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Partnership for Patients

In working to achieve CMS Innovations’ Partnership for Patients goals: increasing quality of patient care and decreasing hospital readmissions, the GHPC and Communities Joined in Action (CJA) initiated a project aimed at better understanding the movement of and issues faced by the dual eligible population (persons eligible for both Medicare and Medicaid) within our health system.  Dual eligibles were chosen for focus, because as a more vulnerable population (low-income elderly and disabled), they face extremely high rates of hospital readmissions and medical costs.

Brainstorming sessions with community organizations working with this population were held in October 2011 as a part of the CJA national meeting, and again in February 2012 in conjunction with the GHAREF HEN kick-off meeting.  It was determined that a systems map, a high-level visualization of the system, would be the best way to capture the movement of dual eligibles from hospitals to communities and back, and would illustrate the main issues and areas for improving the care of this population. 

In-depth interviews were then conducted between  a systems engineer, the GHPC/CJA, and representatives from community based health organizations, CMS, the Georgia Department of Community Health, and Medicare subject matter experts.  The subject matter expert interviews informed the map, giving critical insight into how dual eligibles currently move in the system.  From these interviews, the map was created and final follow up with the group concluded the map creation.  The final products – a map PowerPoint presentation, and video walk-through of the map – have been made available to a variety of health care partners whose work involves the dual eligible population.  We encourage organizations at any level (community based organizations, federal, state and local governments, hospitals and health care providers, etc.) to use the map as a means of better visualizing and identifying parts of the health care system that could be changed in order to keep this population healthier.

Dynamics in the Dual Eligible Population: A Systems Map (PDF)

Dynamics in the Dual Eligible Population: A Systems Map (Webinar)