Complete Home Care has incorporated Complete Home Care has incorporated Emergency Access Information into Emergency Access Information into every pt. admission packetevery pt. admission packet

Patients are instructed to call Complete Patients are instructed to call Complete Home Care Home Care FIRSTFIRST for any problems, for any problems, unless chest pain (unresponsive to unless chest pain (unresponsive to meds) or severe SOB occurs when they meds) or severe SOB occurs when they are told to go directly to ERare told to go directly to ER

Emergency ProceduresEmergency Procedures Are reviewed and reinforced at Are reviewed and reinforced at every every

nursing visit to remind the patient that nursing visit to remind the patient that we have nursing staff (RN’S) available we have nursing staff (RN’S) available 24/7 to address any problems or concerns24/7 to address any problems or concerns

All emergency calls are handled quickly All emergency calls are handled quickly and PRN nursing visits will be made if and PRN nursing visits will be made if necessary to manage the situation at necessary to manage the situation at homehome

Emergency ProceduresEmergency Procedures

Every attempt will be made to Every attempt will be made to manage the patient situation in manage the patient situation in the home through communication the home through communication with the physician or Medical with the physician or Medical Home / Care ManagerHome / Care Manager

CHC staff are proficient with high-CHC staff are proficient with high-tech skills that may be needed to tech skills that may be needed to treat the pt. at home (IV’s, pulse treat the pt. at home (IV’s, pulse ox, KCI VAC etc.)ox, KCI VAC etc.)

CHC Outcomes in Acute Care Hospitalizations

CHC ACH Rate

State ACH Rate

National ACH Rate

3/2006 32% 26% 28%

11/2007 20% 25% 29%

04/2010 19% 27% 29%

** Remember lower numbers are better here!!

%

ACH Home Health Compare - CHC

Other Measures CHC Other Measures CHC uses to Decrease uses to Decrease

Hospitalization RatesHospitalization Rates

Electronic Medical Electronic Medical RecordRecord Each nurse has a mini-laptop that is Each nurse has a mini-laptop that is

able to access all patient information able to access all patient information and our clinical software system and our clinical software system from the patient homefrom the patient home

Patient data can be monitored and Patient data can be monitored and modified in “real-time” connecting modified in “real-time” connecting what is currently happening with the what is currently happening with the patient to our office systempatient to our office system

Electronic Medical Electronic Medical RecordRecord Nurses have the ability to access Nurses have the ability to access

Internet resources right from the patient Internet resources right from the patient home to look up meds, disease-related home to look up meds, disease-related information and patient teaching.information and patient teaching.

Nurses can access pt. current med list Nurses can access pt. current med list and labworkand labwork

This helps to greatly improve the value This helps to greatly improve the value and quality of patient assessment & and quality of patient assessment & teaching at each nursing visit.teaching at each nursing visit.

S-BAR ToolS-BAR ToolSSituation ituation BBackgroundackground AAssessmentssessment & &

RRecommendation ecommendation SEE APPENDIX BSEE APPENDIX B

CHC developed its own version of the CHC developed its own version of the S-BAR Communication Tool S-BAR Communication Tool

Tool is faxed to physiciansTool is faxed to physicians Intended to improve physician Intended to improve physician

communication, care coordination and communication, care coordination and more efficient management of pt more efficient management of pt issuesissues

Intended to decrease hospitalization Intended to decrease hospitalization by expediting management of adverse by expediting management of adverse pt situations at homept situations at home

S-BAR Tool BenefitsS-BAR Tool Benefits

Quicker response time for patient Quicker response time for patient issues / problemsissues / problems

RED FLAGS RED FLAGS being managed more being managed more efficientlyefficiently

Physicians can use the tool as an Physicians can use the tool as an order and fax right back to us order and fax right back to us manage the patient problem manage the patient problem

Individualized Pt. Individualized Pt. TeachingTeaching Nurses teach pt /caregiver specific s/s Nurses teach pt /caregiver specific s/s

of worsening condition of worsening condition (RED FLAGS) (RED FLAGS) relative to their primary disease and relative to their primary disease and co-morbiditiesco-morbidities

Nurses teach Nurses teach self-management skills self-management skills and require return demonstration and and require return demonstration and knowledge comprehension to prevent knowledge comprehension to prevent future exacerbations and future exacerbations and hospitalizationshospitalizations

CHF Patient Best CHF Patient Best PracticesPractices - CHC will . - CHC will . . .. .

Teach pt to weigh themselves and fill out Teach pt to weigh themselves and fill out daily CHF symptom log (Self-Care Booklet daily CHF symptom log (Self-Care Booklet provided)provided)

For those patients who do not have a working For those patients who do not have a working scale, our agency provides them with a scale scale, our agency provides them with a scale at no costat no cost

Teach about CHF ZONES and what to do Teach about CHF ZONES and what to do **SEE SEE

APPENDIX CAPPENDIX C

Teach about diet – LOW SALTTeach about diet – LOW SALT Teach about meds and check complianceTeach about meds and check compliance Alert the medical home worker for problemsAlert the medical home worker for problems

Other Patient Best Other Patient Best PracticesPractices - CHC will . - CHC will . . .. . Arrange for pre-poured med boxes or Arrange for pre-poured med boxes or

pre-filled insulin syringes for patients pre-filled insulin syringes for patients who need itwho need it

Teach patient or a family member Teach patient or a family member how to correctly fill med boxhow to correctly fill med box

Will alert Medical Home worker of Will alert Medical Home worker of patient non-compliance with meds, or patient non-compliance with meds, or symptoms of potential problems, etc.symptoms of potential problems, etc.

““Bottles Out Program”Bottles Out Program”

Every week the home health nurse Every week the home health nurse pulls out the patient’s med bottles and pulls out the patient’s med bottles and goes through each med and checks goes through each med and checks them against our current med listthem against our current med list

Pills may be countedPills may be counted Physician is contacted if there is a Physician is contacted if there is a

discrepancydiscrepancy We have been doing this for the last We have been doing this for the last

10 years!10 years!

Quality Improvement Quality Improvement is our FOCUSis our FOCUS

CHC was an active participant in CHC was an active participant in each Quality Insights instructional each Quality Insights instructional session covering improving pt. session covering improving pt. outcomesoutcomes

CHC and staff were frequently CHC and staff were frequently quoted and noted in several quoted and noted in several issues of issues of Home Health InsightsHome Health Insights (a (a publication of Quality Insights of PA)publication of Quality Insights of PA)

- 2010- 2010

CHC is among the top 25% of home CHC is among the top 25% of home health agencies in the countryhealth agencies in the country

Based on quality outcomes and Based on quality outcomes and financial performance measuresfinancial performance measures

CHC is designated as one of the top CHC is designated as one of the top 500 agencies in the United States500 agencies in the United States

Chosen by Decision Health annuallyChosen by Decision Health annually

Home Health CompareHome Health Compare Check out this site and see how the agencies you Check out this site and see how the agencies you

are currently using have performed in their are currently using have performed in their outcomes and, more specifically, ACH outcomes and, more specifically, ACH

Ask your home health agencies about their Ask your home health agencies about their outcomes outcomes

Utilize home health agencies with consistently good Utilize home health agencies with consistently good outcomesoutcomes

www.medicare.gov/hhcompare/home.aspwww.medicare.gov/hhcompare/home.asp

Data obtained from the CMS Data obtained from the CMS Home Health Compare Home Health Compare website . . .website . . .

Reflects actual patient outcome data obtained from OASIS tool over a 12 month period

Each home health agency’s improvement in selected quality measures, is compared against State & National benchmark

Data is updated quarterly

Our Agency “Report Our Agency “Report Card”Card” Benchmarking ToolBenchmarking Tool Marketing toolMarketing tool Staff educationStaff education Quality improvement toolQuality improvement tool

We utilize it as:

* SEE APPENDIX D

Barriers to SuccessBarriers to Success

Patient in the wrong setting – not Patient in the wrong setting – not appropriate for home careappropriate for home care

Patient non-compliancePatient non-compliance Patient inability to learnPatient inability to learn Patient goes directly ER before calling usPatient goes directly ER before calling us Physician’s office unavail to see patient Physician’s office unavail to see patient

with a problemwith a problem Physician’s office slow or no response Physician’s office slow or no response

when called with pt. problemwhen called with pt. problem

Medical Home ModelMedical Home Model

Has made a huge difference in Has made a huge difference in breaking down these barriersbreaking down these barriers

Has made care, communication Has made care, communication and follow-up much more readily and follow-up much more readily available and effectiveavailable and effective

Will be a huge factor for future Will be a huge factor for future success in preventing ACHsuccess in preventing ACH

Our Commitment to prevent acute Our Commitment to prevent acute care hospitalizations within our agency care hospitalizations within our agency can help to decrease your group’s ACH can help to decrease your group’s ACH rate, rate, if you utilize usif you utilize us

Let’s put the pieces together and Let’s put the pieces together and make a difference to improve make a difference to improve healthcarehealthcare

Make home health agencies a member Make home health agencies a member of your team!of your team!

Working Together is the Key

In conclusion . . . Home Care is especially well-

positioned to impact hospital readmissions and work along with the Medical Home Model

TEAMWORK - utilizing best practices in the home and hospital/physician system, we can collaborate and share our success!

““Care transitions: when Care transitions: when getting there is getting there is NOTNOT half half

the fun.”the fun.”

-Robert Wood Johnson Foundation website-Robert Wood Johnson Foundation website

Patient’s View on Patient’s View on Medical Home Model . . Medical Home Model . . ..

Video courtesy of The Care Transitions Program – Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine.

Medical Home Medical Home Resources:Resources: http://www.medicalhomeforall.co

m/ http://www.quality net.orghttp://www.quality net.org http://www.qualitynet.org/dcs/Con

tentServer?c=MQPresentations&pagename=Medqic%2FMQPresentations%2FPresentationTemplate&cid=1200602400154

Helpful Sites / ToolsHelpful Sites / Tools

http://www.caretransitions.org http://www.transitionalcare.info/in

dex.html http://www.caretransitions.org/http://www.caretransitions.org/

provider_tools.aspprovider_tools.asp

Medical Home Medical Home Resources:Resources: DIABETESDIABETES http://www.qualitynet.org/dcs/Con

tentServer?c=MQPresentations&pagename=Medqic%2FMQPresentations%2FPresentationTemplate&cid=1214232435792

Medical Home Medical Home Resources:Resources: CHFCHF http://www.qualitynet.org/dcs/Con

tentServer?c=MQPresentations&pagename=Medqic%2FMQPresentations%2FPresentationTemplate&cid=1211554360806