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OSF deploys care transition program, reduces readmission rate from 29% to 9%

Healthcare It News

OSF HealthCare, a health system that serves Illinois and Michigan, had a big challenge: Managing the high rate of patient readmissions from hospitals to skilled nursing facilities and eventually to home care. THE PROBLEM This issue stemmed largely from gaps in continuous care during transitions between these settings.

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Supporting the Continuum of Care for Serious Illness in Medicaid Managed Care

NASHP

People with serious and life-threatening health conditions experience care needs that drive costs, including hospital admissions , emergency department utilization , and nursing home care. Arizona’s End of Life and Advanced Care Planning benefit is referenced in its MCO contracts and further described in state regulations.

Medicaid 102
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State Community Health Worker Models

NASHP

ACO Accountable Care Organizations. CBCM Community Based Care Management Program. CDC Centers for Disease Control and Prevention. PH-MCO Physical Health Managed Care Organization. USPSTF United States Preventative Services Task Force. Health promotion education to a member to prevent chronic illness.

Medicaid 122
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Community Health Worker Models

NASHP

CHWs in Connecticut receive grant funding through FQHCs, community-based organizations, the National Institutes of Health (NIH) Center for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA). Health promotion education to a member to prevent chronic illness.