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

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. 

• 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.