Issue link: https://beckershealthcare.uberflip.com/i/644565
26 To counteract this, our system has created more than 36 delivery sys- tem reform projects that address more than 100 quality measures un- der the state's Medicaid 1115 waiver to expand access to those who of- ten experience healthcare disparities. ose projects address primary and specialty care expansion, chronic disease management, behavioral health, medication management, home health visits and palliative care. We also formed an ACO — the Baylor Scott & White Quality Alliance — that emphasizes caring for the 5 percent of our patients who account for about half of the system's healthcare costs. We use health coaches who are registered nurses to do care coordination. Our ACO uses data analytics that allow proactive engagement with patients by assessing health risks and assigning appropriate care resources. is predictive modeling has prevented high-risk health episodes and saved lives. We have decreased all-cause readmission rates by 10 percent, cut hospital admissions per 1,000 by 9 percent and increased wellness visits by 20 percent." Utah Steve Barlow, MD, Population Health Medical Director, Intermountain Healthcare (Salt Lake City) "Intermountain Healthcare is working on prevent- ing diabetes and improving outcomes for diabetic patients through community and environmental interventions, lifestyle programs, pre-diabetes pro- grams and clinical care. e Intermountain team teaches healthy behavior at elementary schools, such as physical activity, nutrition, sleep and stress management. ey also work on environmental interventions with the development and use of walking trails. ese community initiatives are part of Intermountain's mission of helping people live the healthiest lives possible. Intermountain's Primary Care Clinical Program has recently com- pleted a new lifestyle care process model. is is aimed to make phys- ical activity and nutrition counseling a core part of preventive vis- its. A pre-diabetes program is being developed for those at increased risk for developing diabetes, and it emphasizes appropriate screening. For those at risk, there is outreach with a variety of educational pro- grams. Finally, for those with diabetes there is ongoing emphasis that all diabetic patients receive appropriate treatment and screening. is includes A1c testing and control, cholesterol management, nephrop- athy treatment and/or screening, eye exams, blood pressure control and foot exams. Intermountain is combating diabetes from schools and communities to the clinicians' offices. It is hoped this compre- hensive approach will improve the care and prevent diabetes." Vermont John Brumsted, MD, CEO, e University of Ver- mont Medical Center (Burlington) "A clear example of the pressing need for col- laboration — and one in which we've made progress — is the opiate addiction crisis. At the University of Vermont Medical Center, we have been leveraging the resources of Ver- mont's academic medical center, in conjunction with many partners, to better address this crisis both in Chittenden County and beyond. In January, the Day One Clinic at UVMC began taking stable addiction patients from the Hub at the Howard Cen- ter, and transitioning them into the primary care setting. In addition, Steve Leffler, MD, chief medical officer at the UVMC, and Charlie Maclean, MD, from Area Health Education Center, have been work- ing on guidelines that can help guide physicians across the state as they prescribe opiates to patients. We are bringing our collective re- sources to bear on this issue, and together, I am confident that we will meet the needs of Vermonters struggling with this difficult disease." Virginia Nancy Howell Agee, RN, MN, CEO, Carilion Clinic (Roanoke) "Our biggest health concern in western Virgin- ia is effective management of chronic diseases such as diabetes, hypertension, chronic obstruc- tive pulmonary disease and obesity — especially with our aging population. ese diseases are of- ten compounded by other barriers our patients face, such as poverty and lack of education. Our mission is to improve the health of the communities we serve. Carilion Clinic is focused on initiatives that emphasize eating well, staying active and accessing care when and where our patients need it. Another significant part of our approach to addressing chron- ic disease is through medical homes. Medical homes represent a fundamental shi in the relationship be- tween patients and their doctors. Hallmarks of our approach include a higher degree of personalized care coordination, access beyond acute care episodes and identification of appropriate medical and commu- nity resources to meet patient needs. To address issues like poverty and lack of education, we've helped to form organizations like Healthy Roanoke Valley that emphasize working together as a community. Aer all, we cannot go it alone. Our medical home now incorporates 47 family, internal medicine and pediatric practices, 167 physicians, 60 advanced care profes- sionals and more than 270,000 patients. Efforts thus far have been successful. In 2014, the number of Carilion patients with controlled hypertension was 15 percent higher than the national mean, and the number of diabetic patients with controlled blood sugar was 21 percent above the national mean. With those types of results, we know we're on the right path." Washington Michael Glenn, MD, CMO, Virginia Mason Medical Center (Seattle) "One of the top priorities across our large and diverse market is to preserve, and expand wher- ever possible, access to primary and specialty care services. is need is made more pressing because changes in the healthcare landscape potentially disrupt existing patient-provider relationships. Many individuals have limited or no access to appropriate, timely and affordable medical services, which leads to profound questions about quality, safety and trust. Ul- timately, fixing the flaw is oen more challenging than proactively preventing the problem from ever taking root. At Virginia Mason, we constantly strive to remove barriers to sched- uling appointments for consultations and procedures across our orga- nization. We have been expanding hours and adding services, such as