Tag Archives: Care Transitions

Four steps to population health management: Step four— Expand chronic disease management to the full attributed population

In our last blog post, we talked about high-acuity patients, such as those with chronic conditions, who are at high risk for admissions and readmissions. These patients, who drive a disproportionate amount of health care costs, need to be closely monitored post-discharge and targeted for intervention to keep them on the road to recovery. Using […]
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Four steps to population health management: Step three — Invest in in-home intervention

In our last blog, we discussed the importance of helping patients make seamless transitions to their homes or another care facility following their stay in the hospital. Through care management programs supported by data analytics, providers can identify and help patients who need a little extra help — and prevent costly re-admissions. The next step […]
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Four steps to population health management: Step two — Manage care transitions

In our last blog, on “Four Steps to population health management“, we discussed the first step of population health management (PHM), optimizing management of your physician referral network. By using data analytics, you can get a snapshot of which specialists are providing the highest-quality care at the lowest cost. But there is another area that […]
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Four steps to population health management: Step one — optimize network management

In our last blog, we talked about what it takes — a combination of claims and clinical data — to lay a solid foundation for population health management, or PHM. Now let’s take a look at the four steps of PHM, starting with the first step, optimizing network management. Value-based organizations should consider the referral […]
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The four steps of population health management

Providers making the transition to value-based care are looking for new ways to deliver appropriate, cost-effective care and optimize their performance. Population health management, or PHM, is one strategy they’re using to get there. By transitioning from acute, episodic care to a more coordinated, long-term approach, they’re helping patients stay healthier while controlling costs. But […]
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Handling the Handoff: The Key to Care Transitions

In this guest post, Judy Rich, president and CEO of Tucson Medical Center, shares the innovative ways her teams are leveraging technology to support improvements in care transitions. Tucson Medical Center is also part of Arizona Connected Care, which was recently selected to participate in the Medicare Shared Savings Program (Shared Savings Program) Accountable Care […]
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