St. John's: One Story of Coordinated Care

Uploaded by CMSHHSgov on 23.11.2011


Healthcare systems across the country are working hard to coordinate care,
taking a team approach to help patients. The healthcare law provides new tools
to help doctors work together to share information, involve patients
in their own care, and spend dollars wisely.
And that’s exactly what’s happening in Springfield, Missouri
at St. John’s Health System.
Over the last several years while we’ve been endeavoring in our
changing care model, it's more of a team approach.
St. John’s coordinated care approach helped form the blueprint for some of these
new options for health systems who want to take the same kind of steps.
We knew we wanted to touch more patients, so we changed our heart failure
resource center. We have a phone system that has 10 questions on it related to
their heart failure condition, and the patients call in to that program.
St. John’s is helping patients take control of their health.
I have had increasing congestive heart failure. The first thing I do
in the morning is weigh myself, and if I've gained three pounds or more,
there's a phone number in here that I call.
In these new programs, groups of doctors, healthcare professionals,
and hospitals who work together to deliver comprehensive coordinated care
get financial rewards to those who lower costs and see better patient outcomes.
In our, you know, system's history in this business, we've spent
far too much time being reactive to patient care issues or needs.
One thing that we learned was we didn’t communicate with each other.
We didn’t communicate fully with the providers of the patients.
I’ve seen a change in our physician colleagues. Care and assuring
that the care is there is very important work, and it does cost.
It costs in time, energy and effort.
It increases our efficiency because the patient is more engaged.
They understand how to take care of themselves.
And since I've been on this program, I haven't had to go back in the hospital --
I think maybe once.
The communication between doctors improved much more with the
electronic medical record than anything else. The ability to share one
record and to exchange information in real time has improved
the coordination of care more than anything.

The greatest success has been
Reducing our readmission rates
Better health care
Fewer errors
Reduction in medications
Better quality
How our physicians and our non-physicians have come together
It?s made my job better
Ultimately patients stay well, more functional at home out of the hospital.
I feel like that there's somebody that's kind of looking out for me,
and that, when I call them, I know that if they feel like there's a
problem there, they're going to call me back and tell me.
It wasn’t always easy but coming together, we all agreed fundamentally,
it was the right thing to do. And if we could improve quality, and at the same time
save costs, we would make the health in our community better than it was.