Partners HealthCare Population Health Management 2015

health care in the United States is at a crossroads we want to continue to improve healthcare and not crowd out our ability to invest in other important issues like education and housing health care can be frustrating and uncoordinated for patients however delivering health care is not like building cars we can't slow down our work in order to retool we have been delivering patient care the same way for so long it's often hard to imagine delivering care differently clearly the personal touch of being physically together will always remain the bedrock of caring for patients but as medicine has become more complex and the technology for communication has evolved we can now imagine different ways to effectively care for our patients in the last few years there have been major changes to the payment system that encouraged us to think differently about how we care for our patients we have shifted away from fee-for-service payments that require face-to-face visits and entered into alternative payment systems with insurers where the bargain is simple keep costs below target and you won't be penalized but how do we keep healthcare costs from rising and still provide the best possible care including the most recent advances we can do this because these new alternative payment systems give us the flexibility to redesign how care is delivered and focus on improving quality of care while lowering costs for example we are improving care coordination for our most complex patients new care managers are helping to coordinate services for complex high-risk patients these programs help avoid hospital admissions by up to 20% we are making IT investments in virtual visit technology so our patients can get care without leaving their homes changes like these will reduce in-person visits for simple care needs which frees up space for patients who really need to be seen we call these new initiatives and programs population health management what other ways will we improve care with this new flexibility our clinicians have searched the country and our own backyard for proven programs to improve patient outcomes and satisfaction while reducing costs these programs cover every part of the care spectrum from primary care to specialist care to home care let's look at how some of these programs work for example the patient-centered medical home initiative changes the way primary care is delivered primary care physicians are working in teams with other care providers to improve the quality and convenience of care our primary care teams include the primary care physician nurses medical assistants and health coaches the patient specialist is also part of this team reorganizing practice workflows is challenging but working faster isn't the answer our goal is not only better patient care but also a more satisfying work environment we are integrating mental health services into primary care so patients can access these services more quickly and care can be better coordinated for specialty follow-up care patients can meet with their doctors virtually from the convenience of their home or if appropriate by email we are also improving our referral processes so our primary care physicians can ask our world-class specialists simple questions by email because all our physicians are on the same electronic medical record system these consultations can prevent unneeded visits that are costly and inconvenient for patients patients avoid long waits and have their issues addressed without another doctor visit for patients facing complex decisions we are implementing computerized decision support tools for some common procedures that quantify individual patient risk and help patients decide what is best for them these tools provide meaningful assessments of patient risks and outcomes we are beginning to collect feedback from patients on their symptoms and daily living activities this patient reported data provides other patients with a clear understanding of what they can expect after surgery and helps us continuously improve the care we deliver and of course our care redesign efforts extend to nursing homes rehab centers and home care for example we have hired nurse practitioners who are able to respond rapidly to care for patients in their homes so patients don't have to stay overnight in the hospital under observation we are looking carefully at our own care delivery process and asking the question is this the most efficient way to deliver care from the patient perspective including care that is conveniently close to home this work requires a much more widespread use of data so we can track our performance and improvements we have already made considerable progress in launching these initiatives including care redesign high-risk care management patient-centered medical home virtual visits eat consults procedure decision support patient reported outcomes mobile observation unit and more all of these programs together have touched over 30,000 patients and we are just getting started so how are all of us in the partners community supporting this work these programs require the support of everyone who works in the partner system and many of these programs require IT infrastructure to support implementation as we move forward on this agenda we must be careful that patient care is never compromised and all these changes come with the challenges inherent in remodeling our house while we are still living in it while these challenges seem daunting there is no better group of healthcare providers to create the future of healthcare that's why Partners HealthCare was formed together we can lead the way

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