Care Transformation Center Blog

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

Offering housing services? You may require a major mind shift

by Rachel Zuckerman, Vidal Seegobin, and Darby Sullivan September 18, 2019

Editor's note: This is part of a series about care transformation around the globe, where we look at successful population health managers outside the United States. A version of this post previously ran on the The Forum blog.

Patients experiencing homelessness are more likely to struggle with physical trauma, unmanaged chronic conditions, and behavioral health emergencies. They are also less likely to access adequate care. These factors can reduce a patient's life expectancy by up to 36 years. When patients experiencing homelessness are in crisis, safety-net organizations are tasked with meeting their complex needs. 

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Struggling with behavioral health patients in your ED? You're not alone.

by Abby Burns, Andrew McGrath, and Tomi Ogundimu September 11, 2019

Of all the questions care transformation leaders have asked our Population Health Advisor team so far in 2019, one topic is consistently top-of-mind: behavioral health. While questions about how best to manage population behavioral health needs aren't new, the questions we receive are growing in both volume and nuance.

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Here's how UNC Health grew its population health infrastructure (despite a fee-for-service environment)

by Abby Burns and Tomi Ogundimu September 4, 2019

Medicare "fee-for-value" codes present an opportunity for providers still reimbursed under fee-for-service to fund investments in value-based care. However, these codes (e.g., TCM, CCM, ACP, BHI, AWV) are still heavily underutilized. A 2018 analysis found that despite demonstrating significant impacts on total cost of care and mortality, providers billed TCM in only 7% of eligible cases in 2015 (up from 3.1% in 2013). Similarly, a 2017 analysis found that only 4.5% of eligible providers billed CCM in the first 15 months of availability. And research published in JAMA Internal Medicine  earlier this year found that use of ACP codes is less than 3%.

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Fact: Offering rideshare services to patients does not improve the primary care appointment attendance rate

Tomi Ogundimu August 20, 2019

Health systems are increasingly investing in interventions to address social determinants—and transportation is often at the top of the list. The Altarum Institute estimates 3.6 million Americans miss or delay medical appointments each year due to a lack of transportation, and many more rely on medical transport with long-wait times and high rates of driver no-shows. Therefore, many provider organizations (and health plans) have begun to partner with popular rideshare companies like Uber and Lyft, aiming to get patients to their appointments more easily (and at lower cost than traditional NEMT services).

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How the US maternal mortality crisis is rooted in inequality (and 4 ways to combat it)

by Darby Sullivan and Tomi Ogundimu August 14, 2019

The United States is the only industrialized nation where the maternal mortality rate is increasing. Black and Native patients are four times more likely to die from pregnancy-related complications compared to white patients. Transgender men report discrimination and insufficient care when pregnant. And 60% of these deaths are preventable. Researchers directly attribute these worsening trends to a few factors—insufficient access to care, miseducation on the warning signs of complications, and missed or delayed diagnoses.

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Here's why you're behind in chronic disease management

by Darby Sullivan and Tomi Ogundimu August 7, 2019

Chronic disease care currently accounts for $1 trillion in spending across the United States. By 2030, the number of patients with three or more chronic diseases will nearly triple to 83.4 million. Can your chronic disease management program accommodate three times as many patients? Too often we find that providers rely on technology innovations to solve the challenge of scale. But there's no magic bullet to supporting successful self-management.

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Why Medicare's bundled payment model isn't changing SNF discharge patterns (and 6 ways to make a change)

by Clare Wirth and Tomi Ogundimu July 31, 2019

The Bundled Payment for Care Improvement (BPCI) Initiative accelerated the shift of financial responsibility for post-discharge care to hospitals. In response, we'd expect participating hospitals and health systems to develop tighter relationships with post-acute care (PAC) providers to improve care coordination and control costs. Yet, new research suggests that skilled nursing facility (SNF) discharge patterns from hospitals participating and not participating in BPCI are largely the same.

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Two ways natural language processing can transform mental health treatment

Andrew Rebhan July 25, 2019

Editor’s note: A version of this post previously ran on the IT Forefront blog.

Natural language processing (NLP) allows computers to analyze, understand, and derive meaning from text and speech similarly to how humans do. Part of the larger artificial intelligence (AI) landscape, NLP converts unstructured data into actionable information. NLP has various uses in health care today, such as supporting clinical documentation and decision-making.

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