Over the past several years, I have observed many changes in creating the optimal leadership structure for population health and post-acute care services. To date, I have not found a very efficient and successful model. My observations are we tend to work in siloes, with communication challenges and team members across the system performing duplicative work. A successful program may exist already within the system to assist with a particular population, but other service departments are unaware and may look to use a similar product (basically re-start the entire process and not use all of the learning of the other department).
Our Home health program has a successful telehealth program in place for well over 13 years and markedly reduces readmissions at 30 days. Recently I learned of another hospital service department is looking at telehealth as a way to reduce 30 day readmission/ 90 day bundle readmission and. In our health system, I have been told by clinicians and patients that three different nurses have called on the same day to check on how they are doing. The first nurse is from the hospital unit, second nurse is from home health to set up the next visit and the third nurse is from the ACO.
I look forward to hearing any feedback, ideas or suggestions, which might assist us to enhance our services.