Care Transformation Center Blog

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

Patient education that sticks—and doesn't overwhelm

by Chrissy Wild October 12, 2015

Newly diagnosed patients often struggle to understand and manage their conditions.

Patients may feel flooded with clinical information about the cause of and treatment for their condition and have a hard time deciding how to incorporate treatment of their disease into their daily life. Without an understanding of self-care strategies—how to make informed choices, monitor and manage the symptoms and signs of illness, and understand their various treatment options— patients’ conditions can quickly become exacerbated, resulting in ED visits and inpatient stays that could have been avoided with better condition management education.

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3 ways to give patients both palliative and curative care

Tomi Ogundimu October 9, 2015

A wide range of organizations have implemented some type of concurrent care delivery for patients with advanced illnesses, including hospice providers, health systems, academic medical centers, and commercial insurers. However, the design of concurrent programs vary widely across providers and can be generally grouped into three models.

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The story behind top Pioneer ACO Montefiore's success

Ashley Ford October 5, 2015

Montefiore serves the Bronx, Westchester, and Rockland counties in New York. The Bronx is one of the U.S.'s poorest and most densely populated areas. Per capita health care costs in the Bronx are 20% higher than the U.S. average; most patients are covered by public insurance programs, Medicare and Medicaid, which nationally cover only 70-80% of costs.

For the system to survive, Montefiore realized it had to work as efficiently as possible within its own walls and then move beyond them, unifying community providers and enfranchising clinicians to effectively manage the health of its population.

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Triple threat: Achieve multiple goals with community paramedics

by Chrissy Wild October 2, 2015

Many health systems embarking on population health initiatives know they need to bolster their partnerships with community resources, but don't know where to focus their efforts. Community paramedicine is a great place to start.

Community paramedics receive advanced training, allowing them to provide a range of in-home services, such as health coaching and home safety assessments for your rising- and high-risk patients. They can also help you reduce your ED volumes by providing in-home treatments to frequent 911 callers whose needs are not emergent, and reduce your readmission rates by performing post-discharge check-ups on at-risk patients.

Here are answers to questions we get frequently asked about developing a community paramedicine program.

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Concurrent care: The buzzword in hospice services

Tomi Ogundimu September 29, 2015

Studies have shown that providing hospice care earlier in the course of advanced, serious illness leads to better health outcomes, higher satisfaction, and lower care costs. However, when patients and physicians are forced to make the choice between hospice and curative care, hospice enrollment is often delayed.

The concurrent care model—also referred to as open access or simultaneous care—was developed to remove financial and psychological barriers to patients opting into hospice care. Under such models, patients do not need to choose hospice, palliative care, and curative treatments in isolation, and have a more gradual transition into hospice.

Here's why we see concurrent care as an emerging opportunity for population health managers.

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Your primer on hospice services

Tomi Ogundimu September 24, 2015

After CMS's recent announcement that it will expand a pilot project that allows terminally ill patients to continue receiving curative treatments while also qualifying for hospice coverage through Medicare, more population health leaders are evaluating the opportunity for their organization.

Here's what you need to know about hospice services.

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Is 'medical infidelity' breaking up your system? Time to confront leakage.

Dennis Weaver, MD, MBA September 23, 2015

We used to be in the dark when it came to knowing the impact of referral patterns. Now with access to claims data and physician tracking mechanisms, it’s easy to see when patients leave a system, where they go, and if they ever come back. And when you use all of that to quantify the effects of loose network management, it’s pretty stunning.

In fact, one physician executive I spoke with tells his employed doctors that it’s outright ‘medical infidelity’ when they permit leakage—costing millions in network revenue, and forfeiting oversight of patient care.

To give you an example, my team examined the referral patterns of a provider network in the Southwest. Within a subset of patients and across ten medical practices, we found that over $60 million of inpatient revenue was leaving the system annually. For the referring doctor, it might seem like the harmless cost of doing business. But for the health system and the patient, it’s personal.

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Does your PCP-specialist working group actually work?

Amanda Berra September 21, 2015

I recently gave a quick overview of six challenges to building a strong patient-centered medical home (PCMH)-specialist partnership, with a focus on overcoming the first challenge: introducing the medical home concept. In this post, I'll cover overcoming the second: building interdisciplinary channels for medical home-specialist cooperation.

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