Transitional Care Programs for Vulnerable Populations: New Evidence on the Benefits of a Person-Centered Approach
Christine Schaeffer, MD, medical director of Northwestern Medicine Transitional Care Clinic, describes the core components of its transitional care program. She also shares important considerations for health systems interested in implementing person-centered transitional care to address gaps in care and reduce costs.
Special Needs Plans (SNPs) are a type of Medicare Advantage (MA) plan for individuals with special needs. This can mean an institutionalized individual (i.e., someone who lives in nursing home), a dually eligible individual (i.e., eligible for both Medicare and Medicaid), or an individual with a severe or disabling chronic condition.
AAHCM Toolkit: Building Awareness and Engaging Payers to Bring Home-Based Primary Care into the Mainstream
Building a Culturally Competent Workforce to Care for Diverse Older Adults: Scope of the Problem and Potential Solutions
Evidence is mounting about the importance of robust primary care in achieving the Triple Aim of advancing quality of care, reducing costs, and improving the patient experience. Primary care initiatives across the country have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare accountable care organizations (ACOs), primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for patients, providers, and payers.
The individual characteristic that contributes most to complex care needs is the inability to function in activities of daily living (ADLs), such as eating, bathing, and dressing. The winners in population health management will be the health plans and providers that figure out how to identify individuals with ADL impairment and address their needs with comprehensive care management and targeted non-medical services.