The Home-Based Care: National Leadership Conference features concurrent sessions from thought leaders in the home-based care industry in five topic-based tracks: Integrated Systems and Partnerships; Chronic Condition Management and Post-Acute Care; Advanced Illness and End-of-Life; Nonprofit Leadership; and Special Topics.

This activity has been submitted to the Maryland Nurses Association for approval to award contact hours. The Maryland Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation

Thursday, April 20

 

Session 1:  1:30 - 2:30 p.m.

 
 

Being An Integrated Partner in a Value-Based Market

Track: Integrated Systems and Partnerships

The market pressure to form integrated delivery systems has never been greater.  Former competitors are discovering ways to align and synergize their efforts, and fragments are struggling to create continua of care. But are these continua scalable and sustainable? Value-based care and payment is forcing provider organizations to consider how they work across the care continuum to drive down the total cost of care, while improving quality outcomes and patient experience.  What system requirements are necessary for home care organizations to capably sustain and reliably deliver services in the community? What are the imperatives for home care organizations to evidence in order for the industry to be recognized as a key driver of savings under value-based models.

Presenters:

  • Marki Flannery, MA, Executive Vice President and Chief of Provider Operations, Visiting Nurse Service of New York
  • Margherita Labson, RN, MSHSA, CPHQ, Executive Director, Home Care Program, The Joint Commission
  • Scott Vasey, Senior Vice President, Strategy, Visiting Nurse Service of New York

Mobile Technology for Home Health Care Patients

Track: Chronic Condition Management and Post-Acute Care

Presentation will describe the collaboration between Medocity and VNA Health Group in developing a mobile platform to provide the “next generation” of virtual patient support and care coordination. The focus of the platform’s design was to develop an approach that could easily communicate a patient’s symptoms, concerns and questions to their healthcare providers and allow the patient or clinician to schedule a virtual visit. Information will be provided on how the pilot was conducted to test the platform, data collected to evaluate clinician and patient experience, lessons learned and next steps in deploying the application.

Presenters:

  • Cathy Guttman, Vice President, Home Health and Post Acute Care, Medocity
  • Robert Rosati, PhD, Vice President of Data, Research and Quality, VNA Health Group

Marijuana in Home-Based Care: Street Drug, Medication or Something Else?

Track: Advanced Illness and End-of-Life

Marijuana laws are changing rapidly. Legality varies by state, but marijuana remains illegal on the Federal level. What does a home health agency need to consider to provide safe patient care, uphold legally responsible standards, and maintain professional practice? Is it different for hospice agencies? How do you align the needs of the agency, patients, and professional staff? Have you considered the implications of legal status - decriminalized versus  legal for medical use - for medication safety, documentation, communication, patient education, or staff safety? What about requests to administer marijuana or marijuana infused products? Join us for a discussion of what we know (and don’t know) about managing marijuana  in home-based care, and how to address this complex issue in your agency.

Presenter:

  • M. Daria Niewenhous, Member, Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C.

Facilitator:

  • Danielle Pierotti, RN, PhD, CENP, Vice President, Quality and Performance Improvement, VNAA

A Whirlwind Tour for Developing Home Care Leaders

Track: Nonprofit Leadership

This leadership development presentation will outline key priorities and experiences in non-profit and interim leadership, clinical operations and financial management to provide new and not-so-new agency leaders with strategies to develop themselves and their teams, collaborate with a board of directors, and identify key tools for tracking, managing and improving financial operations. Presenters will outline 3 ways to grow agency business through strategic partnerships, referral management and community development initiatives.

Presenters:

  • Teresa Santoro, MSN, RN, CHCA, President and CEO, Ridgefield VNA
  • William J. Simione, Jr., FHHC, Founding Member, Simione Healthcare Consultants

Achieving the Triple Aim with Data: Practical Hows and Whos

Track: Special Topics

Without good data management, no home care agency can succeed at value based payment or achieve Triple Aim goals.  This session will provide participants with a toolkit of practical data management techniques that have been successfully utilized by VNA Community Healthcare. These techniques include: a simple four step process for driving decisions with data, a list of key data analysis tools, methods for developing clinical manager data literacy, the use of data dashboards, methods for using data to solve operational problems and techniques for using data to improve clinician performance.  The session will also describe the structure, roles and responsibilities, resources, training and information systems needed to build a data driven home care organization.

Presenter:

  • Barbara Katz, RN, MSN, Vice President, VP Clinical Program Development, VNA Community Healthcare
 
 

Session 2:   3:00 - 4:00 p.m.

 

A Fresh Look at Defining Standards of Care for Home Health

Track: Integrated Systems and Partnerships

In this dynamic session, attendees will learn practical methods to efficiently manage patient care, achieve better outcomes, and increase episode reimbursement. Participants will hear lessons learned and receive advice on workflows based on targeted episode management tactics. Following the presentation, you'll understand the value of leadership engagement and importance of providing clinicians with opportunities for advancement. Additional topics presented will include the role of innovative technology, visit frequency, training, collaboration among disciplines, and patient input in setting goals to self-manage conditions. The session will address leadership accountability along with clinical and service quality outcomes. Providing the right care at the right time leads to proper reimbursement and improved patient satisfaction and outcomes.

Presenters:

  • Amy Driscoll, DNP, RN, GCNS-BC, Manager of Quality and Education, Aurora at Home
  • Jeri Ann Kelly, BSN, RN, MBA, Chief Nursing Officer, Post Acute Services, Principal, McBee Associates
  • ‎Melissa Jordan, RN, Director of Quality, Aurora at Home

How Encompass Leverages Analytics to Reach the Triple Aim

Track: Chronic Condition Management and Post-Acute Care

With the goal of continuously improving patient care and outcomes and positioning the organization to achieve success in an increasingly value-based landscape, Encompass set out to find new strategies to better manage their population. After deploying analytics technology across their organization, Encompass made significant strides in transforming patient care and achieving the Triple Aim. For instance: they’ve increased hospice days by nearly 70% (meaning the patients who opt for hospice experience their hospice benefit longer which enhances care quality), reduced avoidable readmissions by more than 50% and in less than three months of use facilitated more than 1,000 former patient contacts that resulted in improved customer satisfaction. 

Presenter:

  • Dan Hogan, President and CEO, Medalogix

Facilitator:

  • Danielle Pierotti, RN, PhD, CENP, Vice President, Quality and Performance Improvement, VNAA

Medical Aid in Dying: Are you prepared to support the patient?

Track: Advanced Illness and End-of-Life

Medical Aid-In-Dying is currently legal in six states, with multiple states proposing legislation. Such statutes, or proposed statutes, are called various names such as Medical Aid-in-Dying, Death with Dignity, or End-of Life Options Act.  Agencies in states where the laws have been implemented, must understand the law, and educate staff and employees on how to support both employees and patients in complying with the law. During this session, attendees will gain a stronger understanding of the law, the potential for ethical conflicts, and the ability to assist individuals and agencies in the implementation of the legal safeguards of the law, including how to support the patient if the agency makes the decision to opt out of directly participating in aid-in-dying.  

Presenters:

  • Caroline Boaz, MSN, RN, ACNS-BC, ACHPN, Clinical Nurse Specialist, Palliative Care, Sharp HealthCare
  • Stefanie Elkins, MA, MM, California Medical Outreach Manager, Compassion and Choices
  • Kathleen Hessler, RN, JD, CHC, CHPC, Director, Compliance and Risk, Simione Healthcare Consultants, LLC

Nonprofit Leadership: Are you up to the challenge?

Track: Nonprofit Leadership

In today's dynamic and challenging health care environment an effective Board is critical to ensure organizational performance success and economic survival.  During this session governance best practices will be discussed as well as strategies to assist a board in transforming to a new level of performance.  The role of leadership in supporting a board as well as the pathways towards board membership will be discussed.  As the IOM has indicated nurses and other health professionals should be full partners in redesigning health care in our nation - is this not partially the role of a board?

Presenter:

  • Esther Emard, RN, MSN, MSLIR, Board Member, VNAA and Care New England

Smart Data! Smart Clinical Management! SmartCare!

Track: Special Topics

Due to EMR drivers and environmental stressors, clinician-documented care plans may not reflect needed patient involvement, nor be individualized enough to achieve outcomes desired by the patient. Given increased regulatory pressure and increasing reliance on technology, clinicians and clinical managers need powerful smartcare tools to provide cognitive tunneling intervention, increase congruence amongst clinical documents and promote patient-specific care needs.

Presenters:

  • Stacy Ashworth, MS, RN, COS-C, HCS-D, Executive Vice President of Quality and Standards, Clinical Informatics, Select Data, Inc.
  • Susan Carmichael, MS, RN, CHCQM, ICM, COS-C, FAIHQ, Executive Vice President, Select Data, Inc.
  • Kimberly Kindred, RN, Regional Director of Clinical Services CHI Health at Home
  • Judy Schuler, RN, MBA, Chief Clinical Officer, CHI Health at Home
 
 

Session 3:   4:15 - 5:15 p.m.

 

Developing Payment Reform Strategy through Data and Payment Model Incentives

Track: Integrated Systems and Partnerships

Leaders must be knowledgeable of emerging payment methods, and related incentives, within the entire healthcare continuum to remain competitive in today's home-based care environment.  Providers must effectively harness data to measure, manage, and monitor the payment reform landscape.  This session outlines the emerging payment landscape, essential data to help organizations build strong practices, and strategies to utilize data and payment model incentives in the development of collaborative relationships.

Presenters:

  • Patrick Brown, Vice President, Finance, Trinity Health at Home
  • Paul Giles, Director of Home Health Finance, Dignity Health
  • Mark Sharp, CPA, Partner, BKD, LLP

    Integration of a Pharmacist on the Home Healthcare Team to Address Medication-Related Hospitalizations

    Track: Chronic Condition Management and Post-Acute Care

    In 2013, the University of Rhode Island College of Pharmacy began a patient-centered partnership with the Visiting Nurse Service of Newport & Bristol Counties (VNS) by integrating a PGY1 Pharmacy Resident and 6th year pharmacy students on the care teams. Prior to the partnership, the burden of medication reconciliation and education fell solely to the nursing staff at VNS. It was identified that the addition of a pharmacy resident and students to the VNS team would be the solution to preparing patients for their return home after a hospital stay and potentially reducing rehospitalizations, as well as improving medication adherence, patient quality of life, etc. After two years of successful outcomes, VNS received a grant to expand the partnership to include a pharmacist on the care team to focus on medication reconciliation and teaching to "high-risk" patients. During this session, attendees will learn how to successfully implement an interdisciplinary care model and understand the benefits of providing these increased services to "high-risk" patients and its impact on quality metrics. 

    Presenter:

    • Madeleine Ng, PharmD, CDOE, CVDOE, Pharmacist, Visiting Nurse Services of Newport and Bristol Counties

      Current Trends in Hospice Quality Data

      Track: Advanced Illness and End-of-Life

      CAHPS Hospice and the Hospice Items Set (HIS) scores will soon be publicly reported. CMS has suggested that CAHPS and Hospice Item Set (HIS) scores will be used in a star rating in the near future. Now is the time for hospices to start evaluating their performance and making plans for improvement. We will share trends in the HQRP scores, best practices in creating and managing a quality improvement program and making sure you have a solid foundation to be successful with future changes in quality reporting.

      Presenters:

      • Chris Attaya, MBA, Vice President, Business Intelligence, Strategic Health Programs (SHP)
      • Danielle Pierotti, RN, PhD, CENP, Vice President, Quality and Performance Improvement, VNAA

      Case Study: Nonprofit Organizational Redesign

      Track: Nonprofit Leadership

      The home health and hospice landscape is continuously evolving, which means even minor disruptions can have a meaningful impact on operations. Knute Nelson recently experienced significant changes due to a period of growth and leadership transition that ultimately impacted the agency's operational stability.  This program will present the details of a case study containing the evaluation and redesign of Knute Nelson's organizational structure. We will review their organizational structure, processes and data to explain how they began to operate efficiently.

      Presenters:

      • Konnie Evans, Vice President of Home Care, Knute Nelson
      • Nick Seabrook, Managing Director - Founding Member, Blacktree Healthcare Consultants

      Compliance Program Excellence: Keeping Abreast of Evolving Expectations

      Track: Special Topics

      Today, no healthcare organization can ignore compliance risk. With increasing scrutiny and evolving expectations for what constitutes excellence in compliance programs, the regular assessment of a compliance program’s comprehensiveness and effectiveness is increasingly important. This session will review recent updates in guidance from the OIG and DOJ, outline approaches to reassessing your program, and identify key areas for special attention given recent updates.

      Presenters:

      • Holly Chaffee, RN, BSN, MSN, President and Chief Executive Officer, Porchlight VNA Home Care
      • Debbie Plesich, RN, BSN, Director Operational/Regulatory Consulting, Corridor Group
       

      Friday, April 21

       

      Session 4:   9:15 - 10:15 a.m.

       

      Maximizing Bundles through Integration

      Track: Integrated Systems and Partnerships

      This presentation will share how system integration and provider collaboration has maximized patient quality and provider outcomes in the CJR bundle demonstration.  As CMS continues to shift from fee-for-service to value-based purchasing, best practices for health system and independent agencies, as well as current agency examples with be shared with attendees for both CJR and other bundle types.  Strategies for home health agencies and highlighting  their vital roles in these bundles will also be discussed.

      Presenters:

      • Joy Cameron, Vice President, Policy and Innovation, VNAA
      • Diana Kornetti, PT, MA, HCS-D, Chief Operations Officer, Kornetti & Krafft Health Care Solutions, Inc.

      Kenosha VNA's Collaboration with the County Sheriff

      Track: Chronic Condition Management and Post-Acute Care

      Around 30 years ago, Kenosha Visiting Nurse Association (KVNA) was asked to help with a quadriplegic patient in our county jail.  Today KVNA is the sole provider of health services for two county jails in Kenosha, WI.  This presentation shows how they made this a viable and financially sound partnership.  It also shows how this could be done with any county that operates a jail.  Some of the for-profit national correctional health providers have taken immense heat lately for their propensity to understaff and underdeliver the care to this population.  KVNA has established itself as a quality provider, which has kept the county’s liability in check, as there have been multi-million dollar suits paid out for events including death.  This is not an easy task, but given enough thought and planning, it can be something that continues to establish your organization as a community leader.  It also allows you how to have a revenue source that does not have the same strings attached as Medicare, Medicaid or commercial insurance, although there are other unique pressures on these providers.

      Presenters:

      • Amy Allyn, RN, CCHP-RN, Department Manager, Visiting Nurse Correctional Health, a division of Kenosha VNA
      • Michael Puskarich, President and CEO, Kenosha VNA

       


      Palliative Care: Bringing it Home

      Track: Advanced Illness and End-of-Life

      Presbyterian Healthcare at Home offers an innovative model of team-based community palliative care housed in a home health, house calls, and hospice program. Created as part of New Mexico’s largest non-profit health system, Presbyterian Healthcare at Home has demonstrated success in supporting patients and families coping with serious illness, while reducing the total cost of care significantly. Learn how this program was built from the ground up and how you can create your own community-based palliative program. This session covers critical needs assessments, identifying stakeholders, obtaining key financial support, and demonstrating value through tracking outcomes. Attendees will also learn tips and tricks on using tools in the electronic health record to improve documentation and gather data. This fast-paced session offers insight to those planning a program, as well as ideas for expansion to those working in community-based palliative care.

      Presenter:

      • Nancy Guinn, MD, Medical Director, Presbyterian Healthcare at Home
         

      Leadership Development for the Future

      Track: Nonprofit Leadership

      Presenters:

      • Cindy Goodwin, Senior Education Specialist, Christiana Care Hospital System
      • Ann Painter, MSN, RN, Senior Vice President, Home Health & Community Services, Christiana Care VNA
      • Steven Richard, MBA, CHCE, AVP, Home Health & Hospice, Geisinger Community Health Services

      DNA of a CEO: Lessons for Leading Home Health Care into the Future

      Track: Special Topics

      What motivates CEOs in the top tier of home health care?  What are their leadership styles?  What are the core competencies that make them successful?

      Beginning in January of 2016, Leading Home Care in collaboration with two national associations and 14 state associations conducted a major industry study of CEOs in the top tier of home care.  Over 200 CEOs in the largest home health agencies and private duty home care companies completed a detailed leadership assessment. The results of this cutting-edge research give us a much clearer picture of what it takes to lead a highly successful agency in the ever-changing environment of health care at home.

      In this interactive presentation, Stephen Tweed will describe for you the lessons learned from this study, and explore how you can apply these principles to develop the next generation of leaders in home health care, hospice, and private duty home care.  You’ll explore five specific lessons you can apply to leading your home health agency into the future.  
       

      Presenter:

      • Steven Tweed, BA, MS, CSP, CEO, Leading Home Care... a Tweed Jeffries Company
       
       

      Session 5:   10:45 - 11:45 a.m.

       

      Rewiring Your Agency for the Value Era

      Track: Integrated Systems and Partnerships

      In this presentation, Spectrum VNA and HHSM Executives recount the year-long process that defined Spectrum’s “volume-to-value shift” as they rewired their agency for patient-centered, remodeled processes to address home health care reforms. By re-interpreting Chapter 7 of The Medicare Benefit Policy Manual  in terms of value, Spectrum VNA achieved improved outcomes in multiple areas. Nearly all home health elements were addressed, including OASIS accuracy, plan of care production, efficient staffing, qualified care programs, and productivity. Spectrum VNA re-integrated Medicare Chapter 7 into the general principles of documentation, using the supplied guidance to create noteworthy increases in outcomes and Star ratings through defendable documentation foundations. Each area of daily home health management processes are addressed in this progressive presentation. 

      Presenters:

      • Arnie Cisneros, PT, President and CEO, Home Health Strategic Management
      • Kimberly McCormick, RN, BSN, Chief Clinical Executive, Home Health Strategic Management
      • Kevin Smith, FHFMA, Vice President of Finance, Continuing Care, Spectrum Health

            CJR to EPMs: Leadership's Role in Future Bundles

            Track: Chronic Condition Management and Post-Acute Care

            As the early adopters of bundled payment programs evaluate their experiences and refine management of target populations, a new group of hospital systems will be introduced to mandatory cardiac Episode Payment Models (EPMs) on July 1, 2017.  As a result, acute care leaders may suddenly find themselves in a mandatory bundle program, looking for new ways to partner with post-acute providers to improve quality while reducing cost. By blending data analysis with front line experience from a national home health agency, this session will examine the initial performance years of existing bundle programs to forecast changes in post-acute care utilization and service expectations for EPMs and future bundles.  This session will also discuss strategies for home health care leaders to proactively position their organizations to provide solutions in response to these bundles.

            Presenters:

            • Anthony D'Alonzo, PT, DPT, MBA, Director of Accountable Care, BAYADA Home Health Care 
            • Elizabeth Kleber, PhD, RN, Area Director, Area Director, Clinical Practice and Accountable Care, BAYADA Home Health Care 

            Preventing and Diagnosing Sepsis in Vulnerable Populations

            Track: Advanced Illness and End-of-Life Care

            The Home Care Association of New York State (HCA) Quality Committee's Sepsis Workgroup, led by Amy Bowerman, has developed a unique initiative -- the first of its kind in the nation -- which includes a sepsis screening tool for use by home care clinicians in identifying potential sepsis risk or possible presentations of sepsis/severe sepsis. The tool also prompts follow-up and intervention steps as warranted. An algorithm and protocol have also been created to accompany to tool to further guide home care clinicians. In a parallel initiative, the HCA tool has been incorporated in pilot projects sponsored by the U.S. Centers for Medicare and Medicaid Services (CMS) in New York State. These projects have been implemented by IPRO and focused on community based efforts in early sepsis recognition and entry into care. Learn more about this unique initiative and its potential for integration nationwide in home care.

            Presenters:

            • Al Cardillo, LMSW, Executive Vice President, Home Care Association of New York State
            • Amy Bowerman, RN, Director of Quality Improvement/Privacy Officer, VNA of Utica and Oneida County

            Innovation and Relationships Drive Success in Community-Based Care

            Track: Nonprofit Leadership

            In an era of increasingly larger health care systems, community-based non-profit hospice and palliative care organizations must look to innovative models of care and establish a strong niche in their community to survive and thrive. Mission Hospice & Home Care (MHHC) has seen its growth expand 10-fold over the past decade,  an anomaly for smaller non-profit community organizations.

            MHHC has created a patient-centered approach with an emphasis on establishing and nurturing relationships between healthcare and community providers, coupled with a work environment that supports flexibility and creativity. This has enabled MHHC to become an employer of choice in their community, and has attracted financial support from a growing donor base.  Approaches, techniques and outcomes will be discussed during this presentation, with time for dynamic audience interaction.

            Presenters:

            • Lisa Deal, RN, MPH, ScD, Chief Clinical Officer, Mission Hospice & Home Care
            • Dwight Wilson, RN, Chief Executive Officer, Mission Hospice & Home Care

                Home Health Quality - The goal is staying home

                Track: Special Topics

                Hospital readmissions is a prime quality measure now shared across hospitals and home healthcare. Nationally, hospital readmission rates have been publically reported since 2007, with minimal improvement. Readmission rates are critical to home health agencies striving to excel at star ratings, value based purchasing, and contracting with referring hospitals, physicians, and payers. Why are readmissions so important? What do we know about who is readmitted, when, and why? What actually helps keep people at home? This session will review what is known about readmissions,  the impact of readmissions as a quality measure, and highlight future opportunities for improvement.

                Presenters:

                • Christine Lang, MBA, ABILITY Network
                • Danielle Pierotti, RN, PhD, CENP, Vice President, Quality and Performance Improvement, VNAA