Care Transformation Center Blog

The insights, tools, and resources you need to take on population health management

How school-based asthma care saved one health system $6.7 million

by Tomi Ogundimu and Petra Esseling April 19, 2018

Each year, 1 in 5 children in the United States visit the ED at least once, often unnecessarily. A major driver of this preventable ED use is asthma. That's true across the country, but particularly in Illinois, which has one of the highest asthma morbidity and mortality rates in the United States. Mobile Care Chicago made it their mission to improve access to asthma services in Chicago neighborhoods that are short on asthma specialists.

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Don't reinvent the wheel: How to retrofit your Medicare care management platform for Medicaid risk success

Yulan Egan , Christine Lee April 17, 2018

Although many providers find the prospect of taking on Medicaid risk overwhelming, success under a Medicaid risk contract need not be daunting. In fact, systems that have invested in care management for other populations—particularly Medicare beneficiaries—already possess the necessary foundations for Medicaid care management. With three key adjustments, you can enhance and expand your existing care management platform for success under Medicaid risk. And while the below adjustments are must-haves for success under Medicaid risk, these investments can also be scaled across the Medicare and commercial populations to enhance broader care management efforts.

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The 3 simple steps behind the resounding success of UCSF's care transition overhaul

by Tomi Ogundimu and Clare Wirth April 12, 2018

Health care spending for patients with 3-4 chronic conditions is six times higher in the ED than spending for patients without any chronic conditions. That's around $2,500 more per person per year. The good news it that much of that additional spending could be avoided through extensive coordination across the care continuum. Unfortunately, many health systems are ill-equipped for this degree of coordination, resulting in care gaps, duplicative efforts, and inefficiencies for many complex patients.

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4 ways Cone Health avoided 2,000 COPD readmissions—and you can, too

by Tomi Ogundimu and Abby Burns April 6, 2018

One out of every five COPD patients discharged from the hospital will readmitted within 30 days, making COPD a leading contributor to hospital readmissions in the United States. It's not surprising, then, that over half of hospitals penalized under CMS' Readmissions Reduction Program for FY 2018 were penalized for COPD readmissions. As hospitals look to avoid future readmissions penalties, successfully managing COPD should be top-of-mind. But where should you start?

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3 'must-haves' for taking your telehealth program to the next level

by Liz Cothren, RN, MSN April 5, 2018

Telehealth adoption is rising rapidly across the nation. In fact, more than 70% of hospitals and provider groups have a telehealth program, according to a 2017 HIMSS Analytics survey. Many organizations are now exploring how to maximize the benefits of these programs to deliver better patient engagement, improve access to needed services, and engage physicians in developing new models of care.

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Do palliative and emergency care go together? St. Joseph's Regional Medical Center says yes.

by Tomi Ogundimu and Abby Burns April 3, 2018

A 25-year old patient was nearing the end of her life after a battle with cancer when she presented to the ED at St. Joseph's Regional Medical Center in Paterson, New Jersey with unmet palliative care needs. Her request of the doctors was simple: keep me out of the hospital. So the St. Joseph's team had an idea—they would set up shop in the ED to streamline operations. Like 76% of hospital palliative care programs, the St. Joseph's team already provided services to ED patients in a consult capacity, why not base their operations there?

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Design thinking can improve behavioral health outcomes. Here's how.

by Tomi Ogundimu and Viggy Parr March 29, 2018

Providers face similar challenges to sheriff's offices: high volumes, unpredictable patients, and inappropriate spaces to treat them. And many arrested inmates also need high-acuity health care services. So the Multnomah County Sheriff's Office in Portland, Oregon, started an innovative initiative to use simple design tweaks to address these challenges. If sheriff's offices can use design thinking to drive throughput and effective management, health care providers can apply the same thinking to emergency departments, inpatient psychiatric units, and outpatient clinics.

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We analyzed 25 population health interventions—and these 2 give the best 'bang for your buck'

by Tomi Ogundimu and Darby Sullivan March 22, 2018

Determining investments to make in care delivery transformation is a difficult task without good data on which initiatives have demonstrated success. While most provider organizations look to adhere to evidence-based guidelines, there are few explicit standards for many innovations in care transformation. To make the right investments that change the care delivery model, population health managers should prioritize initiatives proven to move target metrics related to cost, utilization, and quality.

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