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Care Transitions: Effective Models of Care

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Care Transitions: Effective Models of Care …

Care Transitions: Effective Models of Care
Linda Lawson DNP, RN, NEA-BC
Sierra Providence Health Network

Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013


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  • 1. CARE TRANSITIONS: EFFECTIVE MODELS OF CARE Linda Lawson DNP, RN, NEA-BC Sierra Providence Health Network
  • 2. The Affordable Care Act • The Patient Protection and Affordable Care Act (ACA) became law on March 23, 2010 • The ACA makes health insurance coverage a legal expectation on the part of U.S. citizens and those who are legally present
  • 3. Effective Models of Care • Medical Home • Chronic Care Model • Stanford Chronic Care Model • Triple AIM
  • 4. Medical Home The medical home,[also known as the patient- centered medical home (PCMH), is a team based health care delivery model led by a physician, P.A., or N.P. that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes
  • 5. Medical Home It is "an approach to providing comprehensive primary care for children, youth and adults". The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health
  • 6. Medical Home: Care Coordination • Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models • Payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-face patient encounter may help encourage coordination
  • 7. Chronic Care Model The Chronic Care Model (CCM) identifies essential elements of a health care system that encourage high-quality chronic disease care • The community • The health system • Self-management support • Delivery system design • Decision support
  • 8. Chronic Care Model • Evidence-based change concepts under each element foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise • The Model can be applied to a variety of chronic illnesses, health care settings and target populations • The result is healthier patients, more satisfied providers, and cost savings
  • 9. Stanford Chronic Care Model • SCCM is a thoughtful, simple, and cost effective model of telephone triage • Resulted in a reduction in Emergency Room visits by up to 80% • Significantly improved the quality of care that patients receive • Equates to a cost reduction of 25-33% compared to the uncoordinated care
  • 10. A Changing Paradigm Improving the U.S. health care system requires simultaneous pursuit of three aims: • improving the experience of care • improving the health of populations • reducing per capita costs of health care
  • 11. THE TRIPLE AIM • Improving the experience of care • Improving the health of populations • Reducing per capita costs of health care
  • 12. CARE TRANSITIONS: EFFECTIVE MODELS OF CARE Linda Lawson DNP, RN, NEA-BC Sierra Providence Health Network

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