Care Transformation Center Blog

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

Breast cancer risk prediction is less accurate for Black patients. Deep learning is changing that.

by Ty Aderhold, Matt Morrill, and Darby Sullivan June 19, 2019

Editor's note: A version of this post previously ran on The Reading Room.

Health equity is a central strategic goal for many safety-net institutions, and population health investments to address systemic inequities are often focused on the social determinants of health—but those aren't the only factors that lead to unequal outcomes. Clinical processes themselves can contribute to inequities in care, as clinical research often fails to include people of color. Population health leaders can harness artificial intelligence and deep learning to begin to combat these inequalities.

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Here's why you can't overlook trauma-informed care

by Darby Sullivan, Praveena Fernes, and Tomi Ogundimu June 11, 2019

Many provider organizations tell us about how they're addressing social determinants of health to reduce total cost of care, improve patient outcomes, and advance health equity. However, few of those we talk to understand the extent of the impact trauma has on many medically and socially complex patients. Here's what you need to know.

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4 takeaways from CMS' first annual CPC+ report

by Tomi Ogundimu and Abby Burns June 5, 2019

This spring, CMS thrust primary care into the spotlight. The same day CMS announced its new Primary Cares Initiative, a third-party research institution it hired to evaluate the Comprehensive Primary Care Plus (CPC+) initiative released its First Annual Report of the ongoing primary care transformation program. Before we start drawing comparisons between the two programs, here are four things we learned from the first year of CPC+:

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Use this Medicare tool to pinpoint health disparities in your community

by Helen Wieffering, Praveena Fernes and Tomi Ogundimu May 30, 2019

Provider organizations must bring the same strategic rigor to community health investments as they do to traditional hospital programming. Otherwise, efforts stand to lose leadership buy-in, funding, and momentum before they get off the ground. To make the most of limited resources, provider organizations must take a data-driven approach to identifying target patient populations and community health gaps.

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4 steps to develop a successful Hospital at Home program

by Tomi Ogundimu and Clare Wirth May 28, 2019

Editor's note: A version of this post previously ran in the Daily Briefing.

Systems view Hospital at Home (HaH) with renewed enthusiasm. These programs can improve patient satisfaction and total cost of care. CMS may approve HaH as an alternative payment model under MACRA, making it more financially feasible.

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Want to help your patients lose weight? 3 reasons why commercial diet programs alone won't cut it.

by Abby Burns and Tomi Ogundimu May 22, 2019

Editor's note: This story was updated on May 28, 2019.

The health effects of being overweight or obese have been well studied, but adults in the United States currently weigh more than they have at any point since 1999. However, while providers often seek out methods to help patients address their underlying weight issues in order to treat their presenting conditions, few providers actually offer their patients distinct weight management services. Faced with an endless list of competing priorities and a market saturated with commercial weight-loss programs, providers may be tempted to outsource this service to the Jenny Craigs or Atkins Incs of the world.

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Want to cut Medicaid ED visits? Start with ambulatory care access—here's how.

by Hamza Hasan and Clare Wirth May 8, 2019

Editor's note: A version of this post previously ran on Practice Notes.

According to the CDC's latest data release, ED visits hit a record high in 2016. Patients covered by Medicaid and other state-based programs make up 38% of the 146 million visits across the United States—the highest of any payer type.

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How this Georgia organization used telehealth to cut the pre-term birth rate by 50%

by Emily Johnson, Samara Ford, and Abby Burns May 2, 2019

Editor's note: This story was first published on The Growth Channel and has been modified for a care transformation audience.

Maternal mortality rates in the United States continue to rise, even as they decline in other developed nations. Equally alarming are the high rates of pre-term birth and low birth weight infants.

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