Care Transitions Today

This episode is co-presented by the Association of Physician Leadership in Care Management and the American Case Management Association. In this episode, we are joined by two physicians, Dr. Rebecca Severe, a Hospital Medicine-certified physician serving as Medical Director of Care Management for Advocate Aurora Health and Dr. Sweta Singh, Medical Director of Care Management at the University of Michigan Medical School.

In this conversation, Rebecca and Sweta discuss two different cases involving Medicare patients. The first case, a patient who underwent back surgery was initially downgraded to outpatient status, but later needed to be converted back to inpatient status. In the second case, an elderly patient with multiple medical conditions presented with lower abdominal pain after a hip replacement surgery. The decision to convert the patient to inpatient status is discussed, along with considerations for commercial payers. Overall, the conversation highlights the importance of proper documentation and timely decision-making in determining the appropriate status for patients.

The Association of Physician Leadership in Care Management, or APLCM, was created to provide support and education for physicians in this field. APLCM is unique because of its connection to the American Case Management Association, focusing on the partnership and collaborative model of nurse case managers, social workers, and physicians in care management. ACMA has a rich, 25-year history of supporting the case management field.

This episode is co-presented by the Association of Physician Leadership in Care Management and the American Case Management Association. In this episode, we are joined by two physicians, Dr. Rebecca Severe, a Hospital Medicine-certified physician serving as Medical Director of Care Management for Advocate Aurora Health, and Dr. Sweta Singh, Medical Director of Care Management at the University of Michigan Medical School.

In this episode, our physicians discuss two intriguing cases. The first case involves a 67-year-old female with a history of COPD and aortic stenosis who presents with shortness of breath and fever. The doctors discuss whether the patient should be admitted as an inpatient or placed in observation status. The second case involves a 71-year-old female with a history of seizures who is undergoing long-term EEG monitoring. The doctors discuss the challenges of obtaining inpatient status for planned admissions and the importance of documentation in justifying the need for inpatient care.

The Association of Physician Leadership in Care Management, or APLCM, was created to provide support and education for physicians in this field. APLCM is unique because of its connection to the American Case Management Association, focusing on the partnership and collaborative model of nurse case managers, social workers, and physicians in care management. ACMA has a rich, 25-year history of supporting the case management field.

This episode is presented by the American Case Management Association and sponsored by Xsolis. Join our host, Deb McElroy, along with featured guest, Rikki Moye. Rikki is a registered nurse with 20 years of progressive leadership experience in the field of Case Management. She has been the Vice President of Case Management for the Oklahoma division of Ardent Healthcare, Hillcrest HealthCare System for the last 5 years. Her responsibilities include planning, managing, directing and evaluating the activities, functions and the personnel of the division Case Management program.  In this episode, the discussion focuses on innovative ways in which technology has been leveraged, leading to a redesigned care management model and improved outcomes. They also dive into implications for the future.

Today’s episode is presented by the American Case Management Association. Join our host, Deb McElroy, along with featured guest, Dr. Vikram Patel. Dr. Patel is the Pershing Square Professor of Global Health and Wellcome Trust Principal Research Fellow at the Harvard Medical School. He is a psychiatrist whose work over the past two decades has focused on addressing the vast unmet needs for mental health care, especially in low resourced settings.  He holds honorary professorships at the Harvard TH Chan School of Public Health, the Public Health Foundation of India, and the London School of Hygiene & Tropical Medicine.

The pandemic has led to an economic downturn and associated increase in the prevalence of mental health problems globally and considerably worsened the pre-existing crisis of unmet need for care. Dr. Patel argues this presents a historic opportunity to reimagine mental health care, by scaling interventions designed to improve the access, quality, and person-centered features of care. Several programs are discussed throughout this discussion, including the Mental Health for All Lab, the Global Mental Health Initiative at Harvard and Sangath.

Resources referenced by Dr. Patel include:

This episode is presented by the American Case Management Association. Join our host, Deb McElroy, along with featured guest, Thomas Rhodes. Thomas has over 16 years of experience in respiratory care with ten of those years in leadership. He currently oversees two locations for Houston Methodist. Today the conversation focuses on the impact of a respiratory therapist led COPD education program on acute care hospital readmissions.

This episode is presented by the American Case Management Association. Join our host, Deb McElroy, along with featured guest, Kathleen Bellamy. Kathleen has been an inpatient case manager at the Arthur James Cancer Hospital at the Ohio State University Wexner Medical Center for almost 28 years. Today the conversation is centered around the development, implementation, challenges, and advantages of a case management clinical ladder. The work discussed in this episode won the most innovative poster presentation at the 2019 National ACMA conference.

This episode is presented by the American Case Management Association (ACMA). Join our host, Deb McElroy, along with featured guests from Trinity Health - Colleen Fitzgerald and Kyle McDaniel, and from the ACMA, Kathleen Ferket. In this episode, the discussion addresses the application of case management simulation, the process for implementation, how simulation for the case management teams is used to improve care transitions, and much more.

This episode is presented by the American Case Management Association. Join our host, Deb McElroy, along with featured guests from the Hartford HealthCare Center for Healthy Aging, Wendy Martinson and Michelle Wyman. This episode discusses Caregiver Coaching, an approach to case management for persons with dementia. This approach won the most innovative poster presentation at the 2018 National ACMA conference.

The conversation walks through the initial signs and symptoms of dementia, ways to increase the quality of life for people with dementia, options for long term case management, and resources available for the caregiver of the person with dementia.

This episode is presented by the American Case Management Association. Join our host, Deb McElroy, along with featured guest, Kim Brady. Kim is the System Director of Care Management at United Health Services. In this episode, the conversation is centered around the role artificial intelligence has played in risk stratification, efficiency, care management satisfaction, observation rates, patient safety, and more.

This episode is presented by the American Case Management Association. Join our host, Deb McElroy, along with featured guest, Sarah Bradshaw. Sarah is the principal investigator for the research and development of the High Acuity Readmission Risk Pediatric Screen Tool, also known as the HARRPS Tool. She has presented her quality improvement and research findings at several regional and national conferences and has been published in the Journal of Pediatric Nursing and the American Case Management Association’s Collaborative Case Management publication.

In this episode, the conversation is centered around identifying patients at risk for poor transitions, quality improvement, and the process for development of the High-Acuity Readmission Risk Pediatric Screen Tool.

This episode is presented by the American Case Management Association . Join our host, Deb McElroy, along with featured guest, Marlene Bober. Marlene is currently the VP of Practice Development at the American Case Management Association (ACMA). In this episode, the discussion addresses plans and strategies for emergency preparedness, successful models for staffing and communication, and what steps ACMA has taken to support members and the case management community throughout the COVID-19 pandemic.

This episode is presented by the American Case Management Association and sponsored by Shirley Ryan AbilityLab and Paradigm. 

Join our host, Deb McElroy, along with featured guests, Dr. Leslie Rydberg, Diane Rowles, and Sheila Bennion. Their discussion addresses transitioning COVID-19 patients to rehabilitation facilities, identifying aspects of good rehab programs for COVID-19 patients, psychosocial issues and challenges faced by patients after COVID-19, and includes innovative processes for managing cases when access to the patient is limited. They also focus on the lasting rehab and support needs of patients and much more.

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation. Join our host, Deb McElroy, along with featured guest, Dr. Ariana Peters. Dr. Peters is currently a board member of the Association of Physician Leadership in Care Management (APLCM). In this episode, the conversation involves a reflection of the changes and challenges that arose during the COVID-19 pandemic, the impact the pandemic has had on the roles of physician advisors, how staff’s emotional well-being was addressed, and much more.

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation. Join our host, Deb McElroy, along with featured guests, Dr. Robert Grant and Dr. Julie Mirkin from New York. Their discussion addresses lessons learned during the height of the pandemic in New York including innovative work processes for staffing, workload, and emergency preparedness. They also focus on the lasting impact of COVID-19 in case management and transitions of care practice and much more.

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation. Join our host, Deb McElroy, along with featured guest Diane DiFiore, Director of Care Management, Development, and Education at Beaumont Health. Their conversation highlights training for case management staff during the COVID-19 pandemic, how staff was educated about ongoing changes in legislation and processes, challenges faced, and more.

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation. Join our host, Deb McElroy, along with featured guest and Chair of ACMA Public Policy Committee, Pat Kramer, in their discussion regarding changes in public policy, information regarding CMS waivers , current and future ACMA advocacy efforts, and much more!

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation. Join our host, Deb McElroy, along with featured guest and National ACMA Board Member, Lynn Bree, in their discussion regarding the payer perspective of COVID-19, information regarding how health plans are working to assist providers and members, a look into 2021 and beyond, and much more!

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation.  

Join our host, Deb McElroy, along with featured guest Max Perkins, Senior VP of Lobbyit, in their discussion regarding the regulatory impact of COVID-19, potential changes in the future, and much more.

This episode is presented by the American Case Management Association and underwritten by The Pfizer Foundation.  

Joining host Deb McElroy are two leaders from Trinity Health - Mary Beth Pace, VP of Care Management, and Sheila Johnson, VP of Population Health Clinical Operations. Here they will dive into the impact of COVID-19 on population health, lessons learned, challenges faced during this crisis, and more.