I thought you may be interested in this recent report. Although home care is not emphasized, improving coordination of care is identified as one avenue for decreasing avoidable events – and home care is specifically mentioned on the last page.

 

Kathy

From: Minnesota Department of Health [mailto:mdh@public.govdelivery.com]
Sent: Tuesday, August 11, 2015 2:46 PM
To: Kathy Messerli
Subject: MN e-Healht Roadmap Community of Interest

 

Minnesota Department of Health

For the first time, the Minnesota Department of Health (MDH) has analyzed the state’s emergency department visits, hospital admissions and hospital readmissions and found that over the course of a year nearly 1.3 million of those patient visits costing nearly $2 billion were potentially preventable. For this study potentially preventable health care events were defined as hospital and emergency department visits that patients possibly could have avoided under the right circumstances such as timely access to primary care, improved medication management, greater health and health system literacy, and better coordination of care among clinicians, social service providers, patients and families.

Volume and Cost Associated with Potentially Preventable Health Care Events in Minnesota, 2012

 

The full report, available through the Health Economics Program, includes a number of strategies for reducing potentially preventable events that align closely with and are supported by the work of the Minnesota e-Health Roadmap. Potential policy levers and recommendations that could have an impact on reducing avoidable events include:

  • Ensure that secure electronic exchange of clinical information occurs effectively and in real time across settings and provider systems.
  • Improve coordination of care across settings of care, in particular between long-term care settings and hospitals.
  • Improve comprehensive discharge planning, medication management and transition care support/transition communications.
  • Ensure consistent and strong engagement by patients and families, with a focus on the availability of information or guidance about preventive care and treatment that is accessible to patients with varying levels of health literacy and in multiple languages.
  • Make use of emerging providers, such as community paramedics or community health workers, to provide care coordination and connect vulnerable patients to social supports that can help them avoid hospitalizations or ED visits.
  • Take full advantage of support services like transportation, interpreter services and case management.
  • Ensure all patients have access to timely, high-quality preventive care in outpatient settings, and a usual source of care or medical home.
  • Strengthen the primary care system, including expanding the array of professionals as part of the care team.

The MN e-Health Roadmap Steering Team and Workgroups will continue to consider and incorporate the policy levers and recommendations from the report into the development phase of the Roadmap. This phase will entail documenting and analyzing the use cases to identify gaps in how care is currently occurring. Many of these gaps lead to potentially preventable health care events and are due to missed opportunities in workflow, information sharing, individual/family engagement, and use of e-health including standards, health information exchange, and other health information technology. The gaps, and steps to address the gaps, will be synthesized into recommendations for actions that support the adoption and use of e-health in behavioral health, local public health, long-term and post-acute care, and social services to improve health outcomes.

For more information on the MN e-Health Roadmap, contact mn.ehealth@state.mn.us.

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