Older adults with multiple chronic conditions (MCCs) typically have risk factors (e.g., functional deficits, social barriers) that complicate the management of their healthcare, often with devastating human and economic consequences. Finding new ways to provide patient-centered care to community-based older adults with MCCs is essential. Two current models of care, the Patient-Centered Medical Home (PCMH) and the Transitional Care Model (TCM), have demonstrated improvements in the outcomes of high-risk older adults at different points on the chronic illness trajectory. However, neither care management approach has optimally engaged vulnerable patients to address needs throughout both acute and more stable transitions in health. In this article, we summarize the development of the PCMH plus TCM (hereafter, PCMH + TCM), an innovative approach to care, and the experience of the providers involved in testing the feasibility of implementing the PCMH + TCM. Using content analyses to code open-ended survey responses from transitional care nurses and PCMH clinical leaders', two major themes, collaboration and communication, emerged as critical to the process of implementing the PCMH + TCM. Barriers and facilitators to implementing the PCMH + TCM are presented. Findings support that the TCM can be adapted and integrated into the PCMH with meticulous planning and implementation.

Oil and gas project development in the North Sea is known for large discoveries, requiring the need for highly complex, capital intensive infrastructure, which can take decades to complete. Recognizing that such discoveries were becoming less common, a faster and less capital intensive approach was needed to develop smaller fields. The idea was to target fields close to existing infrastructure that could tie back to current installations and only require a seabed template. Historically, these types of projects would take the company over five years to complete. A dedicated team was established to plan these smaller projects, appropriately called “Fast Track” projects, and was challenged with cutting development time in half. The Fast Track team used lean principles to analyze project lead times and target improvement opportunities. Lean is a methodology made famous in automotive manufacturing, which seeks to eliminate time wasting activities and reduce overall lead time (De Wardt 1994). The primary lean technique employed by the team was value stream mapping. First, the team mapped out the entire project development process, from discovery to production, and identified all the key steps in the process. Second, the team estimated the time it takes to perform each major step in the process and calculated the total lead time for project development. Finally, the team quantified all the sources of delays and developed opportunities for improvement. These opportunities were then ranked based on the potential time and cost savings. With the prioritized opportunities, an improvement road map was developed to steer the team in the right direction. The improvement road map contained a four-pronged approach to cut project development times in half: StandardizationCollaborationStreamlined processesChange management Standardization involved developing standard subsea templates, well designs, and completions equipment to cut the time to develop solutions. Collaboration involved integrating the operator and the service company and making use of teams in different time zones to accelerate well design and planning. Streamlined processes focused on combining decision gates in capital projects and working the well construction process in parallel to the project development process to reduce planning time. Finally, change management involved establishing a continuous improvement process, a system to implement ideas and engrain them into the organization, and a common set of key performance indicators to align different stakeholders and drive execution results. Implementation of these improvement opportunities led to a reduction of over two years in the time needed to complete the development projects: from 5.3 years to an average of three years.

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Producibility refers to lowering of acquisition costs of a system without degradation to system performance. The Navy has conducted many efforts in pursuit of improved ship producibility, but no systematic methodology or study format is currently implemented in Naval Sea Systems Command (NAVSEA). Two factors which suggest that a standard, systematic approach to ship producibility should be implemented are the large size of the NAVSEA design organization with its myriad of ship programs, and the requirement of access and manipulation of large volumes of digital data and process documentation. A "Producibility Framework" is offered which models producibility in the ship design and construction process as an iterative algorithm in which producibility concepts are identified, evaluated, incorporated into or rejected from the design, and examined to provide lessons learned and feedback. The framework is described using the DDG-51 Guided Missile Destroyer as the major illustrative case.