Moving to wrap up the day with a plan of action:Survey results: Priority Problem Statements: – There is no care plan that includes my medical and social factors coordinating interdisciplinary input – including the patients.
– The care providers who may have the most input may not have visibility to inform or see the plan. Existing IT Solutions that can be scaled: – Interoperable information exchange
– Get a model that works effectively and scale it.
– More effective risk stratification Innovation Opportunities:
– Feedback loops when things don’t happen.
– EHR/PHR that can merge a medication record, including community pharmacies Beacons:
– Rhode Island offers itself as a Petri Dish looking for partners. – Hawaii – Challenges of an island community – Idaho – 3,000 rural providers in a test of care transitions. – Bangor – Feedback Loops
– Iowa – Patient should own, control and vet the care plan – This is an experiment they will undertake. Feedback loops and cost containment. Plenty of evidence available to show cost reduction potential. NY – Home care: Happens today via paper and fax. Home Care Vendors developing interoperable standards for home care: Treatments, patient goals etc. Things that aren’t addressed in other parts of the Care Transitions Efforts. Start a conversation on http://medicaring.org