Play by Play

Playbook postings and exclusive perspectives from leaders in the field


The Keystone ACO is a partnership between Geisinger, Evangelical Community Hospital, Wayne Memorial Hospital, and the Wright Center for Graduate Medical Education. It serves 73,000 Medicare beneficiaries in the Medicare Shared Savings Program (MSSP). Keystone ACO’s beneficiaries include residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland.
One of the most pervasive challenges in our health care system is allowing people to optimize their independence and continue living at home as they age and develop more complex health and social needs. These individuals often need long-term services and supports (LTSS), and their number is increasing. It’s estimated that the population of Americans in need of LTSS will rise to 27 million by 2050.

By David Blumenthal, MD, MPP, President, The Commonwealth Fund, and Tanya Shah, MBA, MPH, Assistant Vice President, Delivery System Reform, The Commonwealth Fund

The dialogue on caring for patients with complex needs has moved beyond a recognition that social factors like housing or nutrition have an outsize impact on health to practicalities. Now, health care providers are asking: what can we actually do to help?

Caring for the complex chronically ill — a population that makes up about 5 percent of patients and nearly 50 percent of health care spending — is remarkably challenging. It’s also essential, as the United States transitions to a health care system that is driven by value.

If you’ve seen how quickly a relatively mobile older adult can turn into a frail and bedbound patient — not because of a primary illness, but because of a lack of movement — then you can appreciate how dramatically different care is at Saint Joseph Mercy Health System in southeast Michigan, and Anne Arundel Medical Center in Annapolis, Maryland.

The program, known as Community Aging in Place — Advancing Better Living for Elders (CAPABLE), is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults.
On June 21, 2018, an episode of WIHI featured a discussion on integrating addiction treatment into health care. Madge Kaplan, Director of Communication at IHI and WIHI’s host, moderated the discussion. The guests were Catherine Mather, MA, Director at IHI; and R. Corey Waller, MD, MS, FACEP, DFASAM, Addiction, Pain, Emergency Medicine Specialist; Managing Partner, Complex Care Consulting, LLC; Chair, Legislative Advocacy Committee for the American Society of Addiction Medicine (ASAM).
Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.

By Corey Waller, Better Care Playbook Faculty and Principal at Health Management Associates

I currently do some work as a locum tenens physician in the emergency department, filling in during staff shortages. In this capacity, I get to work in a few different hospital systems around the country. No matter which one I go to, I can count on the fundamental aspects of basic cardiac care to be delineated no matter where I am.

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