After identifying the top 5% of the patients that need more coordinated care, we have three recommendations Recommendation

n 1.1: Implement home monitoring system / Telehealth system Telehealth is the use of electronic information and technologies such as streaming media, videoconferencing, etc. to remotely collect, track, and transmit patient health data from a patients home to a health care provider in a different location. By doing that, we could reduce hospitalizations and activate patients to better manage their own health and care. An example of success if the Telehealth system in Geisinger, which helped reduce 44% readmission rates for heart failure. Our suggestion is that PMC could apply for grant to develop telehealth system for the chronically ill patients. Recommendation 1.2: Group meeting between chronic disease patients and physicians So people who have the similar diseases and health conditions should be arranged for a group meeting (instead of 1 to 1 meeting) with their physicians. By doing this, patients not only learn from their physicians, but also learn from other patients. Meetings can be held for patients that are listed under 5% high-cost patient group. Kaisers data shows that seniors who attended groups made one and a half fewer visits to their primarycare doctors than the control patients did. Recommendation 1.3: Care management team for those 5% high cost patients. We suggest PMC to hire registered nurses, physicians, social workers and care management associate make care management team. The teams work with patients make sure they get the health care and services needed (make appointments for any health care services, set up the transportation the patients need to receive those services,) coordinate other health providers such as physicians visits, and hospital admissions. Result shows a 10% reduction in total hospitalizations relative to a control group

Recommendation 2: Engage and educate patients to take more responsibility for their own care. Recommendation 2.1: Provide handouts that educate consumer about cost effective treatments and common unnecessary tests. Handouts materials can be given to patients in order to educate the public about their doctors responsibility to avoid unnecessary tests or treatments. One example of the effort to improve care and eliminate unnecessary tests and procedures is the Choosing Wisely program materials, which identify five tests or procedures commonly used, whose necessity should be questioned and discussed

Recommendation 2.2: Offer self-management training program that designed to cover persons with chronic diseases. Using the same idea, Porter could develop classes offered to its patients to educate patients how to manage their pain, fear, and depression. Recommendation 2.3: Develop Patient Portal Patient portal are online applications that allow patients to interact and communicate with their healthcare providers. The application could be linked with electronic medical record, allowing patients to interact with their medical information via the Internet. A patient portal used by medical center in Phoenix helped reduce 60 phone calls per day. We suggest Porter to build a patient portal or ask OneCare to support financially to build this application.