Transitions—when patients move from one care setting to another—represent a state of vulnerability for both the patient and the healthcare organization. Patients need referrals to the most appropriate provider in a timely, seamless fashion so they get the level of care they need. If patients leave the network, it could result in revenue leakage for the provider organization. I’ve heard healthcare leaders estimate that between 20-30% of their patients ultimately leave their network during a transition of care. This renders the care team less able to ensure patients get the best possible care—and less able to track patient progress and monitor follow-up. Plus, it means missed revenue opportunities. When patients see out-of-network ambulatory or post-acute providers, healthcare networks are unable to capture the revenue that would otherwise be associated with patient care. There are downstream financial effects, too. When patients […]

Leaving the hospital is good news, yet it can be difficult for patients to manage their own care at home. The task may be especially challenging for elderly patients who have complex medical issues. University of California Irvine Health (UCI) recently piloted a program to improve transitions of care for older patients. UCI’s focus on care coordination with remote home monitoring helped improve outcomes for participants. UCI shared its story at our recent annual user group event, Population Health University. “We wanted to make sure patients were getting the care that they needed,” said UCI’s Senior Project Manager of Health Reform Joan Hoppe, RD, CDE. Addressing needs of a growing elderly population UCI serves the people of Orange County, California, where the population is aging. In 2010, there were 360,000 seniors, and that number will double by 2030. One in […]

I read a recent report from The Advisory Board, called Three Key Elements for Successful Population Health Management. It focused on information-powered clinical decision-making; primary care-led clinical workforce; and patient engagement and community integration. The Advisory Board briefing suggests that healthcare organizations must prioritize these things to succeed. This is great news for our clients, because our solution strategies at Allscripts align well with these elements: 1. Information-powered clinical decision-making We must integrate systems to talk with one another across the healthcare continuum. It’s essential to deliver actionable insights and clinical decision support at the point of care.  However, it’s critical to have access to information that lies beyond the four walls where the patient happens to be receiving care. We’re applying our clinical analytics assets to community-level data, in addition to just information from a single care setting. Our […]