Thought Leader Podcast Series: Social Determinants of Health and Transitional Care

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In the latest installment of our thought leader podcast series, I chat with Billie Lynn Allard, MS, RN, and Jennifer Fels, RN, MSN, co-founders of Southwestern Vermont Medical Center's transitional care program. Allard and Fels explain how they designed a program that addresses recurring gaps in care caused by social determinants of health in their rural community. 

Social determinants of health, such as the availability of housing, education, and transportation, drive patients’ everyday choices, and can significantly impact their health outcomes. The podcast highlights the specific programs SVMC put in place to keep patients healthy and engaged, and their partnerships with community organizations that made the initiative a success. 

Their efforts yielded impressive results, including:
  • 18.3 reduction in ED visits 180 days post-transitional care nurse intervention
  • 52.1 percent decrease in inpatient visits post-TCN intervention
  • 10.8 percent reduction in average Hemoglobin A1C after diabetes management intervention
  • 0 percent readmission rate three months after graduation from pulmonary rehab program


Specific topics covered in this podcast include:

  • Introductions: 1:44
  • How SVMC began this initiative: 2:46
  • Program costs versus savings: 4:05
  • Gaining executive buy in and support: 5:24
  • Problems with post-discharge patient education: 9:22
  • The value of utilizing community partners: 10:26
  • Creating new clinical roles and retraining staff: 12:02
  • Creating a community care team: 12:57
  • Managing chronic disease populations: 15:32
  • Reactions from patients: 19:36
  • Reactions from providers: 24:01
  • Establishing a governance structure with community partners: 27:42
  • Advice for other providers: 30:50
  • Lessons learned: 34:20

Learn how MEDITECH's Population Health solution will help you with healthcare's paradigm shift from volume to value by joining our webinar "Population Health: Supporting the Challenges of Today and the Opportunities of Tomorrow" on Aug. 23.

Sign Up For The Population Health Webinar

Topics: Population Health, Patients, Social Determinants

Written by Scott Godbout, Senior Marketing Solutions Manager, MEDITECH

Scott Godbout is a MEDITECH marketing solutions manager with a long history of working with information technology and services. During his 17 years with MEDITECH, Scott has served in a variety of roles in Marketing and Development, with a particular emphasis on software design and implementation methodologies, oncology, healthcare information technologies (HIT), MACRA/MIPS initiatives, and computerized provider order entry (CPOE). Today, he focuses on brand development for MEDITECH’s Oncology Management, Surgical Services, and Population Health solutions.

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