The Performance Improvement Imperative: Utilizing a Coordinated, Community-Based Approach to Enhance Care and Lower Costs for Chronically Ill Patients

Proposes principles for federal leadership and a community-level strategy for improving healthcare performance for high-cost patients as a way to curb health spending. Lists programmatic priorities and design considerations for intervention initiatives

Information technologies that facilitate care coordination: provider and patient perspectives

Health information technology is a core infrastructure for the chronic care model, integrated care, and other organized care delivery models. From the provider perspective, health information exchange (HIE) helps aggregate and share information about a patient or population from several sources. HIE technologies include direct messages, transfer of care, and event notification services. From the patient perspective, personal health records, secure messaging, text messages, and other mHealth applications may coordinate patients and providers. Patient-reported outcomes and social media technologies enable patients to share health information with many stakeholders, including providers, caregivers, and other patients. An information architecture that integrates personal health record and mHealth applications, with HIEs that combine the electronic health records of multiple healthcare systems will create a rich, dynamic ecosystem for patient collaboration

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BackgroundRecurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.Methods/designIn this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.DiscussionIf this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.Trial registrationClinicalTrials.gov Identifier NCT01763203

Complex Care Management Program Overview

This report includes brief updates on various forms of complex care management including: Aetna - Medicare Advantage Embedded Case Management ProgramBrigham and Women's Hospital - Care Management ProgramIndependent Health - Care PartnersIntermountain Healthcare and Oregon Health and Science University - Care Management PlusJohns Hopkins University - Hospital at HomeMount Sinai Medical Center -- New York - Mount Sinai Visiting Doctors Program/ Chelsea-Village House Calls ProgramsPartners in Care Foundation - HomeMeds ProgramPrinceton HealthCare System - Partnerships for PIECEQuality Improvement for Complex Chronic Conditions - CarePartner ProgramSenior Services - Project Enhance/EnhanceWellnessSenior Whole Health - Complex Care Management ProgramSumma Health/Ohio Department of Aging - PASSPORT Medicaid Waiver ProgramSutter Health - Sutter Care Coordination ProgramUniversity of Washington School of Medicine - TEAMcar

Digital technologies and chronic disease management

Raises awareness of the potential benefits of using digital technologies for improving practice efficiencies and patient health outcomes. Background Digital technologies will become a major part of our healthcare system, with particular impact in primary care. However, many healthcare professionals are not sufficiently informed of the digital technologies available today and how they and their patients can gain substantial benefit from adoption of these technologies. Objective To raise awareness of the potential benefits of using digital technologies for improving practice efficiencies and patient health outcomes. Discussion Implementing best practice care for patients with chronic and complex conditions is one of the greatest challenges facing gen-eral practice and other primary care providers. It has been suggested that digital technologies could assist by decreasing the administrative burden of care delivery, improving quality of care, increasing practice efficiencies and better supporting patient self-management. In this paper, we consider some areas in the management of chronic and long-term conditions where digital and mobile health solutions can make a difference today

Organizing the U.S. Health Care Delivery System for High Performance

Analyzes the fragmentation of the healthcare delivery system and makes policy recommendations -- including payment reform, regulatory changes, and infrastructure -- for creating mechanisms to coordinate care across providers and settings

Increasing the Capacity of Primary Care Through Enabling Technology.

Primary care is the foundation of effective and high-quality health care. The role of primary care clinicians has expanded to encompass coordination of care across multiple providers and management of more patients with complex conditions. Enabling technology has the potential to expand the capacity for primary care clinicians to provide integrated, accessible care that channels expertise to the patient and brings specialty consultations into the primary care clinic. Furthermore, technology offers opportunities to engage patients in advancing their health through improved communication and enhanced self-management of chronic conditions. This paper describes enabling technologies in four domains (the body, the home, the community, and the primary care clinic) that can support the critical role primary care clinicians play in the health care system. It also identifies challenges to incorporating these technologies into primary care clinics, care processes, and workflow

Gundersen Lutheran Health System: Performance Improvement Through Partnership

Highlights Fund-defined attributes of an ideal system and best practices such as using data for benchmarking, increasing transparency, and driving improvement; investing in primary care and disease management; and hiring engineers to improve operations

How 5G wireless (and concomitant technologies) will revolutionize healthcare?

The need to have equitable access to quality healthcare is enshrined in the United Nations (UN) Sustainable Development Goals (SDGs), which defines the developmental agenda of the UN for the next 15 years. In particular, the third SDG focuses on the need to “ensure healthy lives and promote well-being for all at all ages”. In this paper, we build the case that 5G wireless technology, along with concomitant emerging technologies (such as IoT, big data, artificial intelligence and machine learning), will transform global healthcare systems in the near future. Our optimism around 5G-enabled healthcare stems from a confluence of significant technical pushes that are already at play: apart from the availability of high-throughput low-latency wireless connectivity, other significant factors include the democratization of computing through cloud computing; the democratization of Artificial Intelligence (AI) and cognitive computing (e.g., IBM Watson); and the commoditization of data through crowdsourcing and digital exhaust. These technologies together can finally crack a dysfunctional healthcare system that has largely been impervious to technological innovations. We highlight the persistent deficiencies of the current healthcare system and then demonstrate how the 5G-enabled healthcare revolution can fix these deficiencies. We also highlight open technical research challenges, and potential pitfalls, that may hinder the development of such a 5G-enabled health revolution