Under its partnership with CMS to improve quality of care in long-term care (LTC) facilities by reducing avoidable hospitalizations, the University of Pittsburgh Medical Center RAVEN project embeds clinical staff within eighteen nursing facilities. Here, April Kane, co-director of the RAVEN project, explains how the on-site presence of enhanced care and coordination providers (ECCPs) elevates the facility’s clinical capabilities, from goal development to advanced care planning.
During Hospital-Nursing Home Collaborations to Reduce Avoidable Admissions and Readmissions: A UPMC Case Study on Curbing Long-Term Care Hospitalizations, an August 2016 webinar now available for replay, April Kane shares the key details of the RAVEN program and how UPMC is preparing for Phase 2 of the program.
Even when employing sophisticated predictive analytics to zero in on population health risk, healthcare organizations shouldn’t discount providers’ intuition, advises Luke Hansen, MD, vice president and chief medical officer, population health for AMITA Health.
With a future plan to adopt a risk prediction tool, AMITA currently creates chronic illness registries to track its high-cost patients. Listen as Dr. Hansen discusses the tradeoffs of mathematically intense risk predictors versus physicians’ guts.
During an August 2016 webinar, Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care Management Strategy, now available for replay, Dr. Hansen and Susan Wickey, AMITA Health vice president, quality and care management, share the key components of AMITA Health’s care management process, how the various care management teams work together and the impact the program is having on healthcare costs and utilization.
By focusing chiefly on moving high-risk patients down to the low-risk band, population health management programs are in danger of missing the “natural inertia” driving low-risk patients right back into that high-risk stratum, cautions Dr. Adrian Zai, clinical director of population informatics at Massachusetts General Hospital (MGH).
Dr. Zai describes why MGH, ranked the number one hospital in the nation by U.S. News & World Report,® advocates a multi-pronged approach addressing both low-risk and rising risk patients—a strategy that has improved MGH care quality and provider performance while reducing high-cost healthcare utilization.
During an August 2016 webinar, Targeting High-Risk and Rising-Risk Patients: A Multi-Pronged Strategy, now available for replay, Dr. Zai shares the key details behind his organization’s strategy and the results it has achieved.