Care Across Settings

Safety-Net ACOs Hold Promise to Achieve the Triple Aim

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...

Connecting the Dots, Changing the Way Patients Navigate Care

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...

Reaching People Where They Are: On the Highway, in Giant Trucks

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...

Breathe In, Breathe Out: Asthma Ready

More than 7 million children live with asthma in the United States. As a school nurse, Lizzie Cockrell has seen children struggle to control their asthma symptoms. One of her students, Judy, darkened the doorstep of the health room often. “Recess, PE, health—she was spending those times with me in the health room,” said Cockrell. Looking for answers and help, Cockrell remembered the Asthma Ready Program and used its tools and guidelines to coordinate among Judy’s family and her doctor to assess control of her asthma. Judy’s story is one that “...

Breaking Down the Barriers to Health Care in Detroit

Detroit health care leaders are working to improve access to health care by addressing chronic disease, better communicating with patients about making wise care choices and helping the newly insured navigate a complex health system. These efforts are led by the Greater Detroit Area Health Council, one of RWJF’s Aligning Forces for Quality (AF4Q) communities, which has brought together providers, patients, employers and insurers to help improve regional health care.

This program is a part of a larger effort by AF4Q to boost the overall quality of...

Kansas City Partnership Helps Children Manage Asthma

Kansas City health leaders are working together to tackle high pediatric asthma rates by building solutions to better identify and treat the condition. By working closely with children and their families, physicians, nurses and community partners have been able to reduce the severity of asthma for children in a unique pilot program.

These efforts are led by the Kansas City Quality Improvement Consortium, one of RWJF’s Aligning Forces for Quality (AF4Q) communities, which has brought together providers, researchers and patients to improve the way...

Creating Regional Partnerships to Improve Care Transitions

As patients move from one care setting to another, problems such as lack of follow-up care and miscommunication among clinicians often occur and can put patients at risk for serious complications and hospital readmission. Some patients have additional problems such as depression, social isolation, or a lack of housing or transportation that may increase their risk of hospital readmission. Nearly one in five Medicare patients discharged from the hospital is readmitted within 30...

Care Transitions Gain Ground

Patients in Western New York hospitals are having less fraught transitions from the hospital to home thanks to a community initiative. Under the leadership of the P2 Collaborative, 10 hospitals and eight community-based organizations have banded together to reduce avoidable hospital readmissions. Contracted by the Centers for Medicare and Medicaid Services through the Community-based Care Transitions Program (CCTP), the coalition provides coaching services to Medicare Fee-for-Service patients who are at risk for readmission to the hospital after an acute care...

Patients with Depression Don't Walk Through the Clinic Door

Depression can be debilitating. Major depression causes pain, disability, or even death and may also lead to workplace absenteeism. According to the Institute for Clinical Systems Improvement (ICSI), primary care doctors detect depression in patients only about 30 to 50 percent of the time. Typically, of the patients who do receive a diagnosis of depression, between 20 and 40 percent show improvement within one year. Primary care physicians have lacked the know-how, time, and other resources to help patients with depression get the treatment they need.

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Keeping Mental Health Readmissions RARE

It’s well known that the RARE (Reducing Avoidable Readmissions Effectively) Campaign has been highly successful in Minnesota. The most recent data from the third quarter 2013 show that participants have helped prevent 7,030 avoidable readmissions since 2011 and allowed patients in Minnesota to spend 28,120 nights of sleep in their own beds instead of in the hospital.

The RARE Campaign was launched in 2011 by the Institute for Clinical Systems Improvement (ICSI), the Minnesota Hospital Association (MHA), and Stratis Health and...