Care Transformation Center Blog

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

CMS just finalized new discharge planning rules. Here's what you need to know.

by Tripti Rathi and Monica Westhead October 23, 2019

Each year, millions of patients must decide where to receive post-acute care following an inpatient admission.

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How UCSF launched the Trauma Recovery Center and cut costs by one third

by Darby Sullivan and Tomi Ogundimu October 16, 2019

In June, we discussed three key components of trauma-informed care. Some of you emailed us thoughtful feedback about what constitutes the scope of trauma. Specialized care can promote resilience among patients who've endured many types of trauma, including patients who have parents with substance use disorders, refugees from war zones, and survivors of the AIDS epidemic. However, traumatic experiences widely vary, so a one-size-fits-all approach risks re-traumatizing patients and interfering with recovery. Instead, providers should tailor each patient's treatment plan to the type of trauma endured.


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How Intermountain's neonatal telehealth program saved $1.2M, improved care, and secured community hospital revenue.

by Lauren Lawton and Tara Viviani October 9, 2019

Editor's note: A version of this post previously ran on The Growth Channel blog.

Up to 10% of newborns require breathing assistance or extensive resuscitation. While neonatal providers attend biannual resuscitation trainings, skill deterioration is common within months of the course, especially for those who rarely use resuscitation.

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How Hebrew SeniorLife is managing the growing dementia population—and how you can too

by Carolyn Buys and Monica Westhead October 2, 2019

The number of patients with Alzheimer's and other forms of dementia is expected to grow from 5.8 million to 14 million by the year 2050, costing the U.S. health system nearly $800 billion. These patients have twice as many hospital stays as other older adults, and present unique clinical challenges to providers, such as frequent wandering and ED utilization.

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Inside Atrium Health's scalable behavioral health strategy

by Clare Wirth and Tomi Ogundimu September 25, 2019

Despite the increasing demand for behavioral health treatment in primary care and the ED, many providers are ill-equipped. In fact, 60% of visits resulting in a mental health diagnosis are made to a primary care provider (PCP). However, behavioral health is only one of the many issues PCPs treat and their assessment and treatments are inconsistent. And one in eight ED visits is related to a mental health or substance misuse issue. However, only 17% of ED physicians say they have access to an on-call mental health professional.

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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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