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Innovative Use of Technologies and Methods to Redesign Care: The Problem of Care Transitions

Richman, Mark MD, MPH; Sklaroff, Laura Myerchin MA; Hoang, Khathy BA; Wasson, Elijah MD; Gross-Schulman, Sandra MD, MPH, RN

Journal of Ambulatory Care Management: April/June 2014 - Volume 37 - Issue 2 - p 100–105
doi: 10.1097/JAC.0000000000000028
Original Articles

Organizations are redesigning models of care in today's rapidly changing health care environment. Using proven innovation techniques maximizes likelihood of effective change. Our safety-net hospital aims to reduce high emergency department visit, admission, and readmission rates, key components to health care cost control. Twenty-five clinical stakeholders participated in mixed-methods innovation exercises to understand stakeholders, frame problems, and explore solutions. We identified existing barriers and means to improve post–emergency department/post–inpatient discharge care coordination/communication among patient-centered medical home care team members, including patients. Physicians and staff preferred automated e-mail notifications, including patient identifiers, medical home/primary care provider information, and relevant clinical documentation, to improve communication efficiency/efficacy.

David Geffen School of Medicine and University of California (UCLA) (Drs Richman and Wasson), Department of Medicine, Olive View-UCLA Medical Center (Drs Richman and Wasson); Ambulatory Care Network: Research and Innovation (Ms Sklaroff and Dr Gross-Schulman), Los Angeles County Department of Health Services, Sylmar (Drs Richman and Wasson and Gross-Schulman and Ms Sklaroff); Olive View-UCLA Education and Research Institute (Ms Hoang); and The Tseng College (Ms Sklaroff) and Master of Public Health Program, Department of Health Sciences (Ms Hoang), California State University, Northridge.

Correspondence: Khathy Hoang, BA, Olive View-UCLA Education and Research Institute 14445 Olive View Dr, Old Lab Bldg, R&I Headquarters, Sylmar, CA 91342 (

Blue Shield of California Foundation, with support from The Center for Care Innovations, provided generous funding (grant TFR13-00457) and technical assistance for regularly scheduled team meetings and guidance. Technical assistance consisted of conference participation with other grantee organizations, weekly telephone and in-person coaching, and innovation instruction using the Innovator's Guidebook. The Olive View Education and Research Institute is the fiscal incubator for research at Olive View UCLA Medical Center and was responsible for funds administered for the completion of this project. The authors thank LAC DHS leadership, the LAC DHS Ambulatory Care-Network: Research and Innovation, and leadership and clinical staff at Olive View UCLA Medical Center who generously contributed to and provided feedback on this project.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins