Drive Change in an ACO

The View from The CENTER

As ACOs proliferate across the country, SHM is developing resources and programs to shape the role hospitalists play in care coordination across the ACO continuum. In SHM’s Glycemic Control and Innovative Care Coordination program, a comprehensive survey was conducted of multidisciplinary glycemic management teams, identifying best practices and gaps in care regarding education of inpatients and providers, as well as processes to proactively identify patients at special risk of complications across the spectrum of care. Utilizing the survey results to inform interventions, 10 hospitals will participate in a demonstration program that will focus on improving care transitions between the hospital and post-discharge facilities for patients with diabetes.

Many of SHM’s programs are being developed with population health and post-acute-care transitions in mind. In the near future, SHM will be releasing an implementation guide for atrial fibrillation management. A full chapter is devoted to the patient who has been newly diagnosed and prescribed anticoagulants. This chapter discusses the critical need for careful coordination between the inpatient and post-acute setting and for patients to fully understand their discharge plan in order to ensure optimal outcomes.

SHM’s Project BOOST has long been promoting effective and quality discharges and will receive an update to its toolkit to specifically address transitions to post-acute care.

We also note an increase in SHM members devoting more of their time to caring for patients in skilled nursing facilities, so called “SNFists.” As this trend continues and hospitalists move along the ACO continuum, SHM is committed to staying abreast of the challenges facing our membership and providing the most up-to-date resources and programs to support your work.

For more on quality improvement and care coordination, visit www.hospitalmedicine.org/qi.