Care Transformation Center Blog

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

One hospital's secret weapon to tackling social determinants: Volunteer medical students

by Rebecca Tyrrell and Clare Wirth July 21, 2017

We know that social determinants of health can derail even the best clinical care, yet many organizations lack clearly defined processes and "owners" for the tasks of identifying non-clinical needs and connecting patients to services. Lankenau Medical Center, part of Main Line Health, recently told us how they incorporated medical students into their Patient-Centered Medical Home (PCMH) workflow to tackle patients' social needs.

Through a partnership with the Philadelphia College of Osteopathic Medicine (PCOM), Lankenau engages volunteer medical students to assess patients' non-clinical needs and connect them with community-based resources. The program serves a dual purpose: It helps patients overcome barriers to care and inspires future doctors to take a more holistic approach to treatment. 

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6 things 340B and non-340B hospitals need to know about CMS's proposed $900M cut to drug reimbursement

by Lindsay Conway and Molly Stein July 20, 2017

Last week, CMS released the proposed Outpatient Prospective Payment System (OPPS) rule for 2018—which includes a major proposed cut for separately payable drugs purchased under the 340B program. Read on for our analysis of the proposal, what to expect, and action steps hospital leaders should take today.

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3 imperatives for reducing opioid misuse and abuse

by Rebecca Tyrrell and Colleen Keenan July 11, 2017

The opioid epidemic is wreaking havoc in communities across America. Opioid misuse and abuse contribute to 420,000 ED visits each year and are responsible for 37% of overdose deaths annually.

Many health care leaders have asked us about immediate actions they can take to respond to the crisis. Here are three steps hospitals and health systems should take now to address current issues and prevent future opioid-related abuse or misuse cases:

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How to tell if you're ready to implement a community paramedicine program

by Tomi Ogundimu and Clare Wirth July 6, 2017

Community paramedicine programs can help address care needs of frequent ED users, recently discharged patients, and at-risk patient populations who lack access to primary care or adequate insurance coverage for home care services. Many health organizations have begun partnering with local Emergency Medical Services (EMS) providers to deliver patient-centered in-home health care services.

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Coordination isn't just for patients: How one system is 'coordinating the coordinators'

by Rebecca Tyrrell and Carolyn Buys June 29, 2017

As providers expand care management services across patient populations, managing the various stakeholders involved in coordinating care is becoming more challenging.

A high-risk patient diagnosed with cancer, for example, could simultaneously be managed by an oncology nurse navigator and a primary care coordinator. However, these individuals may not communicate regularly or have a clear understanding of who ultimately "owns" certain coordination functions. As a result, efforts may be duplicated, certain tasks might fall through the cracks, and patients may become overwhelmed.

One system in the Midwest has created an innovative program for "coordinating their coordinators" by using three distinct strategies for managing disparate stakeholders involved in a patient's care plan:

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How co-locating with the police can reduce avoidable ED use

Tomi Ogundimu , Petra Esseling June 23, 2017

One in eight emergency department (ED) visits is associated with a behavioral health issue. These visits are not only costly to the system, they are often unnecessary and preventable.

A key driver of many of these visits is the shift away from providing services in psychiatric institutions to providing them in community-based settings—but limited funding for community-based programs has left individuals with behavioral health problems struggling to access care.

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2 strategies for engaging patients to boost medication adherence

by Rebecca Tyrrell and Samantha Freedman June 21, 2017

Of the 187 million Americans who take at least one prescription medication to treat acute or chronic illnesses, about half—93.5 million individuals—don't take their medication as prescribed.

The reasons for non-adherence are complex and highly variable. They include poor patient-provider communication, cost and access barriers, inadequate knowledge about a drug and its use, concerns about side effects, complex regimens, and simply not being convinced of the need for treatment. Moreover, adherence for a single individual may vary over time because of changes in condition, symptoms, personal circumstances, and many other factors.

Given the prevalence of non-adherence, prescribers and other care team members must assume greater responsibility for understanding and discussing potential barriers to medication adherence in order to choose treatment regimens likely to be followed. Here are two strategies providers should adopt.

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How UUHP saved $9.4M and avoided 7,000 ED visits—in just one year

Austin Weaver, MBA June 15, 2017

In an era where many health care organizations are struggling to reduce costs while still improving quality of care, University of Utah Health Plans (UUHP) has been able to successfully do both. We sat down with Joe Mercado, an Advisory Board population health consultant who has worked closely with UUHP, to find out how they did it. 

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