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When AMITA Health set out to devise a more efficient method of moving its highest-risk Medicare beneficiaries across its care continuum, the newly minted Medicare Shared Savings Program (MSSP) accountable care organization (ACO) abandoned its siloed approach in favor of an enterprise-wide human-centric model of care. Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations describes how the nine-hospital system inventoried, reexamined and revamped its care management resources, ultimately implementing a centralized care management model that would support the Institute for Healthcare Improvement's Triple Aim goals.
In this 25-page resource, AMITA Health's Susan Wickey, vice president, quality and care management, and
Luke Hansen, MD, MPH, vice president and chief medical officer, population health, guide readers through their organization's care management redesign, which operates on the premise that AMITA's patients are never really discharged but only are transitioned to the most appropriate care site. Explaining the impacts achieved by focusing on a population considered at high risk for readmission and pairing those individuals with a dedicated care coordinator, Ms. Wickey and Dr. Hansen cover the following areas: - Inventory and assessment of the roles of patient navigators, case managers, patient-centered home care managers and ACO care managers;
- The health system's 11-point punch list for increasing efficiencies across the care continuum;
- Criteria for determining the high-risk target Medicare population;
- Essential elements of multidisciplinary, data-driven patient-centered care management;
- Establishment of a centralized, patient-centric care management hub;
- The role of registries in tracking chronic illness in high-risk patients;
- Key results from the organization's robust care management redesign;
and much more.
Table of Contents
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Reducing Readmissions and Avoidable Emergency Department Visits Through a Connected Care
Management Strategy
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7 Drivers of Change in the Healthcare Environment
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Fulfilling the IHI Triple Aim
- 5 Elements of Enterprise-Wide Care Management Redesign
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11 Elements to Increase Care Management Efficiency
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8 Key Components of Patient-Centric Care
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Utilization Metrics
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3 Key Takeaways
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Q&A: Ask the Experts
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Improvements in Length of Stay
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Role of the Outpatient Nurse
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Patient-Centric Strategies to Enhance Health Literacy
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Transition Form and Care Plan Monitoring
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Patient Engagement Strategies
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Average Nursing Workload
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Integrating Behavioral Health
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Telehealth and Remote Monitoring
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Weekly Staff Huddles
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Social Determinants and Care Management
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DME Management and Care Transitions
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Addressing Medication Management
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Patient Navigation of Care Continuum
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Care Management Performance Indicators
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Care Management Hub
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Glossary
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For More Information
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About the Contributors
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