AFMC : A CLOSER LOOK their health conditions , helping them prevent or decrease cardiovascular events through cholesterol management and improving aspirin use , for example . Additionally , effective interventions can prevent Medicare beneficiaries from developing diabetes , and slow progression of chronic kidney disease .
Care Coordination Medicare beneficiaries experienced 1.7 million hospital readmissions within 30 days in 2015 , which cost Medicare roughly 14 billion dollars . Most of these readmissions — about a million — could have been prevented with better care coordination upon discharge . Integrated care plans among community-level health care providers and organizations benefits those in vulnerable populations who often need access to social services and other assistance , but may not have the means to secure those services .
Care coordination also requires us to consider social determinants of health ( SDoH ). Many factors affect beneficiaries ’ health , including underlying genetics , health behaviors , and social and environmental conditions . In fact , according to the Robert Wood Johnson Foundation , 80 % of our well-being is influenced by socioeconomic factors , physical environment and health behaviors ( see graphic ). Care plans , therefore , should include ways to address the SDoH beneficiaries ’ can control , such as health behaviors .
Immunizations The Medicare population is particularly vulnerable and are at high risk for illness , hospitalization , disability and even death from vaccine-preventable diseases like COVID-19 , Influenza , and Pneumonia . The Centers for Disease Control recommends vaccinations for adults based on age , health conditions , prior vaccination history and other factors to prevent vaccine-preventable diseases and related outcomes . Increasing immunization could result in an improvement in other health conditions , such as heart disease , which contribute to the disparities in immunization rates in racial and ethnic groups .
THE LOCAL SOLUTION
The TMF QIN-QIO is engaging Arkansas health care providers across the continuum of care and communities to :
• Collaborate on the prevention of opioid ADEs by sharing best practices for opioid prescribing , alternatives to opioid use , Naloxone distribution and patient education , increase use and awareness of medication-assisted treatment , and other local solutions developed by each community .
• Prioritize health equity efforts to improve preventive services for racial and ethnic minorities , individuals with disabilities , sexual / gender minorities , and individuals living in rural areas . Health equity efforts also include helping people better manage chronic conditions .
• Facilitate improvements in how health care services are delivered to Medicare beneficiaries across care settings ; implement best practices and evidenced-based interventions to reduce hospitalizations and readmissions , as well as emergency room use .
• Increase vaccinations and immunizations at the community level using plans , strategies , and practices that consider the SDoH and a focus on vulnerable populations .
LEARN MORE
Arkansas health care providers are invited to sign up to create a free account on http :// www . TMFNetworks . org for topic-specific change packages , community level SDoH data reports and other tools and resources to help improve health outcomes and the care experience for Arkansas patients and families . s
Mandy Palmer , RN , CPHQ , CPPS , is the Director of Quality at AFMC . She provides oversight for multiple quality initiatives focused on improving health care quality , patient safety , population health and care transitions . She has more than 25 years in nursing working in Intensive Care , Burn , Cardiac , Hospice and Quality .
FALL 2022 | VOLUME 119 | NUMBER 2 49