A population-based care transition model for chronically ill elders.

Area of Science:

• Health Informatics
• Geriatric Medicine
• Public Health

Background:

• Elderly individuals with chronic illnesses experience higher hospitalization rates.
• Approximately 20% of hospitalizations lead to readmission within 30 days.
• Care transition management programs aim to reduce hospitalizations and improve care quality.

Purpose of the Study:

• To describe how informatics influenced a managed care organization's shift.
• To move from disease prevalence focus to population-specific chronic condition complexity.
• To improve care transitions and reduce hospital admissions.

Main Methods:

• Utilized informatics to transform a regional managed care organization.
• Shifted focus from specific chronic diseases to population-specific chronic conditions.
• Applied a population-based informatics approach.

Main Results:

• Informatics facilitated a transformation towards managing complex chronic conditions.
• The approach amplified the impact of quality improvement programs.
• Evidence-based interventions were translated more rapidly to the Medicare population.

Conclusions:

• Population-based informatics effectively prevents avoidable hospital admissions.
• This approach enhances care transitions for the Medicare population.
• Informatics accelerates the translation of evidence-based research into practice for improved population health outcomes.