UCLA Health – Improving transitions of care

Over 70 healthcare improvement professionals gathered to learn about the process improvement model UCLA has implemented and how they have improved transitions of care through use of integrated technology tools.

The key to UCLA Health’s Improvement strategy is aligning improvement with strategic organizational goals.  Each year the executive team comes together over several meetings to align performance improvement to the mission and vision of UCLA Health.  The goals that are generated at these meetings are then translated to actionable objectives for each manager and healthcare team member.  Each goal is linked to a measure that is directly impacted by work on the unit floor.

Data is a key component of the UCLA Health integrated PI model.  They have dedicated resources that mine, clean and combine data in one central data warehouse. This data then feeds live dashboards that are accessible to everyone in the organization from a link on the intranet homepage.  Data transparency has allowed UCLA Health to build a data centric culture that strives to continually improve.

Data and communication across the care continuum are key in UCLA Health’s strategy for improving transitions of care, reduce their readmissions and manage their high risk super utilizers.  A combination of technology integrations give UCLA Health the ability to give view access to patient records to providers across the continuum of care from acute to post acute as well as payers.  In combination with an advanced referral tracking platform, UCLA Health is able to more effectively manage its patient population as it moves between different care instances through the care continuum .  To manage the most at risk high utilizers, UCLA Health implements an extensivist medical home model.  This combination of technology, data, and patient centered touch have allowed UCLA Health to provide better care to its patient population while reducing costs.

Slides of the presentations can be downloaded here:

Aligning Efforts Throughout the Care Continuum

Cultivating a Culture of Data Driven Improvement

Multidisciplinary PAC Collaborative

Leveraging Technologies for providers and patients

Leveraging Technology for Follow Up phone call to patients

Extensivist Program. High Risk and Super Utilizer Patients