Illinois Health Connect held its Sixth Annual IHC Quality Conference on June 28 at the Metropolitan Chicago Healthcare Council (MCHC) conference center. The title of the conference was Mind the Gap: Care Coordination Between the Hospital and the Medical Home.
IHC medical director Dr. Margaret Kirkegaard opened the conference with an introduction that included these comments:
"Paul Grundy, the global CMO of IBM and chairperson of the patient-centered primary care collaborative, has likened the medical home to a battleship —that is — the horizontal platform from which vertical weapon systems can be launched. We are here today to talk about care coordination strategies and vertical integration between primary care and hospital care. These “vertical weapons systems” rely on the platform of a robust medical home network. IHC has spent the last five years working to establish and strengthen that medical home network throughout Illinois. We are now ready to turn our attention more fully to what happens at the interface of the medical home and the rest of the healthcare delivery system.
Today’s conference is titled Mind the Gap. Mind the Gap is a sign that travelers see in the British rail and subway system. It literally asks riders to be careful not to slip between the platform and the train while boarding. When a patient has a poor outcome, we often say that the patient has “slipped between the cracks,” and, in fact, if our patients have a really poor outcome, we often refer to them as “train wrecks." That’s why Mind the Gap seem appropriate for today’s discussion.
We are going to focus today on how we can leverage the skills and strengths of the primary care medical home — our fleet of battleships positioned throughout Illinois — to help our patients Mind the Gap and navigate between the acute care environment in the hospital and the medical home."
MCHC graciously donated the conference space, hosting for the second consecutive year. An estimated 80 attendees engaged in active dialogue and information sharing lead by a distinguished panel of speakers.
Denise Levis Hewson, RN, BSN, MSPH
Director of Clinical Programs and Quality Improvement, Community Care of North Carolina.
Ms. Levis Hewson shared a presentation titled Community Care of North Carolina – Enhanced Medical Home Model Supporting Transitional Care. She discussed the development and growth of coordinated care networks in North Carolina, their operational components, their positive impact on hospital admissions and re-admission rates, and strategies for patient engagement.
Carrie Nelson, MD, MS, FAAP
Medical Director for Special Projects, Advocate Physician Partners
Dr. Nelson shared a presentation titled Care Coordination across the Continuum: Lessons Learned. She walked the group through the components of AdvocateCare, which is a new method of addressing patient care and care coordination through outpatient, acute care, and post-acute care services within the Advocate network. The strategies shared shift the culture and focus from discharges to transitions for patients. Results from year one of implementation show reduced costs and improved quality.
Cheryl Lulias
CEO, Medical Home Network (MHN)
Ms. Lulias shared a presentation titled Collaboration and Connectivity: A Blueprint for Safety Net Transformation. She took the group through the methods for identifying patients in South Side of Chicago neighborhoods who would benefit from patient engagement and integrated services. MHN developed MHN Connect to help providers impact the right patients and track services and outcomes for patients, and is tracking its recent implementation.
Kathleen Kelly, MD
Chief Medical Officer, Swedish American Health System
Dr. Kelly shared a presentation titled ED Case Management for Super Users. She explained a pilot program targeted to reduce the number of ambulance runs and control the complex health conditions for an identified group of ED super users in the Rockford area encompassing all financial classes (Medicare, Medicaid, Managed Care, Commercial, and Self Pay). Outcomes shared included better connection to the medical home, reduced re-admissions, reduced ambulance runs, identification of the various social factors affecting community solutions, and protocol development.
The latter part of the conference was spent discussing payment models to support care coordination. Panelists for the discussion included: Scott Sarran, MD, Chief Medical Office for Government Programs, Health Care Service Corporation; Julie Schilz, BSN, MBA, Program Director of Patient Centered Primary Care Transformation, Wellpoint; and Michelle Maher, Bureau Chief, Illinois Department of Healthcare and Family Services.
