For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time. Providers, payers, hospitals and health systems should look for ways to innovate their care delivery models and to manage and improve care for their patients.
‘Eyes in The Home’: ACOs Use Home Visits to Improve Care Management, Identify Needs, And Reduce Hospital Use
Building Blocks of Robust Primary Care Delivery, Part 1: Moving from Reactive to Proactive Care with the Annual Wellness Visit
The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs each year. Getting to the bottom of the checklist of preventive screenings and evaluating all ongoing chronic care needs simply takes time. Enabling office staff to assist in this work, under the direction of the supervising provider, presents a tremendous opportunity to create a patient-centered and comprehensive care plan that matches each patient’s unique needs and desires.
From continued enrollment growth to expanded flexibility to offer non-medical supplemental benefits, Medicare Advantage (MA) plans are playing an increasingly important role in the lives of older adults.
Frail Older People with Multi‑morbidities in Primary Care: A New Integrated Care Clinical Pharmacy Service
ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges and Future Opportunities
Effects of a Transitional Care Practice for a Vulnerable Population: A Pragmatic, Randomized Comparative Effectiveness Trial
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.