Care Across Settings
Aligning Forces Alliances in Maine, Minnesota, and Oregon were recently featured in Health Affairs for their efforts in developing safety-net accountable care organizations (ACO). ACO-focused initiatives have early signs of success in delivering cost-effective, patient-centered care while advancing patient engagement, thus achieving Medicaid’s Triple Aim. Safety-net ACOs are collaborative entities of...
If communities can create a focus around information sharing, about patients and with patients, Craig Brammer believes we can radically improve health and the way patients navigate health care. Part of that is getting people in a room to talk about things they don’t agree on. How do you give people a nudge to do this? In Cincinnati, they use data as a “magnet” to pull people together. Part of it is extending a low-risk opportunity to participate. “We learn together and give ourselves an opportunity to improve.” Brammer knows firsthand the importance of...
The New Mexico Alliance had a dilemma. The three major health care providers in the Albuquerque metro area were struggling to find a way to tell patients not to use the emergency departments for non-emergency situations, without making it seem like they were turning people away. No one hospital wanted to be perceived as unwelcoming. The Alliance brought the hospitals together and borrowed a tested messaging campaign from the northwest part of the state. The campaign mostly used radio advertising—and in New Mexico, where people drive long distances every day, radio proved to be a...
When a patient moves across settings, like from a hospital to a nursing home, they are particularly vulnerable. Lapses in care, miscommunication of information between providers, mixups with medication – all are possible side effects of “handoffs” that are not well coordinated.
AF4Q Alliances have done significant work to improve the quality of care in hospital settings, and are connecting these efforts to improve care across settings. Alliances are working to design care delivery systems that focus on the continuity of care, avoid unnecessary risks in quality and safety, and promote coordination between providers.
Eric Coleman, MD, MPH from the University of Colorado at Denver, is a leader in improving quality and safety during times of “hand offs.” In a conversation with AF4Q communities, Dr. Coleman provides an overview of evidence-based transitional care models that have improved patient outcomes and reduced the cost of care. He showcases the Care Transitions Intervention (CTI)—a 4 week program for patients with complex care needs transitioning from hospital to home and which emphasizes coaching and self-care management. Dr. Coleman described CTI’s impact on achieving higher value health care in an era of reform and shares specific lessons, strategies, and implementation resources for hospitals interested in adopting this model of care.