9 – Innovative Approach to Care Transitions: An Evolution of Whole Person Care

Hospital readmissions cost Medicare $26B annually and are often a source of frustration for patients and providers. Allina Health describes its innovative, comprehensive approach to improving care transitions and preventing unnecessary readmissions. The organization uses its robust analytics to identify and understand factors influencing readmissions and improve the care provided. It addresses care needs as a collective, coordinated body of work, continually improving care transitions, reducing readmissions, and avoiding millions in excess costs annually. It has developed a sustainable path forward, offering care across the continuum with seamless connections and recognizing the factors affecting health—mind, body, spirit, and community.

Participants will:

• Identify critical technology and information framework components to effectively stratify patients at risk for transition failure, readmissions, and unwarranted care utilization.
• Describe coordinated care transitions that match the right level of care upon discharge to improve healthcare quality, safety, experience, access, and affordability.
• Explore success stories of care management for high-risk patients spanning the care continuum.