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A pilot program by an Accountable Care Organization (ACO) reduced per capita health care expenditures at a rural hospital by 70% and admissions by 98%. A key component of the initiative was a “Four Questions” framework for goals-of-care conversations. Clinicians also did home visits with nurses on call 24/7.
Even more so, specific Medicare and Medicaid policies perpetuate this cycle. After experiencing a functional decline at the hospital, the woman, no longer able to live at home safely, was sent to an SNF for post-acute care, covered by Medicare. There, she developed an infection and was readmitted, continuing the cycle.
You see, I knew, in a sense, anatomically what was occurring, but she helped me to understand how to break down the concerns into smaller, practical terms for the family to understand. And to this day I owe my ability to quote Medicare Benefit Policy Manual Chapter 15 Sections 220 and 230 to Liz. Billie Joe, thank you!
You know, baby boomer generation started to turn 65 and older back in 2011. We’re very fortunate to have Medicare chronic care management, which is a wonderful resource that really is very goal driven, incorporating things like patient priorities, care and what matters most. And ideally at other times too.
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