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Care Transformation Center Blog

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

How to determine which elective surgeries are optional

Christina Wild February 8, 2016

When deciding whether to perform preference-sensitive procedures, such as joint replacement or spinal surgery, providers face a host of competing incentives. Aging patients and new health insurance marketplaces have created significant opportunity for increased surgery volumes.

However, beginning fiscal year 2015, provider organizations will be subject to Medicare penalties if patients who receive total hip and total knee replacement surgery are readmitted within 30 days post-discharge for any reason. Now more than ever, it is important to ensure that the “right” patients are receiving the “right” care at the “right” time.

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Map your organization's transition to population health

Megan Clark February 1, 2016

While the end goal of population is clear, the transition path couldn’t be murkier. Here are our top three resources mapping out the transition path to population health.

First, our colleagues just published an infographic that helps organizations see how far along they are on the path to value-based care, with helpful guidance on key investments for each stage. Looking for more details? Check out our guide to transitioning the physician network, payment strategy, and care model. Finally, view our recommended top ten opportunities for care management.

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Why patients with complex drug regimens could use a pharmacist

Lindsay Conway January 22, 2016

Depending on which study you read, between 20% and 50% of patients do not take their prescription medications as directed. Often patients try to follow through, but they are stymied by high costs, formulary restrictions, confusion about when and how to take their medications, and having to juggle multiple regimens at once, among other obstacles.

These breakdowns are estimated to account for 10% of all hospital admissions and 125,000 deaths each year. And the risks only increase for patients taking complex drug regimens over extended periods of time.

Fortunately, there are many practical steps health care providers can take to support patients, including thorough medication reconciliation; optimizing the medication regimen by adding or removing drugs as appropriate; removing barriers to access; patient education; and ensuring patients know where to turn with questions.

Often involving pharmacists directly in patient care yields even better results. Below are lessons from two highly successful pharmacist-led programs.

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Empathy: A common ingredient for happy patients, staff, and margins

Jenny Love January 19, 2016

Consumerism and patient experience are big buzzwords in health care right now, but it was still a surprise when I saw them in action.

Recently, a friend's mother was diagnosed with cancer. She chose the hospital that was most convenient for her treatment. The medical care she received was adequate, but she felt like a widget in a cancer-treatment factory. The missing ingredient: empathy.

Another hospital offered a more patient-centered approach. The hospital was 40 miles farther from her home, but despite the additional driving—and the piles of paperwork and multiple phone calls needed to change the location of her treatment—she switched facilities. Being supported as a human being was worth the hassle during such a difficult time in her life.

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Q&A: Lessons for organizations interested in community paramedicine

Christina Wild January 14, 2016

In last week's interview with Dr. James Dunford, Professor Emeritus of Emergency Medicine at the University of California-San Diego and Medical Director for the City of San Diego, we talked about the impetus for the City of San Diego’s successful community paramedicine program: the Resource Access Program (RAP).

Here, Dr. Dunford gives us more details about the RAP services provided to complex patients, the community collaboration that was necessary to scale the program, and what’s next for the City of San Diego EMS.

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The ACO quality challenge: Not just about reporting

Shelby Harrington, MS, BSN, RN January 13, 2016

At the end of 2015, we learned that 65 accountable care organizations (ACOs) missed out on bonus payments from CMS last year even though they generated savings for the Medicare program. The reason? They didn’t hit their target for quality measure performance required by CMS.

At the time, I couldn’t help thinking, “I wonder if those organizations were surprised by the results?”

Without a doubt, all the ACOs in Medicare’s shared savings program, including those 65, were working hard to achieve the goals of value-based care: improved care, improved health, and reduced costs. But this news highlights how hard it can be to capture and understand—let alone improve—quality performance.

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Q&A: Inside San Diego's community paramedicine program

Christina Wild January 8, 2016

Emergency departments nationwide—from the largest medical centers to the most remote critical access hospitals—spend a disproportionate share of staff and financial resources providing non-urgent care to patients who often would have been better served in the home or a primary care setting.

I recently participated in the West Health Advisory Council on ED to Home-Based Care—a multidisciplinary council comprised of emergency physicians, geriatricians, home health nurses, policy makers, and caregivers brought together to discuss how to expand the use of home-based care options for patients initially seen in the ED.

I sat down with one member of the Advisory Council—Dr. James Dunford, Professor Emeritus of Emergency Medicine at the University of California-San Diego and Medical Director for the City of San Diego—to discuss the development of the City of San Diego’s community paramedicine program and his team’s efforts to improve the health of medically and behaviorally complex members of San Diego’s community.

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Care transformation priorities for 2016, inspired by you

Tomi Ogundimu December 17, 2015

As a population health researcher, I spend a lot of time speaking with providers about their care transformation goals and barriers to achieving them. And regardless of where population health leaders sit in their respective organizations, they have a difficult charge: quickly scale population health efforts.

As I reflect on the conversations we’ve had to date, here are two population health resolutions providers should keep their eye on as we head into the New Year.

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