BY LISA SIMMONS-FIELDS, DNP, MSA, RN, CCM, CPHQ, FCM, AND MAUREEN PIKE, MPH, MBA, RN
For the past three years, Trinity Health’s Clinically Integrated Networks (CIN), Community Health & Well-Being (CHWB) departments and the Medical Groups (THMG) have engaged in a national strategy for reducing preventable hospitalizations among Medicare Shared Savings Program (MSSP) beneficiaries with a special focus on our vulnerable dually enrolled (Medicare/Medicaid) population. Nationally, patients who are dually enrolled are more likely to experience poverty, have disabilities and be part of a racial and/or ethnic minority. Shared accountability and key performance indicators (KPIs) among the CINs, THMG and CHWB teams with a clinical and social care focus were integral to the success of this strategy.