---
title: "Thought Leader Podcast Series: Social Determinants of Health and Transitional Care"
description: The co-founders of Southwestern Vermont Medical Center's transitional care program explain how they designed a program that addresses recurring gaps in care caused by social determinants of health in their rural community for our Thought Leader Podcast series.
---

[MEDITECH Blog ](https://blog.meditech.com)

# [Thought Leader Podcast Series: Social Determinants of Health and Transitional Care](https://blog.meditech.com/thought-leader-podcast-series-social-determinants-of-health-and-transitional-care)

 Written by [Scott Godbout, Senior Marketing Solutions Manager, MEDITECH](https://blog.meditech.com/author/scott-godbout-senior-marketing-solutions-manager-meditech) | July 31, 2018

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](https://blog.meditech.com/how-providers-can-bridge-care-gaps-caused-by-social-determinants-of-health), such as the availability of housing, education, and transportation, drive patients’ everyday choices, and can significantly impact their [health outcomes. ](https://ehr.meditech.com/ehr-solutions/meditech-population-health)The podcast highlights the specific programs SVMC put in place to keep [patients ](https://ehr.meditech.com/ehr-solutions/to-improve-patient-engagement-focus-on-the-patient)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 ](https://ehr.meditech.com/ehr-solutions/bridging-the-gaps-in-care)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](https://ehr.meditech.com/ehr-solutions/to-improve-patient-engagement-focus-on-the-patient): 19:36
- Reactions from [providers](https://ehr.meditech.com/ehr-solutions/meditechs-physician-productivity): 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.**

[View full post](https://blog.meditech.com/thought-leader-podcast-series-social-determinants-of-health-and-transitional-care)

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