Person-Centered and Data-Driven Care: How Innovation Among Centers for Medicare & Medicaid Services Innovation Center (CMMI) Demonstration Projects is Personalizing Care Across Several States

Session Year: 
Clare I. Hays, MD, CMD Charles A. Crecelius, MD, PhD, CMD Arif Nazir, MD, CMD Steven L. Phillips, MD

Session Summary
In 2012, the Centers for Medicare & Medicaid Services Innovation Center (CMMI), in partnership with the Medicare/Medicaid Coordination Office, funded a project in seven sites to improve the quality of care for residents in nursing homes by reducing avoidable hospitalizations. The organizations involved partner with nursing homes to implement evidenced-based interventions aimed at improving care and lowering costs. Most interventions entail promoting person-centeredness. In this session, four of the seven project medical directors will present examples from their projects that demonstrate how they are using person-centered care concepts and data to drive change in their facilities. Barriers and facilitators to change will be discussed. Presenters will describe ways to identify residents at high risk for rehospitalization, ways to improve care coordination/care transitions, ways to improve advance care planning, and ways to engage physicians in quality improvement efforts.

3.5 Management