Highlights:
..."What I knew from my office is that I'm paid to go from room to room to room as fast as I can, and the faster I go from room to room to room, the more money I make. When I slow down and I get involved in a complex case, I may as well hand money over the patient. I lose money. So that's a terrible model of care… You can't do good care in 10 minutes".
"Essentially what's happened over time is that we built a specialty care and hospital system on steroids ... We have shrunk and shriveled our primary care base".
"We have inflated a capacity bubble in our country to do expensive, high-tech, hospital-based care... At some point you inflate a bubble past its true need in society"...
... "So we went back and asked each hospital for all their claims data for a full-year period, ... and began to find buildings in the city that were hot-spot buildings, where there were a lot of elderly and disabled people living in the building that were generating enormous amounts of costs, going to the emergency room and hospital over and over; that there were specific patients in the city that were going over and over to the hospital".
"1 percent of the patients [that] are costing about 30 percent of the health care resources".
"His team is a nurse practitioner, community health worker and a social worker. It's our outreach team, and every week they do internal case conferences, and they run all the cases, and they talk about what the barriers to care are, the challenges, and brainstorm solutions. And every month the whole city comes together -- front-line providers, social workers -- and we do anonymous case discussions at the city level. And what we do is try and pull out common barriers and themes that we're seeing over and over among the patients, and then elevate that up to my board and think in an organizational level, how can we be solving systematically the barriers to care"?
"We think that we're pointing the way with this team to better care at lower costs by bringing care to patients in the community". (Reducing hospital visits/ costs).
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