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Health Care Value Week

What is Health Care Value?

Increasing value in healthcare is about providing high-quality care that is patient-centered, accessible, and affordable. Jefferson works across its enterprise to continually improve the health outcomes of the full spectrum of populations we serve. Jefferson is proud to be an innovator, working to identify health care gaps and develop programs to address unique and special needs, keeping equitable care for all at the forefront of this work.

As a part of our celebration of Health Care Value Week, we’re highlighting:

  • Initiatives that make it easier for people to access healthcare services
  • Programs that serve the unique social and cultural needs of the communities we serve  
  • Resources to help make healthcare more affordable

Jefferson Health participates in many value-based arrangements serving over 400,000 lives. These arrangements allow us to enhance services to our patients.  The care coordination team helps patients and families managing challenging conditions. 

The Population Health Care Coordination team organizes a patient’s care across multiple health providers and care settings. It is designed to serve patients with complex needs related to one or more chronic conditions (such as COPD, diabetes, hypertension, or heart failure) or advanced illness. Our multidisciplinary team of Registered Nurses, Licensed Practical Nurses, Social Workers and Community Health Workers work with patients to achieve their goals in times of transition. 

Care Coordination helps patients navigate the health system, connect to community resources, and offers education about disease management, medications, and preventative health. The objective is to make health care delivery safer and more efficient, while providing patients and their families with the tools they need to successfully maintain their health within the community. 

Community Health Worker Program

The Jefferson Collaborative for Health Equity’s Community Health Worker (CHW) Program is a cornerstone of our multifaceted efforts to improve the health and socioeconomic status of vulnerable Philadelphians in the communities that we serve. These trusted members of the communities they serve, help community members, navigate complex systems, provide information and resources, and support behavior change.

In line with our mission to build capacity in collaboration with our communities, and address structural barriers to health, the CHQ Program involves  a multi-pronged approach that includes 3 core components: 

  • CHW Academy is a foundation and training pipeline open to Jefferson staff, community partners, and unemployed or underemployed community members. It offers  opportunities for Individuals committed to serving their community to enter healthcare careers. Participants are provided with training in a supportive learning supportive learning environment to gain CHW certification.
  • Jefferson CHW Community of Practice provides learning and networking opportunities with the goal of sharing resources, supporting growth, attending professional development programs, and fostering connections. 
  • CHW Care Delivery is facilitated through collaboration with others across Jefferson, to ensure CHWs are an integral part of care delivery teams. It involves telephonic and in-person support through social needs screening and resource navigation; health care navigation; and supporting the health and wellness of patients and their families through self-management practices and building a trusting and reliable partnership.                                                                                                        

Evidence suggests that a systematic program to support 7-day post-acute follow-up appointments for high-risk patients can significantly reduce preventable readmissions. Jefferson is committed to engaging our patients across the care continuum to ensure successful care transitions from acute care in the hospital. Our innovative workflow leverages artificial intelligence and newly designed clinical care processes to allow the inpatient care teams to work in partnership with Care Coordination. This holistic approach to patient-centered care demonstrates our commitment to improving lives.

The Sidney Kimmel Cancer Center (SKCC) at Jefferson Health has been on a  journey to improve patient-centered cancer care over the last 10 years. Cancer care is complex, and it is our job to make it easier for patients to navigate that journey.

  • Jefferson Health’s Center City and Einstein teams were some of the first providers to participate in the Oncology Care Model (OCM), the first natonal demonstration project aimed at improving care and lowering cost for Medicare beneficiaries. 
  • In 2021, SKCC was invited to be part of the Oncology Medical Home pilot with the goal of creating a system of high-quality cancer care that delivers value to patients and payers. SKCC was the first academic medical center to achieve Certification from the American Society of Clinical Oncology’s (ASCO). 

At SKCC, dedicated Oncology Navigators are available to support patients throughout their care journey. Navigators can help patients gain access to healthcare services, ensure their records and relevant clinical information is available during visits with their oncologist, and provide education and clinical support as patients transition through phases of their care. Oncology Navigators also play a critical role in connecting patients to additional services that can support their needs and keep patients out of the hospital. These services are offered at no cost and can have great impact on outcomes. 

Chronic Kidney Disease (CKD) affects 37 million Americans and is the 9th leading cause of death in the U.S. Value-based kidney care enhances patient outcomes by promoting early CKD diagnosis and interventions and addressing disparities. Our program is focused on early access for CKD, and developing home dialysis programs, early transplant referrals, and live donor kidney transplants.

Our ongoing work in this field:

  • Pioneering regionally, we have successfully implemented race-neutral Glomerular Filtration Rate (GFR) adjustments for Black patients on our kidney waitlist. 
  • In partnership with the Jefferson Collaborative for Health Equity, our kidney transplant program strives to eliminate barriers to advanced CKD care and raise awaress about options in the community. 
  • In collaboration with the Davita Innovation Lab, we are working to improve access to the kidney transplant waitlist.
  • Jefferson participates in Nephrology value-based arranagments that support the provision of wrap-around care; and control costs, and ensure optimal patient outcomes.
  • Jefferson leverages data analytics and Electronic Medical Record (EMR) to  streamline early referrals for both advanced CKD and transplant care.  

The Clinical Program uses a person-centric approach to care using member utilization data, results from health risk assessments and information about the population and communities we serve. 

A critical component of our care management programs is working together with the member, families/designated member representative, and the member’s healthcare providers and community agencies to develop goals and interventions. Based on the member’s preference, collaborations can occur by phone, virtually and face to face interactions. 

Using an assessment tool that integrates physical, cognitive, functional, and behavioral health with psychosocial wrap around services, the team works to build on individual and family strengths while also addressing social determinant needs.

All staff are trained on health plan benefits, have access to a data base of Community Resources, provider directory and pharmacy transactional software. All assessments address members’ disease condition and comorbidities driven by evidence-based guidelines and support care gap closure. 

The Wyss Wellness Center is a community-led primary care site dedicated to serving immigrant and refugee communities in South Philadelphia. The Center is a comprehensive family medicine practice that provides care for children and adults of all ages - including women’s health and prenatal care – regardless of ability to pay. The Center provides thousands of families with access to health care that would have otherwise been unavailable to them.

Pride at the Jefferson Center for Healthy Aging provides high-quality primary and specialty care to older adults who identify as LGBTQIA+ while also advocating for the overall improvement of LGBTQIA+ healthcare. The Center provides patients a health care environment where they can feel comfortable expressing themselves as they truly are to staff and providers. Services include sexual health, HIV prevention and treatment, gender-affirming care, wellness, preventative health screenings, and primary care services.

 

The FAB Center (for Adolescents and Beyond) serves patients with intellectual and developmental disabilities, and other complex childhood-onset conditions, who have reached adulthood to transition to adult providers. The FAB Center provides specialized care and support to ensure that patients remain healthy, including regular screenings, preventative medicine, and care coordination with other providers.  

Jefferson College of Population Health (JCPH) is positioned to foresee the emerging complex global healthcare demands, and the necessary skills to adapt to change and lead. Quality graduate and professional development programs equip students with the knowledge to improve the healthcare system and well-being of communities.  

JCPH graduate programs shape future leaders in healthcare through diverse academic programming in: 

The college also provides a robust professional development program designed to enhance the skills of professionals in the healthcare field. Training programs include: 

Research is an integral part of informing and assessing initiatives to improve population health. Our Main Line Center for Population Health Research emphasizes the value of care, rather than the volume of services provided. 

Through scholarly publications and conferences, JCPH communicates best practices and new concepts to the public and healthcare professionals.  

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