Control Medication and SDOH-Related Readmissions through HomeMeds 3.0 and Care Transitions

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Effective transition from facility to home is a goal for health care institutions and plans. When done well it saves money, increases patient/member’s satisfaction, reduces readmissions, and eliminates or reduces future CMS penalties. Let us show you how to combine two evidencebased tools to increase your CBO’s effectiveness and improve outcomes. HomeMeds 3.0 is the latest version of evidence-based HomeMeds℠ with a friendly user-interface and more power to detect and flag existing and potential medication-related problems. Care Transitions is a powerful tool for identifying SDOH-related gaps impacting an individual’s ongoing medical recovery and care within a framework that makes it simple to craft and implement a care plan. When combined (as in HomeMeds Plus) you have a process that is powerful, simple, and effective.

Amy Adams

Director, HomeMeds

Partners in Care Foundation

Amy Adams has been the Director of HomeMeds at Partners in Care Foundation for the past 10 years. She holds a B.A. in Gerontology from the University of Northern Colorado. Background and expertise include Senior Transportation and Housing, Alzheimer?s, and Caregiver programs, as well as Evidence-based programs. Amy successfully started HomeMeds at the United Way of Tarrant County in Ft. Worth Texas before moving back to Colorado.

Esther Sefilyan

VP Network Services

Partners in Care Foundation

Esther Sefilyan has been with the Partners in Care Foundation since 2008. She has a Masters? in Gerontology from the University of Southern California (USC). In her work with Partners, Ester oversees startup and operations of multiple contracts and programs with hospitals, health plans, and medical providers in providing an array of services to ensure successful outcomes around readmission reductions and total cost of care. Ester is responsible for sales, implementation, contract management and infrastructure to support the Call Center and state-wide Network of agencies who provide regional coverage. She manages over 15 short-term care management/care transitions contracts focused on identifying Social and Behavioral Determinants of Health and putting safeguards in place to close those identified gaps. She has extensive experience with Long Term Services and Supports and is fully knowledgeable of Medicare, Medi-Cal, and commercial lines of business. These lines of business have grown significantly during Ester?s tenure. With her experience, she brings innovation, passion, and dedication to the Partners team.

Dianne Davis MPH

Vice President, Community Wellness

Partners in Care Foundation

Dianne Davis is Vice President, Community Wellness at Partners in Care Foundation leading 16 professionals implementing evidence-based programs as well as overseeing the nationally-recognized HomeMeds program. She has 25 years’ experience in healthcare administration, Managed Care and Gerontology. Ms. Davis oversees federal, state, county, city and private foundation relationships, and Partners’ contracts for evidence-based programs with health systems. Ms. Davis holds a MPH from UMASS, Amherst and a post-graduate certificate in Gerontology from UMASS Boston. She speaks at numerous conferences, is a member of the Evidence-Based Leadership Collaborative, a mentor for the NCOA Network Development Learning Collaborative and taught a course at UCLA, Evidence-based Programs for Older Adults.

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