One percent of Americans account for 20 percent of the nation’s health care costs; five percent account for 50 percent. Who are these patients? They are known as “super-utilizers”—patients who make frequent trips to the emergency room and have many hospital admissions. Often they are alone and need help determining where to go and how to get healthier.
In six of the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) sites, communities are reducing ER visits and hospitalizations for super-utilizers. In her new article, “Caring for...
Change has come quickly in Oregon over the past few years. In 2009, the Oregon state legislature created the Oregon Health Policy Board and Oregon Health Authority (OHA) to address the issues of cost, quality, and access to health care. In 2010, the Oregon Health Policy Board developed Oregon’s Action Plan for Health to lay out strategies and a timeline for actions that will lead to lower costs and improved quality in Oregon’s health care system. As part of the strategy, the Patient- Centered Primary Care Home Program (PCPCH) within the OHA sets the standards, recognizes, and...
“I met other people with critical illnesses, and I knew I wasn’t alone. Our voices were heard, and we were able to make a difference in how health care is promoted in our area,” said Belinda Wee, PhD.
Wee joined Bangor Beacon Community’s Patient Advisory Group after her positive experience with the community as a chronic diabetes patient. With the help of her care manager, Debbie Grover, RN, Wee was able to get her diabetes under control.
“Because she cared, I cared,” said Wee. “I wanted to serve the community that helped me. I...
According to the Robert Wood Johnson Foundation (RWJF), health care spending in the United States is unevenly distributed, with the sickest five percent of patients causing more than 60 percent of health care costs. These “super-utilizer” patients make frequent trips to hospital emergency rooms or have repeated inpatient hospital stays, resulting in costly health care.
Aligning Forces for Quality Humboldt County (Aligning Forces Humboldt) was among the recipients of a $200,000 grant for its Care Coordination for Emergency Department Super-Utilizer project. Humboldt...
“I knew I needed to make a change and be proactive in reducing my risk for heart disease. The exercise program helped me lose over 25 pounds, and my blood pressure is down to 112/65. The personal trainers were amazing. I have more energy than ever,” said Gloria Kennedy.
Kennedy, 53, a Detroit resident and mother of two, is a testimonial to the importance of the Cardiac Disease Prevention Exercise Program 
led by the Aligning Forces for Quality (AF4Q)...
WellSpan Health, a partner organization of Aligning Forces for Quality South Central Pennsylvania, is expanding an online portal to give patients more access to their medical information. As the movement towards greater patient engagement continues, technology is an essential piece of the puzzle. The online portal is being expanded on the heels of the transition to electronic medical records.
Patients are the heart of any primary care practice. Patients and practices share a mission to improve patient health—a mission in which both parties play indispensable roles. Three AF4Q Alliances (Humboldt County, Maine, and Oregon) have developed a compendium of resources that details the implementation of patient engagement strategy. The toolkit provides case studies and insights into patient recruitment and training, clarifying roles and responsibilities, and developing a...
The conveners of the Maine Patient Centered Medical Home Pilot Project, the Dirigo Health Agency's Maine Quality Forum, Maine Quality Counts (QC), and the Maine Health Management Coalition announced that 50 primary care practices from across the state were selected for participation in the expansion of the Maine PCMH Pilot. The second phase of the Maine PCMH Project began on January 1, 2013. The Selection Committee received more than two applications for each available opening in the pilot program from primary care practices throughout Maine. The large number of applications...
The Aligning Forces for Quality alliance in south central Pennsylvania, which includes York and Adams Counties, adapted Humboldt’s Patient Partner project to enhance its existing Patient-Centered Medical Home Collaborative. Patient Partners have focused on patient communication and self-management to help other patients take an active role in their care. Practices have begun using a validated tool to measure baseline and subsequent changes in Patient Partners’ active engagement in their own health and health care. One of the successful outcomes is the creation of a “brown...
Aligning Forces for Quality in South Central Pennsylvania (SCPA) strives to ensure patients with chronic disease have a voice in local practices’ transition to patient-centered medical homes. Patient partners are integrated into each practice’s team to ensure that the perspective of those receiving care is considered throughout the improvement process—and reflected in changes. Each practice appoints a physician champion to serve as a liaison between patients and practices and review the flow of interactions with patients with diabetes.
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