In order to build healthier communities and improve population health management, providers need information about a patients’ health that goes beyond clinical factors. 

How can we achieve this? 

Topics: EHR, Population Health, Health IT, nurses

When people think of life in California, they often think of movie stars, mansions, and pristine beaches. The reality can sometimes be less glamorous. Since 2016, the homeless population in California has risen by 13 percent. There are now an estimated 130,000 homeless individuals living across California, including 50,000 in Los Angeles alone. Walking the streets in San Bernardino County, the sight of people sleeping in cars, under bridges, and in parks is all too common. 

Topics: Population Health, Patient Engagement, Social Determinants

Lisa, a 45-year old single mother, visits her primary care physician complaining of fatigue and excessive thirst; blood tests reveal she has high blood glucose. She walks out of the clinic with a prescription and a pamphlet about type 2 diabetes. Now what?

Topics: Population Health, Patient Engagement

In our latest Thought Leader podcast, I speak with Phil Campbell, CIO and VP of Information Services at CalvertHealth (Prince Frederick, MD), about how his organization has been addressing the opioid crisis through its award-winning Opioid Stewardship Program. 

Topics: CIO, Podcast, Population Health, Patient Engagement, Patient Safety

September is National Recovery Month — a time to recognize the more than 11 million Americans who are struggling with opioid addiction. This massive problem has grown exponentially over the years and, unfortunately, seems to be the new norm.

Topics: Nursing, Physician, Population Health

In 2014, Parkview Medical Center realized that it needed to reduce its readmission rate significantly while also fixing a communication gap between home health care agencies and other post-acute facilities. To address these issues, my director and a team of other leaders joined together to pilot a new transition care center that went live in 2016.

Topics: Population Health, Patient Engagement, Patients, Care Coordination

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. 

Topics: Population Health, Patients, Social Determinants

As healthcare continues to evolve, there is one constant when it comes to treating patients: The critical role that nurses play in delivering quality care. That role has certainly expanded over the years, particularly in the areas of establishing and maintaining patient safety, finding workflow efficiencies through evidence-based clinical documentation, and recognizing and responding to social determinants of health.

Topics: Security, Home Care, Nursing, Population Health, Integration, Patient Safety

In behavioral health, social determinants is something we look at, but many of us haven’t made it a part of our everyday language. We know social factors have an impact, but because of how broadly defined they are, finding the next steps to take can be difficult.

Topics: Population Health, Patient Engagement

There are distressing similarities between what the United States faced with HIV/AIDS in the 1980’s and the current opioid epidemic. Most people have a personal story related to the harm that can be associated with opioids. The numbers of opioid deaths and people suffering from substance use disorder has reached staggering numbers.

Topics: EHR, Population Health