The rising costs of health care have prompted stakeholders to look at ways to address the deep gaps that exist in care transitions; an imperative if health care is to become more efficient and cost-effective. With accountable care organizations (ACOs) now eligible to participate in the Medicare Shared Savings Program, the hope is that health quality will improve and readmissions fall. But filling those gaps in care may not be quite so simple. Improving transitions in care will require a deeper understanding of where and why the problems exist and a willingness to work in an innovative and collaborative manner with stakeholders across the health care continuum.
Video: Strategies for better care coordination transitions
The emergency room is an inflection point in the care of many patients. Regardless of whether the patient is admitted to the hospital or sent home after treatment, the transfer of care has to be done carefully—including detailed follow up and thorough education—or that patient may well end up being admitted or re-admitted to the hospital. Optum experts Mark Crockett, MD, and Simon Stevens, with Palmer Evans of Tuscon Medical Center, discuss the importance of investing adequate resources into transition management, the need for better electronic medical records, and real-time patient information exchange.
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Podcast: Improving health care transitions
Care transitions are one of the most significant levers in achieving the triple aim of ACOs—advancing care for patients, improving population health, and reducing costs. Join OptumInsight expert Michael Goran, MD, as he explores the avenues ACOs are taking and opportunities for improving care transitions from the hospital setting. These include having adequate resources to ensure the patient is properly informed about medication management and where to turn for help, improving outcomes by keeping health professionals connected through electronic records and data sharing, and achieving the optimum goal of a health information exchange that reaches all stakeholders, including the patient.
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Expert Q&A: High-tech vs. high-touch care transitions
Whether from hospital to home, hospital to outpatient clinic, or another move between care settings, patients can become lost in the gaps of care transitions. And without sufficient care planning, they may end up back in the hospital. To address these costly and often unnecessary readmissions, the Affordable Care Act created the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program. This program will reduce Medicare reimbursements to hospitals with higher-than-average 30-day readmission rates beginning in October 2012. Ignite magazine spoke with Pramod Gaur, PhD, vice president of telehealth at OptumHealth, to discuss this program as well as ways to improve the continuity of care.
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Article: Model ways to address the gaps in care transitions
Hospitals and other providers are developing and adopting new care transition strategies to improve the care patients receive from hospital admission staff far after they have been discharged. Models range from using a transitions coach to track patient progress and help them learn self-management skills, having nurses or multidisciplinary teams work with patients in hospital and conduct post-discharge follow-up calls, and using social workers to provide care coordination and information about community-based resources. To learn more about the models some providers are adopting and their experiences with these programs, read A Leap Across in the spring edition of Ignite.
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Provider insights
"The true efficiencies to be gained in the health care system are in better information exchange, which will result in improved efficiency, less duplication of service, and better care for the patient in general."
—Justin Chang, M.D.
Chief of emergency services, Kaiser Permanente, Colorado, and medical director, Exempla St. Joseph Hospital Emergency Department
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