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2015 Meeting Agenda

Monday, April 20

12:00 – 3:45 p.m.


5:00 – 6:30 p.m.

Opening Reception

Tuesday, April 21

8:00 – 10:00 a.m.

Opening Keynote

Community Partnerships with Nontraditional Providers
Ceci Connolly | PriceWaterhouseCoopers
Nancy J. Gagliano, MD | CVS Caremark; MinuteClinic

10:00 – 10:45 a.m.


12:00 – 3:45 p.m.

Breakout Session One

Clinical Operations

Kimberly Mora and Marie Perillo | VNA Health Group

Transitional Care prevents the adverse outcomes that are prevalent during the movement of a patient from one setting of care to another. VNA Health Group is the lead community based organization (CBO) in a collaborative transitional care partnership between six acute care hospitals, four home health agencies, and four community health partners that seek to improve care transitions for high risk patient populations. By conducting PDSAs and developing process improvement initiatives we have improved enrollment numbers and decreased all-cause readmission rates. This breakout session shares the value behind establishing partnerships and the critical steps involved in creating a successful transitional care initiative.

Innovation and Partnerships

Mary Kate Rolf and Andrea Lazarek-LaQuay | Home Care of Central New York

Description coming soon.

Description coming soon.

11:45 a.m. – 1:45 p.m.

Exhibit Hall Lunch and Poster Session

2:00 – 2:45 p.m.

Breakout Session Two

Clinical Operations

Tina Marrelli, MSN, MA, RN, FAAN | Marrelli and Associates
Mary Narayan, MSN, RN, HHCNS-BC, CTN | Clinical Education Specialist

Your clinicians' documentation can support or jeopardize: 1) clinical management and outcomes, 2) payment from Medicare and other payers, 3) reviews of regulatory compliance, and 4) legal liability defense against claims of malpractice. All agencies require their clinicians to document well, but achieve varying amounts of success.

The purpose of this presentation is to arm agency leaders with information and strategies they can bring back to their clinicians to help them "get" and deliver good documentation.

The presenters bring two different perspectives to the documentation challenge. One presenter has developed nationally-acclaimed publications with "best practice" recommendations for supporting documentation standards in home health care. The other presenter is a home health clinical nurse specialist, who has analyzed home health documentation in malpractice cases as an "expert witness."


Arnie Cisneros, P.T | Home Health Strategic Management

The Affordable Care Act outlines the care delivery model of the future: Episodic care programs managed by the ACO in terms of Care Transitions and efficiency, void of silo influences from individual Provider types. How can you begin today to improve your processes for the ACA Care models; it involves the evolution of your current programming to a more focused, efficient delivery model? By rewiring today's care protocols, Home Health Providers can prepare for the care models of tomorrow while improving clinical and financial results. This presentation will outline specific areas of the Home Health PPS Care Model that offer opportunities to elicit more efficient clinical outcomes while improving the care you currently deliver to your patients. What are ACOs seeking from Home Health in the episodic model, and how do you currently perform in those areas? Where should you begin to address your processes to create new efficiencies, and what problems will you encounter, and how do you resolve those issues with supervisory and front-line clinical staff? Don't miss this progressive presentation on ushering your care (and clinicians) into the future of your care delivery.

Innovation and Partnerships

Kenneth Schonbachler, MBA, MPT | VNA of Western New York

As the healthcare landscape in the United States reinvents itself around the triple aim model, hospitals, health systems, and post-acute care providers often struggle with the optimization of transitioning care from facilities to the community. This presentation details the implementation of an innovative partnership between a health system's flagship tertiary care hospital and their home health care agency, the VNA of Western New York. This partnership ultimately involved contracted management of the patient management department to the home care agency, a re-design of the patient management model, a larger role for VNA staff in the patient discharge process, and improved relationships with community post-acute providers. Key metrics which were measured and tracked included hospital length of stay, readmission rates, home care referrals, and patient experience data. By all accounts the implementation, while not without barriers and modification, was a resounding success resulting in improvement in all key metrics related to patient and financial outcomes.


Andrew Reed, CPA | Multi-View Incorporated Systems

Accountability or lack of accountability determines whether or not initiatives are accomplished and if standards maintained at an organization. Large or small, the mission is accomplished through people, and given unclear standards/direction, people will often do little or end up with costly, ineffective, low-quality results. Among the problems with most organization's accountability approach is that they are typically dependent upon a manager's personal supervisor of work. Why is this a problem? Because human beings' levels of energy are not consistent, and therefore rise and fall over time. In today's hospice environment, more and more energy is demanded to comply with increased requirements and complexity. Much of the solution lies in the use of "structures" that are non-dependent upon manager's levels of energy or physical presence and that perpetually maintain the established standards of the organization over long periods of time. This program addresses the topic of Accountability head on...from the establishment of clear standards to the structures needed to ensure that the ideals and standards of the organization are carried out by every person of an enterprise.

3:00 – 4:00 p.m.

Breakout Session Three

Clinical Operations

Paula Suter, Beth Hennessey, Jennifer Pearce | Sutter Care at Home

The Integrated Care Model (ICM) was designed to realize the vision of providing care that facilitates true partnerships with patients and families. This presentation will outline steps our organization has taken to deliver person-centered, evidence-based, health literate care that is coordinated across providers, sectors and time. The presentation will highlight how ICM model delivery is in line with the new CMS proposed conditions of participation; in particular how ICM promotes a shared decision-making approach to care that is understood and valued by patients and caregivers. Lessons learned about how best to hardwire these concepts in daily care delivery will be shared.


Mark Sharp | BKD
Paul Giles | Dignity Health

This program will provide insight to strategies associated with diversifying an organization's revenue models. There are many things to consider as you evaluate alternative programs from understanding your demographics to the financial feasibility of a particular revenue diversification. There is one thing for sure: There is no cookie cutter approach to the right revenue diversification strategy. The program will help participants recognize the importance of revenue diversification in home care and hospice, understand the methods for evaluating the opportunities for revenue diversification, and identify the steps needed to plan and implement a diversification into new lines of home care business.

Innovation and Partnerships

Jennifer Rittereiser | Visiting Nurse Service of New York
Patty Resnik | Christiana Care Health System
Judy Peterson | VNA of Chittenden and Grand Isle Counties

Description coming soon.


Cindi Pursley RN, CHPN | VNA of Colorado
Danielle Pierrotti HCI PhD RN, AOCN, CHPN | HCI Services

In this breakout, the presenters will outline the essence of documentation in hospice. They will cover how to efficiently document drilling down on the key components from admission to discharge with specific emphasis on how to provide specifics on decline. They will offer some practical approaches to incorporating information to the IDT so all team members are up-to-date on the patient/caregiver status. Specific attention will be on the spiritual leader's team members and ways to keep them involved. Successful strategies for managing ADRs and documentation will be discussed.

4:00 – 4:15 p.m.


4:15 – 5:15 p.m.

Breakout Session Four

Clinical Operations

Rhonda Combs, Susan Northover, Sue Payne, Kathy Peirce

Intake Redesign: Presentation on the changes healthcare reform has presented to home care services and how we redesigned our intake process to adapt to these changes and better meet our patient's needs.

Preceptor Redesign: Presentation on Advanced Home Care's recently revised Preceptor/New Hire Program and its impact on retaining new hires and ensuring successful performance of staff.

Individual Practitioner Accountability: Presentation on Christiana Care Visiting Nurse Associations approach to accountability and performance on a team level with scorecards incorporating goal oriented metrics and baselines and targets.

Avoiding Re-hospitalization: Presentation on the struggle home care agencies share with re-hospitalization. After participating in many studies I have worked closely with our hospital to partner on reducing readmissions using best practices and monitoring tools.


Aaron Little, Patrick Brown

Today's home health and hospice agencies are challenged by payment reductions, shifting payer mix, substantially increased Medicare and Medicaid regulations, and heightened program integrity activity. Providers must find efficiencies and more effective ways of optimizing revenue cycle performance while also managing regulatory risks. This session will focus on one provider's initiative to assess compliance risks in its revenue cycle and its implementation of a compliance scorecard system to monitor key compliance risks, measure key compliance metrics, and manage personnel accountability, processes and controls responsible for compliance. The session will review how the provider assessed its key controls and risk areas, performance metrics for ongoing scorecard reporting purposes, compliance weaknesses, and performance accountability, as well as share tools and strategies employed during the initiative and the results to date.

Since late 2013, VNA Health Group has been working with RelateCare a subsidiary of Rigney Dolphin an Irish-based Contact Center provider. RelateCare's calling programs were developed to reduce avoidable readmissions, manage transitions of care and help lower healthcare costs. For several years, RelateCare has had a successful partnership with the Cleveland Clinic and looks to expand across the US and abroad.

This presentation will share VNA Health Group's experience working with RelateCare in implementing the program and the impact on patients. During 2014, RelateCare contacted over 5,000 patients on select care deliver teams. Since the calls were not made to all patients, VNA Health Group was able to assess the impact of the calls compared to a comparable group of patients that did not receive calls. Comparisons were made on patient satisfaction (HHCAPS) and outcome measures (emergent care and hospitalization).

The presentation includes three components. First, background on RelateCare will be presented, including information about their model of patient engagement. Second, VNA Health Group will share its experience working with RelateCare and implementing the model in its call center. Third, data will be presented that shows significant improvements in patient satisfaction and patient outcomes.


Lenora Ritchie, Kerry Bartlett

Philanthropy is defined as the desire to promote the welfare of others, expressed especially by the generous donation of money to good causes. Building a culture of philanthropy for fundraising success requires a shift in thinking from charitable giving to philanthropic development. This does not happen easily or quickly. Rather it takes a comprehensive infrastructure and mind set, co-created by leadership staff and Board members, to support this transformational shift. The goal of this session is to educate participants on the characteristics of a home health care agency with a culture of philanthropy and the potential long term outcomes. In addition to the speakers, a panel of three current VNA leaders will share their real life best practices on how they built this culture and the invaluable benefits to the mission of the organization.

5:30 – 7:30 p.m.

Exhibit Hall Reception and Poster Session

Wednesday, April 22

8:45 – 9:30 a.m.

Breakout Session Five

Clinical Operations

Margaret Terry, PhD, RN | VNAA
Meg Doherty, MSN. ANP, MBA | Norwell VNA and Hospice

The presentation will provide updates to the Blueprint for Excellence for Home health Transitions of Care and Hospice and Palliative Care End of Life. The new work in Clinical Conditions, Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD) and Hips and Knees will be discuss in detail. The presenters will outline approaches to integrate these practices in home care organizations as well as approaches to measure these approaches.

The increased hospital penalties for 30-day readmission rates are now in effect as of October 1, 2014, and about three-quarters of all hospitals are impacted. Home health offers hospitals one of the best strategies to reduce admissions, but are we living up to the challenge? CMS provides national data on the rates of rehospitalizations by hospital and plans to start sharing 30 day rehospitalizations rates of HHA’s sometime in FY15. With the impacts to hospitals and a likely HHA pay-for-performance measure, agencies need to continually look at their performance and understand the relationships of patient characteristics and the utilization of services provided to improve their scores. Using data from the Strategic Healthcare Programs (SHP) national database, we will share the data behind hospital readmissions that will analyze these different characteristics and agency profiles. The data provided during this session will help inform the audience characteristics and elements of readmissions that can lead to better performance.

Innovation and Partnerships

Faith Scott, Lisa Salamone, Brian Dwyer

Strategic thinking has become a business objective that is no longer optional. Planning for operations, with limited resources, in advance of hardship, may appear obvious to many leaders. It has been proven that by shaping a vision for business and outlining business metrics for each division, leadership can move more nimbly and with great accuracy. The result is an organization that is integrated and responds to common goals. During a time when internal and external changes are the norm, it is critical to align the organization with strong partners, talented staff, and an unwavering strategic plan with measurable outcomes.

This presentation will high a business / vendor relationship that involved, against a few odds, developing a strong partnership that led to a reallocation of resources and an alteration in product roadmap with the ultimate outcome of a stronger resource for both. The Organization will ultimately describe its vision, planning methodology and guiding metrics. While the vendor, will outline its decision-making process to reallocate resources, and redefine its product and strategic roadmaps; no small task.


Nicole DePace, MS, APRN, GNP-BC, ACHPN | NVNA and Hospice
Judith Labossiere, RN, BSN, MBA, ACHCE | NVNA and Hospice

When faced with life-threatening or end-of-life conditions, life review is a common response. However, this can be a difficult process for some and actually impact the emotional and spiritual well-being of some patients, both negatively and positively. This workshop will highlight a partnership program that offers patients a positive, creative way to tell their stories, impart wisdom for future generations, and record the legacy that they wish to leave for loved ones. Workshop participants will learn about this unique program and its components, how to access creative resources and begin the process, and steps to implementation within a hospice program. Case studies will be presented to illustrate the process, program goals, and successes.

9:30 – 9:45 a.m.

Breakout Session Six

Clinical Operations

Barbara Gage PhD, MPA | The Brookings Institution

Dr. Barbara Gage was the lead researcher in the development of the Continuity Assessment Record and Evaluation (CARE) Item Set (CARE Tool), the precursor to the IMPACT Act. She will provide the background and history of this ACT and the far reaching consequences for the post-acute sector including home health agencies. She will provide an overview direction of the incorporation of measures into the data set of the post-acute providers of home health (HH), skilled nursing facilities (SNF), Inpatient rehabilitation facilities (IPR) and long term care hospitals (LTCH). New directions for quality measure development will be discussed. Dr. Gage will also describe ways to prepare for these changes including resources that are available.


Jeanette May, Christy Lang

Description coming soon.

Innovation and Partnerships

Patty Upham

Using The Institute for Healthcare Improvement's Triple Aim initiative as the underpinning for project planning, FirstHealth has developed and implemented the Chronic Disease Transitional Care Model with very positive results. The FirstHealth Model was developed, tested and refined and includes a comprehensive cross continuum approach, evidenced based principles of care and a holistic patient centered foundation. FirstHealth created chronic disease pathways of care for heart failure, COPD, diabetes, cardiac surgery and hip and knee replacements. New models of care also require new staff competencies. FirstHealth developed specific on boarding competencies and milestones for the first 12 months of employment and ongoing annual competencies for all clinical staff. Using the Chronic Disease Transitional Care Model, FirstHealth created Care Transition Services, three distinct services that support the move to population health. Home Health is evidenced based, pathway driven care for patients that qualify. Hospitalization and emergent care results are now significantly below the national benchmark. The Home Health 30 day rehospitalization rate for 2014 is 8.8 percent, and the acute care hospitalization rate is 17 percent. Complex Care Management is pathway driven care for patients who do not qualify for home health but who require ongoing management and support. Complex Care Management is provided for the high risk, high utilizing uninsured and Medicaid population and for the high risk members of FirstHealth's Medicare Advantage Plan. The FirstHealth Center for Telehealth provides remote monitoring across care settings under a $1,000,000 HRSA Telehomecare Network Grant and includes remote monitoring for Home Health, Complex Care Management, the Community Care Network of North Carolina and the North Carolina PACE Program. Accordingly, this session will focus on how one health care system designed and implemented a comprehensive chronic disease transitional care model, engaged key strategic partners and positioned itself at the forefront of new models of care.

Description coming soon.

10:45 a.m. – 12:30 p.m.

VNAA National Awards Program

Closing Keynote

Insights for Managed Care Partnerships
Michael Monson | Centene Corporation
Jeff Myers | Medicaid Health Plans of America

12:45 – 1:15 p.m.

Business Meeting

1:15 – 2:00 p.m.

Joint Council Meeting

2:15 – 3:00 p.m.

Interest Group Meetings


Member Type Until 3/6/2015 After 3/6/2015
VNAA Member $700 $800
Non-member $1,000 $1,000
Additional Registration Options  
One Day Pass $550
Preconferences $120/each (two options)


Ceci Connolly

Managing Director, Health Research Institute, PriceWaterhouseCoopers

Nancy Gagliano, MD

Chief Medical Officer, MinuteClinic

Senior Vice President, CVS Caremark

Jeff Myers

President and CEO, Medicaid Health Plans of America

Michael Monson

Vice President, Long Term Care and Dual Eligibles, Centene Corporation

Chad Westover

President, Molina Healthcare of Utah

. 2121 Crystal Drive, Suite 750, Arlington, VA 22202

. 571-527-1520 / 888-866-8773

. [email protected]