Leveraging data

 Alfred Clavel, MD, Minnesota Head & Neck Pain Cllinic and FPA Staff, Mike Schlichting
 Alfred Clavel, MD, Minnesota Head & Neck
Pain Cllinic and FPA Staff, Mike Schlichting
We use data to help make care more consistent and improve transitions of care to support population health. We are working to provide independent primary care clinics in Fairview Health Network--our shared savings network-- with information to manage patient populations and enhance care and shared savings.

Data sharing and reporting
We are providing Fairview Health Network independent primary care clinics with information to manage patient populations by enhancing care, patient experience and shared savings.

Transitions of care
We are working to reduce the number of avoidable hospital readmissions and improve the movement of patients from one level of care to another. Efforts include:

• Automated discharge reports from all Fairview hospitals
• Inpatient and Emergency Department visits to Fairview Health Network primary care clinics
• 48-hour follow-up calls and seven-day primary care physician visits.

Remote monitoring
We participate in Fairview's remote monitoring program, providing 30-day post-hospital surveillance for Medicare fee-for-service enrollees with congestive heart failure, chronic obstructive pulmonary disease (COPD) and other chronic and orthopedic conditions. Patients can enroll at no cost after discharge from a transitional care unit or hospital.

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