Developing Meaningful Metrics for Post-Acute Care Provider Networks

by Timothy Gieseke MD, CMD

Recently, I read with interest a report on the efforts of the Cleveland Clinic and Baystate Medical Center (Massachusetts) to develop a preferred Post-Acute Provider Network.

In my area, both of the referral hospitals have been meeting with community SNFs to better coordinate care transitions and reduce readmissions.  I have been invited to attend one of the hospitals monthly care coordination meetings where the focus has been on presenting readmission data and attempting to understand what could have gone better.  In addition, there have been brief discussions on improving palliative care, diabetes care, and other clinical topics. I’m not aware of either hospital narrowing their networks of providers as in the above article, but suspect the discharge planners do have their preferences based on similar metrics.

2018 Poster Winner: Enhancing Medication Safety Among Community-Dwelling Frail Seniors
CALTCM 2018 Poster Session: 1st Place Winner
Presented by: Marsha Meyer, PharmD, BCGP, [email protected]*
*Dr. Meyer is the team’s corresponding author (See full list below).

Background: Medications play a key role for frail seniors in community or post-acute settings. Yet, medication misuse can increase health risks and negatively impact outcomes. The Community Medication Education, Data and Safety (C-MEDS) program was designed to provide brief, in-depth, at-home customized medication safety interventions for seniors and family caregivers. Key goals of the C-MEDS program include: (1) reducing medication-related problems, (2) increasing self-efficacy in medication management, (3) improving communication and coordination of care between the patient and caregiver and the health care system and (4) improving medication adherence. It is a pharmacist-directed program, utilizing a team of geriatrics experts.

THINKING AHEAD: My Way, My Choice, My Plan

by Timothy L. Gieseke, MD, CMD

In 2008, the project I developed as a participant in the CALTCM LMG (Leadership and Management in Geriatrics) course was to implement the POLST in Sonoma County.  Fortunately, others in my county were on the same page. Susan Keller, a long time and persistent community advocate for improving palliative care wrote and submitted our first grant request for this project.  In the years since then, she has led innovative programs to support faith based palliative care and most recently has worked for improving THINKING AHEAD 2 for those with serious mental illness in collaboration with Sonoma County’s behavioral health division, the Coalition for Compassionate Care of California, and Goodwill Redwood Empire.  The final product is now available and worth your review.

CALTCM 2018 CME at the Bedside
by Timothy Gieseke MD, CMD

It's summer and I’m admitting more patients for rehab due to vacation coverage. Lately, many of my admissions have had an exacerbation of COPD. There are now many options for assessing the severity of COPD and for treating it. I’m grateful for our digital syllabus of this year’s annual meeting, which had the slides from Dr. Michelle Zeidler’s comprehensive evidenced based approach to this complicated subject. As she said in her talk, many of our patients with COPD receive substandard care for their condition and come to us with a plan that we can improve. With that in mind, I reviewed her presentation and now have some ideas on how I might better care for my recent admissions.  

At CALTCM, we want to partner with you in your efforts to improve the care you provide your patients. For this reason, we are making a PDF available of this excellent talk.  

Here’s to a cup of “Jo” and a time of cognitive stimulation.  
Click here to access Dr. Michelle Zeidler’s COPD presentation at the CALTCM 2018 Annual Meeting .
Is Reducing Serious Hypoglycemia one of your PIPs?

by Timothy Gieseke MD, CMD

This year, our state QIO, HSAG, has been sponsoring webinars that help our facilities reduce the risk for incurring a readmission payment penalty, when the financial penalties go live January 1, 2019.  I will be presenting the webinar on June 27th for reducing the risk of serious hypoglycemia. You can register at:

While there are many traditional things we can do to identify and manage this risk, our tool bag for safely lowering the risk has increased in recent years with the addition of SLG2’s and Incretin Receptor Agonists.  Both classes of medicines have a much lower risk of inducing serious hypoglycemia then oral sulfonylureas or insulin and both may help reduce weight and may reduce the risk of macro-vascular disease. Empagliflozin (Jardiance) and lirglutide (Victoza) now have an FDA indication for macrovascular risk reduction.  Empagliflozin is ineffective if EGFR is < 30, but liraglutide has no dose adjustment for renal or hepatic disease. The expense of both of these medicines is similar to the now high cost of our insulins.

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