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

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