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ForwardPCMH 2025 Post Hospital Follow-Up Sprint - Session #1
Participants will develop a deeper understanding of the Post Hospital Follow Up and Readmission Prevention Sprint key interventions and engage in peer to peer learning on strategies for implementation. Participants will also learn about root causes for the key interventions and effective strategies for increasing the percent of patients seen for follow-up within 10 days hospital discharge.
Agenda:
10:30 a.m. to 10:50 a.m. – Welcome & Presentation of the overall plan for the 2025 sprint, including goals, the description of the measure, and the quality improvement framework
• Share context for the measure
• Describe HEDIS measures and HealthChoices PCMH Program requirements around Post-Hospital Follow-up and Readmission
o Post-hospital follow-up in the HealthChoices PCMH Program requires a provider to see 75% of patients within ten days of discharge from the hospital with an ambulatory sensitive condition. This includes a follow-up visit with a specialist provider.
o Plan All Cause Readmissions - Count of Expected/Observed Ratio assesses the rate of adult acute inpatient and observation stays that were followed by an unplanned acute readmission for any diagnosis within 30 days after discharge among commercial (18 to 64), Medicaid (18 to 64) and Medicare (18 and older) health plan members.
• Q&A
10:50 a.m. to 11:20 a.m. – Panel on key intervention progress to date and discussion
• Nicole Hartung, LSW, Value-based Care Manager, Wayne Memorial Community Health Center o Implement telehealth calls for follow-up
• Erin McFadden, MD, Deputy Chief Medical Officer and Medical Director, The Wright Center o Coordinate with inpatient discharge planners and care teams for follow-up scheduling and shared plan of care
• Rachel Reis, BSN, RN-CCM, Director Care Coordination, Jefferson Health o Use systems for appointment completion reminders and follow-ups
11:20 a.m. to 11:40 a.m. Breakouts
• Identifying and prioritizing patients for post-discharge follow-up
• Getting people to complete follow-up appointments
11:40 a.m. to 11:50 a.m. – Takeaways
11:50 a.m. to 12:00 p.m. – Sprint Timeline, Next Steps & Evaluation
Target Audience
Nurse
Physician
Social Worker
Learning Objectives
• Establish a shared understanding of the 2025 PCMH Sprint goals and framework for addressing post-hospital follow-up and readmission prevention
• Define the key intervention each PCMH is implementing and next steps for making progress
• Identify the root cause(s) to address as part of each respective key intervention.
• Describe strategies for increasing the percent of patients seen within ten days of post-hospital follow-up.
Additional Information
| Attachment | Size |
|---|---|
 Audience Disclosure slides (001.5).pptx | 459.28 KB |
 Agenda_PostHospital_Mar19_HealthChoices PCMH Learning Network.pdf | 147.63 KB |
| 2025.3.19 - PCMH post hospital Sprint Session 1.pdf | 597.53 KB |
Participants will develop a deeper understanding of the Post Hospital Follow Up and Readmission Prevention Sprint key interventions and engage in peer to peer learning on strategies for implementation. Participants will also learn about root causes for the key interventions and effective strategies for increasing the percent of patients seen for follow-up within 10 days hospital discharge.
Participants will develop a deeper understanding of the Post Hospital Follow Up and Readmission Prevention Sprint key interventions and engage in peer to peer learning on strategies for implementation. Participants will also learn about root causes for the key interventions and effective strategies for increasing the percent of patients seen for follow-up within 10 days hospital discharge.
Agenda:
10:30 a.m. to 10:50 a.m. – Welcome & Presentation of the overall plan for the 2025 sprint, including goals, the description of the measure, and the quality improvement framework
• Share context for the measure
• Describe HEDIS measures and HealthChoices PCMH Program requirements around Post-Hospital Follow-up and Readmission
o Post-hospital follow-up in the HealthChoices PCMH Program requires a provider to see 75% of patients within ten days of discharge from the hospital with an ambulatory sensitive condition. This includes a follow-up visit with a specialist provider.
o Plan All Cause Readmissions - Count of Expected/Observed Ratio assesses the rate of adult acute inpatient and observation stays that were followed by an unplanned acute readmission for any diagnosis within 30 days after discharge among commercial (18 to 64), Medicaid (18 to 64) and Medicare (18 and older) health plan members.
• Q&A
10:50 a.m. to 11:20 a.m. – Panel on key intervention progress to date and discussion
• Nicole Hartung, LSW, Value-based Care Manager, Wayne Memorial Community Health Center o Implement telehealth calls for follow-up
• Erin McFadden, MD, Deputy Chief Medical Officer and Medical Director, The Wright Center o Coordinate with inpatient discharge planners and care teams for follow-up scheduling and shared plan of care
• Rachel Reis, BSN, RN-CCM, Director Care Coordination, Jefferson Health o Use systems for appointment completion reminders and follow-ups
11:20 a.m. to 11:40 a.m. Breakouts
• Identifying and prioritizing patients for post-discharge follow-up
• Getting people to complete follow-up appointments
11:40 a.m. to 11:50 a.m. – Takeaways
11:50 a.m. to 12:00 p.m. – Sprint Timeline, Next Steps & Evaluation
Nicole Hartung, LSW, Value-based Care Manager, Wayne Memorial Community Health Center
Erin McFadden, MD, Deputy Chief Medical Officer and Medical Director, The Wright Center
Rachel Reis, BSN, RN-CCM, Director Care Coordination, Jefferson Health
In support of improving patient care, this activity has been planned and implemented by the University of Pittsburgh and The Jewish Healthcare Foundation. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
As a Jointly Accredited Organization, University of Pittsburgh is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. University of Pittsburgh maintains responsibility for this course. Social workers completing this course receive 1.5 continuing education credits.
Physician (CME)
The University of Pittsburgh designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing (CNE)
The maximum number of hours awarded for this Continuing Nursing Education activity is 1.5 contact hours.
Social Work (ASWB)
The maximum number of hours awarded for this Continuing Social Work Education activity is 1.5 contact hours.
Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.
Available Credit
- 1.50 AMA PRA Category 1 Credit™The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
- 1.50 ANCCUPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
- 1.50 ASWB
- 1.50 Attendance