Telligen employee-owners Brianna Gass, MPH, Jane Brock, MD, MSPH, Christine LaRocca, MD and Lacey McFall, MA, MPH are co-authors on a research article published in “Healthcare: The Journal of Delivery Science and Innovation.”

The article, “Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care,” details research led by Telligen, in partnership with the Center for Health Services Research, University of Kentucky, and explores transitional care (TC) improvement efforts through collaborations between providers in multiple settings and community-based organizations. 

The article was developed as a part of Project ACHIEVE, an effort to evaluate the effectiveness of different transitional care efforts using implementation research and funded by the Patient Centered Outcomes Research Institute (PCORI). Telligen’s insights into community-based coordination as the National Coordinating Center (NCC) for the Quality Innovation Network-Quality Improvement Organizations (QIN-QIO) program led Telligen experts to participate in Project ACHIEVE. As the NCC, Telligen employee-owners were exposed to many cross-sector collaborations while supporting other QIN-QIOs as they convened collaborations in their states. 

The article indicates there is a lot to be learned about the benefits of collaboration between providers and with community-based organizations. Including multiple perspectives from clinical settings and social services organizations can better determine social determinants of health for patients and provide better transitional care based on their needs. 

Read the article: 

“Healthcare: The Journal of Delivery Science and Innovation” is a quarterly journal. The journal promotes cutting edge research on innovation in healthcare delivery, including improvements in systems, processes, management, and applied information technology. 

About the Authors 

Brianna Gass joined the Telligen in 2012 to facilitate evaluation activities of QIOs working to improve care transitions, as well as other national and community-based health care quality improvement efforts.  Since then, she has overseen programmatic and evaluation activities for several contracts, including the Data Validation and Administrative contractor (DVA), QIN-NCC and Project ACHIEVE. Brianna graduated from the University of Rochester and received her MPH in Health Policy and Management from the University of California at Berkeley.

Jane Brock is a medical director at Telligen with more than 20 years’ experience guiding local and national quality improvement programs through the Centers for Medicare & Medicaid (CMS) Network of Quality Improvement and Innovation Contracts (NQIIC), Project ACHIEVE and others.  She practiced urgent care and occupational medicine for 20 years before becoming enamored with public health through her Preventive Medicine residency at the University of Colorado and has been focused on innovations to promote integrated medical and social support in the interest of population health ever since.     

Christine LaRocca is a fellowship-trained, board-certified geriatrician. She received her medical degree from Vanderbilt University School of Medicine and completed an internal medicine residency and geriatrics fellowship at the University of Colorado Health Sciences Center. At Telligen, she provides clinical oversight and subject matter expertise for local and national contracts and subcontracts, including the CMS QIN-QIO,12th Statement of Work, the CMS Hospital Quality Improvement Contractor (HQIC) program, the Merit-based Incentive Payment System Data Validation and Audits (MIPS-DVA) task order, and the evaluations of the Comprehensive Joint Replacement (CJR) Model, and the Bundled Payments for Care Improvement (BPCI) Advanced Model. 

Lacey McFall, MA, MPH, is a Senior Program Manager for Telligen. She has over 10 years of experience administering technical assistance and analytic support for Medicare quality improvement projects focused on care coordination, high-risk medication management, patient safety, and health equity in hospital, post-acute, and community-based settings. She is currently part of the DVA. In this role, she is involved in managing many of the national analytic reporting activities of the DVA for the CMS QIN-QIO and HQIC programs.