Care Transformation Center Blog

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

Penn's IMPaCT program cracked the code of deploying community health workers—and you can, too

by Tomi Ogundimu and Darby Sullivan May 22, 2018

"[Doctors] can give you advice, like, 'Here's the kind of medicine you need.' But they don't really know how it works in the real world." Summed in just two sentences, a patient from the University of Pennsylvania Health System succinctly encapsulates the disconnect between health care professionals and at-risk patients who have difficulty effectively self-managing their conditions. For patients dealing with a range of non-clinical barriers to health—from unemployment to food deserts—clinical care isn't enough to improve long-term health outcomes and care utilization.

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Seven lessons on developing a sustainable community partnership

by Tomi Ogundimu and Clare Wirth May 16, 2018

The continued acceleration of value-based payment incentives has almost all providers investing energy into addressing the social determinants of health to some extent, often relying on community-based organizations via partnerships.

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The 4 key policy proposals in Trump's Rx drug speech, explained in charts

By Lindsay Conway, Managing Director, Oncology Roundtable and Pharmacy Executive Forum May 14, 2018

Editor's note: This post was updated on May 16, 2018.

President Trump's Blueprint to Lower Drug Prices, which he outlined in a long-awaited speech on Friday, sets out many ideas for reforming drug markets and reducing drug prices, increasing price transparency and promoting competition.

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You asked, we answered: The top population health questions from Spring 2018

by Tomi Ogundimu and Andrew McGrath May 10, 2018

Editor's note: This blog was updated on May 14, 2018.

Last year, your peers focused on improving care for high-risk patients, including optimizing care management caseloads and addressing acute behavioral health patient needs. But throughout the spring, many of your questions have shifted focus from the high- to rising-risk population, as well as to the collective impact of social determinants of health.

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How Geisinger is responding to the opioid crisis and cutting ED visits in the process

by Rob Lazerow, Rebecca Tyrrell, and Gillian Michaelson April 26, 2018

Drug overdoses are now the leading cause of accidental death in the US. In 2016 alone, fatal drug overdoses (63,632) surpassed the number of individuals who died during the HIV/AIDS epidemic at its peak in 1995 (43,000) and U.S. military deaths in the Vietnam War (58,000). At this point, opioid abuse and addiction have had devastating consequences on communities nationwide.

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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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