EarlElectronSalamander31
read the project below: provide a thorough response/analysis…
read the project below: provide a thorough response/analysis identifying any missing points in this proposal below so that it can be adjusted and improved.
My project for this semester is to analyze data within my own organization and use the data to identify areas of opportunities for center teams to reduce rehospitalization rates. Hospitalizations are very costly, especially for Oak Street Health. We operate on a value-based care model, so we take on all the financial risk for the patient by being responsible for all their medical costs. Hospitalizations are by far the biggest cost to us. We are financially incentivized to keep our patients healthy and out of the hospital. By having this incentive, we simultaneously rebuild healthcare as it should be by focusing on quality of care through preventive measures. Rehospitalizations have increased in my center, and it has been a frustration for staff. I am partnering with my Pop Health Director to come up with a solution.
We currently have our Center Medical Directors providing qualitative data into their center’s recent admissions. Once that is compiled, we will be able to use our data warehouse, which constantly streams data in from our EMRs, to bring it all together and identify areas of focus. We already have some in mind including, utilization of palliative and hospice services, the benefit of our CHW services, and partnerships with the community hospitals and SNFs.
All stakeholders listed under ‘meet their needs’ are those who I thought were immediately benefiting from this project and who would eventually become key players in the interventions and outcomes. The ‘key players’ listed are those who will be working on the project, analyzing the data, and implementing the interventions. Those listed as ‘low priority’ were those high-level players who don’t know much about the project quite yet but may be instrumental if we find lots of success further down the road. Treehouse, for example, would be able to implement interventions on an organizational level. Outreach could educate the community. Oak Street Health also only takes Medicare products, so this could help their mission to reduce hospitalizations. The ‘keep informed’ box are the ‘key players’ supervisors, which act as additional mentors and liasions between us and the Treehouse.
Meet Their Needs
Patients
Patients’ Families
Center Care Teams (Medical Assistants, Registered Nurses, Clinical Informatic Specialists/Scribes, Medical Social Workers, Community Health Workers, Behavioral Health Specialists)
Service Teams (Welcome Coordinators/Medical Receptionists)
Hospitals
Skilled Nursing Facilities
Palliative Care/Hospice Agencies
Key Players
Center Medical Directors
Practice Managers
Population Health Director
Low Priority
Treehouse (Corporate Executives)
Outreach Team (Outreach Managers & Outreach Executives)
Center for Medicare & Medicaid Services
Keep Informed
Regional Vice President
Regional Medical Director
