Health reform strategies: A practical demonstration of patient centered programs in Rhode Island's health care community

Rhode Island, like many states, is actively working to implement the many elements of health reform. As part of this process, health administrators in Rhode Island and across the nation are being empowered to implement meaningful change that will make a dramatic difference in the quality of outcomes and efficiency of costs. As Greenwood (2009) observed “as plans are handed over for implementation, grass roots administrators have the power to make or break health care reform”. Evidence based healthcare initiatives are expanding across the nation and demonstration projects showing potential are being explored with the support of federal and state agencies. Our presentation will examine the successful partnership between Federal and state agencies and Rhode Island's healthcare community. Programs highlighted will include hospital readmission reduction initiatives and advanced medical home models. Hospital readmission reduction initiatives involve the national Transitions of Care model developed by Eric Coleman applied to a Medicaid population. A transition of care model improves health care outcomes by connecting high level strategies to the frontline health care provider. Follow-up care, medication reconciliation, condition specific education and personal health recordkeeping are the core pillars of the Transitions of Care program. The advanced medical home model involves a patient centered, provider driven model where care is continuous, coordinated, culturally competent and linguistically appropriate. The concept behind the medical home model is “one stop shopping” where patient care is initiated at the provider level for all health care services.