Partnering with Community Networks to Transform the Post-Acute Continuum
Thursday, October 20, 2016
12:00 pm – 1:00 pm CT (1:00 pm ET; 11:00 am MT; 10:00 am PT)

The American Hospital Association (AHA) Section for Long-Term Care and Rehabilitation invites you to join on a webinar highlighting a unique approach to building new partnerships between post-acute providers and community care organizations. The dramatic shifts in healthcare payment evolving now drive a new focus on health outcomes and optimizing timely and safe return home from hospital and SNF care. When patients return home from the emergency room, hospital or post-acute setting, they often lack the support and skills needed to successfully manage their health at home and avoid readmission. This has inspired exploration into bold new partnerships with community care organizations with expertise and support and services to achieve these new goals. For several years CMS has led Community Care Transitions demonstrations with positive results at select sites including the Partners in Care Foundation. Social workers and coaches from community-based organizations provide distinctive new skills sets—become the eyes and ears in the home.

Speakers, June Simmons, MSW, CEO, Partners in Care Foundation, San Fernando, CA, leading expert in creating new community care regional delivery networks for home and community care; and Manoj Mathew, M.D., a physician executive and healthcare consultant, with valuable experience as a SNFist, hospitalist, and internist at Providence Holy Cross Medical Center, Mission Hills, CA with broad skills in managing across the continuum in the changing reimbursement environment will share insights on:

  • Strategies to successfully implement the Community Care Transition Program, including trained health coaches to provide patients with tools for self-management and that address social determinants of health to avoid hospital readmissions
  • How to identify organizations with teams/alternative community workforce, skilled in identifying and providing the necessary support to ensure better coordinated care between the post-acute care providers and the community based organizations;

These pioneering new models of care contribute to success in optimizing length of stay and safe discharge from hospitals and skilled nursing facilities.

To register for this member webinar, please click here.  If you have specific issues you would like to have an opportunity to discuss, please note them on the online registration form. A confirmation email with instructions on how to access the webinar and materials will be sent to you on Wednesday, October 19. If you have any question


Presentation slides

Speakers' Bios:

Manoj K. Mathew, MD, SFHM, Senior Corporate Medical Director, Agilon Health

W. June Simmons, MSW, President/CEO, Partners in Care Foundation




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