Care transitions redesign as an innovation incubator at a regional academic medical centre
Abstract
The ongoing transition by federal and commercial payers from fee-for-service to value-based reimbursement increases the need for sustainable and scalable high-performing ambulatory care management programmes to support patients across the continuum of care. In this paper we describe one health system’s approach to integrating distinct care management programmes into one aligned structure and standardising best practice workflows. We established and implemented organising principles for the restructuring, including standard documentation, reducing the burden on clinicians, transparently measuring both process and outcome measures and optimising the use of technology solutions. We internally validated and then applied risk stratification rubrics within the electronic health record to stratify our patient population and calibrate the intensity of our care management models based on patient clinical risk. Risk stratification, standardisation of work and introduction of automated outreach allowed the team to increase call volumes, maintain a 77 per cent connection rate to patients post discharge and create a new chronic care management programme without an increase in the number of full-time equivalent (FTE) roles. Important lessons learned include the importance of clearly communicating changes and performance to front-line clinicians and leadership; and garnering feedback from stakeholders to guide continuous optimisation of our standardised workflows. This article is also included in The Business & Management Collection which can be accessed at https://hstalks.com/business/
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Author's Biography
Ohm M. Deshpande , MD, MHA, is an internal medicine physician and has played a leadership role in enhancing clinical quality; designing and managing clinical and operational redesign; and generating value to patients, Yale New Haven Health System and the communities it serves. He has facilitated a substantial redesign and integration of care management resources and population health infrastructure across the enterprise, with an eye to driving standardisation across health system physician practices and improving important utilisation outcomes like patient follow-up after hospitalisation, readmissions and unnecessary acute care visits. Dr Deshpande also oversees all clinical finance functions, including utilisation review, coding and documentation improvement and management of denials. These areas are complementary to the ongoing work to enhance population health capabilities and clinical quality across the hospital and ambulatory enterprise. Dr Deshpande did his postgraduate training in internal medicine at Yale and holds a medical degree from Weill Cornell Medicine, an MHA from the University of Providence and a bachelor’s degree from Williams College.
Maribeth Cabie , PharmD, BCPS, leads the enterprise ambulatory care management team, comprised of chronic care management, transitional care management and gaps in care/population health management. Starting her career in pharmacy, Maribeth has gone on to lead a variety of initiatives in capacity management, clinical operations and clinical redesign. Maribeth received her Doctor of Pharmacy degree from the University of Wisconsin Madison.
Anita Arora , MD, MBA, MHS, has served in leadership roles within population health and clinical operations at Yale Medicine, and she has experience implementing population health management strategies focused on improving access, quality, efficiency and coordination of care. Dr Arora practices medicine and teaches residents and medical students at the New Haven Primary Care Consortium. Dr Arora received her undergraduate degree from Pomona College and her medical degree and MBA from Dartmouth. After her internal medicine residency at Yale New Haven Hospital she went on to complete the Robert Wood Johnson Foundation Clinical Scholars Program at Yale School of Medicine.
Polly Vanderwoude , MHSA, FACHE, develops and executes the system’s strategy for succeeding in population health management and value-based care. She leads innovative programme development to enhance health outcomes and evaluate and implement payment models that align incentives across providers, payers and consumers. She has driven the execution of Yale New Haven Health’s population health strategy as it has evolved over the last eight years. Polly holds a master’s degree in healthcare management and policy from the University of Michigan and a bachelor’s degree in biology from the University of Richmond. She is a Fellow of the American College of Healthcare Executives.
Citation
Deshpande, Ohm M., Cabie, Maribeth, Arora, Anita and Vanderwoude, Polly (2025, June 1). Care transitions redesign as an innovation incubator at a regional academic medical centre. In the Management in Healthcare: A Peer-Reviewed Journal, Volume 9, Issue 4. https://doi.org/10.69554/ZZYD6086.
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