Decrease Preventable Hospitalizations

Summary
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Data About Priority

MaineHealth remains focused on high-quality community-based primary care to manage chronic illnesses and improve care coordination as patients transition from one setting to another.

Ambulatory care-sensitive conditions (ACSC) are conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease.  About half of Maine's ACSC hospitalizations can be attributed to heart failure and chronic obstructive pulmonary disease/asthma.  Other conditions included in the ACSC rates include diabetes, hypertension, angina, convulsions, bacterial pneumonia, kidney/urinary tract infection, gastroenteritis, cellulitis and dehydration. 

  • Falls, one of the most frequent causes for hospitalization in the elderly, are not included in ACSC.

  • A Matter of Balance program helps seniors to manage concerns about falls and emphasizes practical strategies to reduce this fear and increase activity levels

  • ACSC rates were lowest in southern, central and mid-coast Maine counties.

Indicators

Clinical Strategies

  • Integrate evidence-based/informed strategies across care settings:
    • Chronic Care Model
    • Patient Centered Medical Home
    • Shared Care Plans
  • Provide care coordination and social supports to patients.
  • Strengthen transitions of care and end-of-life care.
  • Enhance communication and coordination with providers, institutions and families.
  • Use technology to improve care management and engage patients.
  • Enhance patient and family engagement in care plans.

Hospitalizations Due to Falls

  • Establish benchmarks for fall risk assessment across all care settings.
  • Screen all patients 65 and over at their annual wellness visits.
  • Conduct fall risk assessments on all patients using standardized questions.
  • Share the results of the assessment with patients, families, providers and across health care settings.
  • Conduct patient environmental assessments.
  • Provide education and guidance on medication reconciliation/management.

Community Strategies

  • Implement evidence-based programs such as:
    • National Diabetes Prevention Program
    • Choosing Wisely
  • Provide education on disease self-management
  • Expand access to medication drop boxes and affordable incineration.

Hospitalizations Due to Falls

  • Provide access to affordable medications.
  • Implement evidence-based programs in multiple settings.
  • Promote physical activity and strength training to at-risk populations.

Policy Strategies

  • Advocate for policy change to improve access to care.
  • Improve regional surveillance efforts.

Hospitalizations Due to Falls

  • Implement policy change to support fall prevention:
    • Reimbursement
    • Built environment
  • Logic Model: Decrease Preventable Hospitalizations
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    Logic Model – A roadmap or diagram showing chain results connecting activities to the expected initial outputs, and intermediate and final outcomes.  It provides a basis for developing the performance measurement and evaluation strategies 

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  • 2016 America's Health Rankings Report
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  • America's Health Rankings
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    America's Health Rankings compares the health of all 50 states to each other.  This ranking tool is used as a benchmark for MaineHealth's Health Index.

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  • CDC National Diabetes Prevention Program Website
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  • Community Commons
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    Community Commons can help with your Community Health Needs Assessment

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  • Community Health Needs Assessment (CHNA)
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  • County Health Rankings - Visit Website
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    Look up your county's rankings, learn about our methods, and download the data you need. This ranking tool is used as a benchmark for MaineHealth's Health Index.

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  • Health Care Leader Action Guide to Reduce Avoidable Readmissions, Schall MW

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  • Health Index Report - 2014
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  • Health Index Report - 2015
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