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New Model to Give Northern Virginia Seniors Simpler Path for Late-Life Healthcare

People with Medicare in Fairfax County soon will be offered an alternative to the medical maze that entangles them when treatment has become less effective for advanced chronic illness. In partnership with VHQC and the Coalition to Transform Advanced Care (C-TAC), selected primary care physicians in the Inova Signature Partners network and two Inova hospitals will be implementing and testing the Advanced Care Model®.

“Older adults in the final year of diseases like congestive heart failure average 54 trips to 9 different physicians and experience multiple transitions from inpatient to outpatient care,” said VHQC President and CEO Donald A. Glozer, MHA, FACHE. “The Advanced Care Model® can not only improve the ability of primary care practices to coordinate care for these patients, it also makes it more likely that care aligns with what patients and families say they really want.”

The project builds on C-TAC’s work with health systems and health plans to redesign care for the “gray zone” between treatable and terminal illness. Key elements of the project include using data to identify patients for care coordination; engaging patients and families in care planning that reflects their preferences and values; and redesigning care team roles, practice workflows and electronic health records for better communication between healthcare providers and with patients.

“This complements Inova’s current initiative to integrate the care we offer to older adults through physicians, hospitals, home health agencies, hospices and nursing homes,” said Signature Partners Chief Medical Officer Matt Poffenroth, MD, MBA. “The result will be better coordination by providers, easier navigation for patients and families, and care that allows people to be comfortable and confident about retaining their independence for as long as possible.”

VHQC will analyze data, support peer-to-peer learning among participating practices, help Inova link to community-based organizations that can educate older adults and their families about options for late-life care, and spread the Advanced Care Model® to additional Signature Partners practices. In addition, the Centers for Medicare & Medicaid Services (CMS) has charged VHQC with assessing the project’s potential for replication elsewhere in the country through CMS’ network of Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs).

As the QIN-QIO for Maryland and Virginia, VHQC’s improvement initiatives convene healthcare providers, patients and families, and stakeholder organizations for sustainable change that results in better care, healthier people and smarter healthcare spending. Funding for this two-year special innovation project, which totals approximately $585,000, was provided to VHQC by CMS.

About VHQC
For more than 30 years, VHQC has been leading the way to better health care for providers and other clients by offering expertise in quality improvement, utilization management, analytic services and health information technology support that improves patient outcomes — and often results in cost savings. In addition to its role as the Maryland and Virginia QIN-QIO, VHQC is the Health IT Regional Extension Center for Virginia and leads the Virginia Practice Transformation Network.

About C-TAC
The Coalition to Transform Advanced Care (C-TAC) is dedicated to the ideal that all Americans with advanced illness, especially the sickest and most vulnerable, receive comprehensive, high-quality, person- and family-centered care that is consistent with their goals and values and honors their dignity. It achieves this by empowering consumers, changing the health delivery system, improving public and private policies, and enhancing provider capacity. For more information, visit www.thectac.org.

About Signature Partners
Signature Partners is a clinically integrated network of physicians and hospitals in Northern Virginia who work together to provide high quality, lower cost care by integrating and coordinating clinical services. In so doing, Signature Partners provides a high value network of providers for patients, employers and payers. Signature Partners in Health, LLC, is a Virginia not-for-profit solely owned by Inova. For more information, visit www.signaturepartners.org.

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