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Challenges Running a Program

Challenges Working with Patients


Bridging Cardiac Rehab and Patient-Centered Care

Michigan Medicine is an Academic Medical Center and Patient is Partner is a small LLC that collaborates with health care to solve challenging problems utilizing the patient voice and experience.

In spite of the positive outcomes over the many years, cardiac rehab continues to face challenges such as lack of awareness and underutilization by providers and patients. Studies show that only 20 percent of eligible patients are referred and of those, only 50 percent participate. We wanted to address the following questions:

Rolling Out the 4Ms for Age-Friendly Care Across the Care Continuum

When determining how to pilot new approaches for enhancing health outcomes for older patients, Kaiser Permanente leaders decided to focus initial efforts at Woodland Hills Medical Center in Woodland Hills, Calif. Twenty-two percent of Kaiser Permanente members who visit Woodland Hills are age 65 or older, which is the highest density of older people in the health system’s Southern California service area. Our goal is to test strategies that can be adapted and scaled across the care continuum.


Structuring Medicare Wellness Exams and Geriatric Consultations Around the “4Ms”

As part of the mission and strategic plan, Indiana-based St. Vincent is working to improve the health, quality of care and functional status of adults age 65 and older. Indiana ranks last among 51 states on a national scorecard that evaluates long-term services and support for older adults, people with disabilities and family caregivers. With the number of elderly patients increasing, St. Vincent is working to change this scenario.


Finding Out What Matters to Older Patients: A Conversation Guide

Older adults routinely receive care they do not want or that is discordant with their goals and wishes. A key reason is that providers do not consistently ask patients what matters to them. Clinicians are very good at problem-based discussions with patients, which focus on assessing symptoms and identifying treatments. But many of us need additional training in how to have conversations with patients about what matters to them versus what’s wrong with them.


Referral Process Improves Cardiac Rehabilitation Participation Rates

Despite well-documented benefits, the rate of referral to outpatient cardiac rehabilitation programs has remained low. We wanted to verify that our institution’s procedure for managing cardiac rehabilitation referrals met or exceeded the national average and if these referrals translated into outpatient participation. We aimed for 70% participation in alignment with the Million Hearts® initiative.


Deploying the 4Ms to Improve Outcomes and Health Experiences for Older Adults

More than 45 percent of patients admitted to Anne Arundel Medical Center (AAMC) are ages 65 and over, and we expect that percentage to increase as Baby Boomers age. We’re located in Annapolis, MD, near Chesapeake Bay, which attracts a lot of retirees. While AAMC has taken a number of steps to improve outcomes for older patients, including opening a geriatric inpatient unit, we believe more needs to be done. Too many older Americans suffer from falls, inappropriate medication use, delirium and other avoidable harms.


Saint Alphonsus is Becoming Age Friendly

Saint Alphonsus Health System has been making changes to be more age friendly for many years. The emergency room (ER) adopted the Senior Emergency Department (ED) initiative, making physical changes to the ER, such as softer beds, bigger clocks, a quieter environment, steps available to get in and out of the bed, closer restrooms, as well as learning how to change the providers’ approach to meet the unique needs of the older patients in a crisis setting. A case manager for the ER, Becky Beaver, concentrated on the older patients and their discharge needs. In many cases, older patients returned to the ER ...


Emergency Department Partners with Community Volunteer Dental Program

In 2009, there were over 13,000 Muskegon County, Michigan, low-income residents who were uninsured or underinsured. These residents have unmet healthcare needs including the inability to pay for dental treatment. These residents are veterans, retired and working families, and people with disabilities. Once provided with access to high quality dental care and oral health education, it can decrease the number of people who utilize the hospital emergency department (ED) for dental emergencies and improve the overall health of our community.

The Muskegon County Oral Health Coalition wanted to assess how man...


Improving Patient Recovery Through Cardiac Rehab

With the help of a supportive and progressive cardiologist as our medical director, the outpatient program started in 1978, work that continues today. We wanted to provide patients with the best care by starting rehab at the right time. However, there is limited research on the ideal time to start cardiac rehab. Without research to guide action, the team decided to start rehab immediately following hospital discharge because we felt there was no benefit in waiting.


Reducing Rural Transportation Barriers

Transportation combined with poverty creates a true barrier to health care in a rural environment. In the Mt. Ascutney Hospital and Health Center (MAHHC) service area, 7% of households have no vehicle available. Compared to New Hampshire and Vermont, 5.2% and 6.6% respectively, the service area has significant disparity in available transportation. In MAHHC’s most recent community health needs assessment (CHNA), transportation ranked third in overall barriers to care. Key stakeholders in the CHNA ranked lack of transportation as the number one barrier to accessing services (72.7%).


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