Care Transformation Center Blog

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

How social workers bolster primary care—and how to maximize their potential

by Abby Burns and Tomi Ogundimu December 11, 2018

If you speak to primary care leaders and physicians who have effectively integrated licensed clinical social workers (LCSWs) into their practices, they'll tell you how critical this team member is. We spoke to one provider who said "to remove a social worker would undermine anything we try to do care for people living in poverty." Another told us that if he could, he'd exclusively hire social workers when looking to enhance his care team.

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Learn how the University of Pennsylvania prevents CHW burnout—and maintains a 2:1 ROI

by Darby Sullivan and Tomi Ogundimu December 6, 2018

Back in May, we introduced the University of Pennsylvania Health System's high-value community health worker (CHW) program called IMPaCT. Given the questions many of you asked on how the program is structured and what the CHWs do day-to-day, we returned to Penn to shadow a CHW. One of our biggest lessons from that day is that without tools to effectively manage time and patients, CHWs can quickly burn out.

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Your missing risk factor? Untreated hearing loss costs an additional $22K per patient—here's what Johns Hopkins does about it.

by Clare Wirth, Petra Esseling, and Tomi Ogundimu December 4, 2018

Few population health managers focus on hearing loss as a contributing risk factor of cost, but hearing loss is a costly and treatable condition hidden in plain sight. It's highly prevalent and impacts two-thirds of people over age 70. Two recent studies in JAMA Otolaryngology demonstrate how untreated hearing loss may impact your bottom line:

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Building a food insecurity program from scratch: 6 tips from Hurley Medical Center

by Darby Sullivan and Tomi Ogundimu November 27, 2018

Editor's note: This story was updated on December 6, 2018.

Food insecurity is often among the first targets for hospitals looking to address the social determinants of health. System leaders and care teams are very familiar with the connection between nutrition and health, which smooths the implementation process. However, that familiarity doesn't mean starting a program from scratch is easy. In fact, there are several potential pitfalls where small mistakes can threaten program viability.

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How the University of Colorado Health cut the total cost of ED patient care by 18%, in 6 steps

by Clare Wirth and Tomi Ogundimu November 15, 2018

Reducing avoidable ED utilization is a top priority for every population health. However, ED optimization is often a missed opportunity to right-size utilization. Inefficient EDs threaten the ability to accommodate growth of covered lives and risk financial loss under value-based care arrangements due to:

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Answers to the top population health advisor questions of Q3

by Darby Sullivan, Andrew McGrath, and Tomi Ogundimu November 13, 2018

Across the late summer and early fall of 2018, our Population Health Advisor experts received and answered 140 questions on best practices in value-based care delivery. At the top of your peers' minds? 1) Improving ED workflow for acute behavioral health patients, and 2) establishing inclusion criteria for palliative care services. Here's what we've shared in response.

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Put an end to drug diversion in your hospital

by Lindsay Conway and Colleen Keenan November 8, 2018

The opioid epidemic continues to take its toll on the United States with an average of 115 Americans dying each day from an opioid overdose. Health systems have worked to support their patients and communities in the fight, but these organizations have often overlooked their own employees in the process. Health care workers are not immune to the effects of the opioid crisis. In fact, it is estimated that 15% of pharmacists, 10% of nurses, and 8% of physicians are challenged with alcohol or drug dependency at some point in their careers.

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