August 7, 2019

The Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-Inclusive Care for the Elderly (PACE) is a capitated benefit authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. The program is modeled on the system of acute and long term care services developed […]
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The Program of All-Inclusive Care for the Elderly (PACE) is a capitated benefit authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. The program is modeled on the system of acute and long term care services developed by On Lok Senior Health Services in San Francisco, California. The model was tested through CMS (then HCFA) demonstration projects that began in the mid-1980s. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home while receiving services rather than be institutionalized. Capitated financing allows providers to deliver all services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems. The BBA established the PACE model of care as a permanent entity within the Medicare program and enables States to provide PACE services to Medicaid beneficiaries as a State option. The State plan must include PACE as an optional Medicaid benefit before the State and the Secretary of the Department of Health and Human Services (DHHS) can enter into program agreements with PACE providers. Participants must be at least 55 years old, live in the PACE service area, and be certified as eligible for nursing home care by the appropriate State agency. The PACE program becomes the sole source of services for Medicare and Medicaid eligible enrollees.
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http://www.cms.gov/pace/

August 7, 2019

Medicare Hospital Readmissions: Issues and Policy Options. A report by the Congressional Research Service.

This report is intended to help Congress address the complex issue of hospital readmissions. It is largely conceptual and does not track legislation moving through the House and Senate.4 After helping to define the issues, this report discusses some of the diverse causes of hospital readmissions. It also provides a […]
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This report is intended to help Congress address the complex issue of hospital readmissions. It is largely conceptual and does not track legislation moving through the House and Senate.4 After helping to define the issues, this report discusses some of the diverse causes of hospital readmissions. It also provides a summary of approaches used to distinguish which hospital readmissions might be preventable. Finally, to help Congress evaluate strategies to reduce readmissions, this report includes a discussion of various strategies to lower the incidence of Medicare-covered hospital readmissions.
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http://www.fah.org/fahCMS/Documents/On%20The%20Record/Research/2009/CRS_Medicare_Hospital_Readmissions_report.pdf

August 7, 2019

Improving Care Transitions and Reducing Hospital readmissions: Establishing the Evidence for Community-Based Implementation Strategies Through the Care Transitions Theme

The Care Transitions Theme is a CMS-funded initiative for Medicare Quality Improvement Organizations (QIOs) to measurably improve the quality of care for Medicare Beneficiaries who transition among care settings through a comprehensive community effort. Fourteen QIOs began working with target communities within their respective States on August 1st, 2008, and […]
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The Care Transitions Theme is a CMS-funded initiative for Medicare Quality Improvement Organizations (QIOs) to measurably improve the quality of care for Medicare Beneficiaries who transition among care settings through a comprehensive community effort. Fourteen QIOs began working with target communities within their respective States on August 1st, 2008, and the project will be completed by August 2011. Each QIO selected a specific geographic area and a Medicare beneficiary population (as defined by beneficiary zip code of residence) where they are now working with the medical services providers, other community health support agencies, unpaid caregivers and patients to identify drivers of poor transitional care and to reduce their influence on patient outcomes. In other words, this work seeks to improve care quality by promoting seamless transitions among care settings, and thereby reduce readmissions to hospitals within 30 days of discharge.
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http://www.cfmc.org/integratingcare/files/Care_Transition_Article_Remington_Report_Jan_2010.pdf

August 7, 2019

The Medicare Physician Group Practice Demonstration: Lessons Learned on Improving Quality and Efficiency in Health Care

ABSTRACT: In April 2005, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Group Practice demonstration, which offers 10 large practices the opportunity to earn performance payments for improving the quality and cost-efficiency of health care delivered to Medicare fee-for-service beneficiaries. This report is based on the proceedings […]
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ABSTRACT: In April 2005, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Group Practice demonstration, which offers 10 large practices the opportunity to earn performance payments for improving the quality and cost-efficiency of health care delivered to Medicare fee-for-service beneficiaries. This report is based on the proceedings of a 2006 site conference held in Baltimore and cosponsored by The Commonwealth Fund, CMS, and the Agency for Healthcare Research and Quality. The meeting provided a forum for PGPs to: 1) explore specific care management models, including methods for implementation and assessment of effectiveness; 2) accelerate learning across PGPs through information sharing; and 3) harvest knowledge and develop a plan for case studies and descriptive reports on successful care management models. A number of promising practice changes were discussed, such as increasing patient engagement, expanding care management, improving care transitions, and expanding non-physician roles.
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http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Feb/The-Medicare-Physician-Group-Practice-Demonstration--Lessons-Learned-on-Improving-Quality-and-Effici.aspx

August 7, 2019

The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care

A policy paper providing proposals for resolving some of the major problems with the health care system in America was released today by The American College of Physicians (ACP) at its annual report on “The State of the Nation’s Health Care.” “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of […]
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A policy paper providing proposals for resolving some of the major problems with the health care system in America was released today by The American College of Physicians (ACP) at its annual report on "The State of the Nation's Health Care." "The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care," proposes a fundamental change in the way that principal - or primary care - is delivered and financed. "ACP proposals would provide patients with access to care that is coordinated by their own personal physician," explained C. Anderson Hedberg, ACP president. "The physicians will be working in a practice environment organized around patients' needs." The paper recommends voluntary certification and recognition of primary care and specialty medical practices that use health information technology, quality measurement and reporting, patient-friendly scheduling systems and other "best practices" to deliver better value and improve care coordination for patients, especially those with multiple chronic illnesses.
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http://www.acponline.org/pressroom/admed_home.htm

August 7, 2019

New Design for Discharge: The Hospitalist, November 2010

Four-part process improves patient outcomes, lowers readmission rates With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower […]
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Four-part process improves patient outcomes, lowers readmission rates With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.
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http://www.the-hospitalist.org/details/article/182425/New_Design_for_Discharge.html

August 7, 2019

Development and Testing of a Measure Designed to Assess the Quality of Care Transitions.

Coleman E, Smith J, Frank, J, et.al. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration.2002;2. http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf . Accessed August 1, 2014. Results: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct […]
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Coleman E, Smith J, Frank, J, et.al. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration.2002;2. http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf . Accessed August 1, 2014. Results: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct validity was assessed by comparing items from the CTM to selected items from a measure developed by Hendriks and colleagues (Medical Care 2001; 39(3): 270–283). Inter-item Spearman correlations ranged 0.388–0.594. No significant floor or ceiling effects were detected. Conclusions: The CTM was developed with substantial input from older patients and their caregivers. Psychometric testing suggested that the measure was valid. The CTM may serve to fill an important gap in health system performance evaluation by measuring the quality of care delivered across settings.
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http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf

August 7, 2019

Reducing Emergency Visits in Older Adults With Chronic Illness

Coleman E, Eilertsen T, Kramer A. Reducing Emergency Visits in Older Adults With Chronic Illness. Eff Clin Pract. 2001;(4) 49-57. http://www.caretransitions.org/documents/Reducing%20ER%20-%20ECP.pdf Accessed August 1, 2014. On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. […]
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Coleman E, Eilertsen T, Kramer A. Reducing Emergency Visits in Older Adults With Chronic Illness. Eff Clin Pract. 2001;(4) 49-57. http://www.caretransitions.org/documents/Reducing%20ER%20-%20ECP.pdf Accessed August 1, 2014. On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. 1.08 visits; P=0.005) and were less likely to have any emergency department visits (34.9% vs. 52.4%; P =0.003) than controls. These differences remained statistically significant after controlling for demographic factors, comorbid conditions, functional status, and prior utilization. Adjusted mean difference in visits was –0.42 visits (95% CI, –0.13 to –0.72), and adjusted RR for any emergency department visit was 0.64 (CI, 0.44 to 0.86).
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http://www.caretransitions.org/documents/Reducing%20ER%20-%20ECP.pdf

August 7, 2019

What is the Patient-Centered Medical Home?

A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other […]
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A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.
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http://www.acponline.org/running_practice/pcmh/understanding/what.htm

August 7, 2019

Hospitalization Rates in Nursing Home Residents with Dementia: A Pilot Study of the Impact of a Special Care Unit. Journal of the American Geriatrics Society. 1990;38(2):108-12

Coleman E, Barbaccia J, Croughan-Minihane M.Hospitalization Rates in Nursing Home Residents with Dementia: A Pilot Study of the Impact of a Special Care Unit. Journal of the American Geriatrics Society. 1990;38(2):108-12. http://www.caretransitions.org/documents/Hosp%20Rates%20-%20JAGS%20Abstract.pdf . Accessed July 31, 2014. Although Special Care Units (SCUs) have recently gained attention as appropriate places for […]
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Coleman E, Barbaccia J, Croughan-Minihane M.Hospitalization Rates in Nursing Home Residents with Dementia: A Pilot Study of the Impact of a Special Care Unit. Journal of the American Geriatrics Society. 1990;38(2):108-12. http://www.caretransitions.org/documents/Hosp%20Rates%20-%20JAGS%20Abstract.pdf . Accessed July 31, 2014. Although Special Care Units (SCUs) have recently gained attention as appropriate places for caring for institutionalized patients with dementia, few studies have evaluated their effectiveness. This pilot study focused primarily on one aspect of patient care, the possible prevention of acute hospitalization. Because transfer from nursing home to the acute hospital can be a traumatic experience for patients with dementia, important services that SCUs might provide include those preventive strategies aimed at reducing the need for transfer to the acute hospital. Medical record abstraction revealed that over one year, the rate of acute hospitalization was 21% among 47 patients with dementia in SCUs, compared with 14% among 36 patients with dementia and 14% among 22 patients with no listed diagnosis of dementia residing in non-SCU settings within the same facility. Thus, no statistically significant difference in hospitalization rates was found, although the trend was for increased hospitalization for SCU patients. There was a trend toward deterioration in functional status among SCU patients following first hospitalization (P less than .10). Since the majority of these patients were hospitalized for hip fractures, this finding was not unexpected. There was a trend toward cognitive decline after hospitalization among patients with dementia who were not residing in an SCU (P less than .10). In order to investigate whether acute hospitalizations among SCU patients were preventable, an expert panel was convened to review each episode of illness leading to acute hospitalization. Of the 15 hospitalizations, none were judged "preventable," four were believed to be "possibly preventable," and 11 were considered to have been "not preventable."
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http://www.caretransitions.org/documents/Hosp%20Rates%20-%20JAGS%20Abstract.pdf

August 7, 2019

Transition Home Program for Patients with Heart Failure

AHRQ. Agency for Healthcare Research and Quality. Transition Home Program for Patients with Heart Failure http://innovations.ahrq.gov/content.aspx?id=2206. Accessed August 13, 2014. Summary The Transition Home for Patients with Heart Failure program at St. Luke’s Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to […]
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AHRQ. Agency for Healthcare Research and Quality. Transition Home Program for Patients with Heart Failure http://innovations.ahrq.gov/content.aspx?id=2206. Accessed August 13, 2014. Summary The Transition Home for Patients with Heart Failure program at St. Luke's Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to home or another health care setting. These components include an ongoing enhanced assessment of postdischarge needs, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handovers, and a standardized process for postacute care followup. The program reduced the 30-day heart-failure-to-heart-failure readmission rate for patients from 14 to 6 percent, and the all-cause heart failure readmission rate is 15 to 17 percent. See the Description section for several updates related to ongoing assessment and patient education; the Results section for updated data on readmission rate and patient satisfaction; and the Planning and Development section for new information about spread to other conditions and an Advance Medical Team pilot (updated February 2013).
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http://innovations.ahrq.gov/content.aspx?id=2206

August 7, 2019

Caring Connections

National Hospice and Palliative Care Organization. Caring Connections. [Web site]. Accessed July 31, 2014. Caring Connections provides people with information and support when they are planning ahead, caring for a loved one, living with an illness or grieving a loss.
National Hospice and Palliative Care Organization. Caring Connections. [Web site]. Accessed July 31, 2014. Caring Connections provides people with information and support when they are planning ahead, caring for a loved one, living with an illness or grieving a loss.
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http://www.caringinfo.org/

August 7, 2019

Massachusetts Strategic Plan for Care Transitions

In this plan, we describe the problems with quality of care and high costs in the US healthcare system and the potential role for effective care transitions to achieve performance improvements at the state and national levels. We review why transitions fail, and what is known about effective transitions based […]
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In this plan, we describe the problems with quality of care and high costs in the US healthcare system and the potential role for effective care transitions to achieve performance improvements at the state and national levels. We review why transitions fail, and what is known about effective transitions based on national models and randomized trials. We outline current projects in Massachusetts that form the infrastructure for future work and state health policy among providers, insurers, patients and policy makers. Finally, we present principles, recommendations, action steps and measures for consideration by the Health Care Quality and Cost Council, legislators and other state leaders. We believe that Massachusetts can lead the nation in improving care transitions and reducing avoidable hospitalizations.
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http://www.mahealthdata.org/resources/Documents/Strategic%20Plan%20for%20Care%20Transitions_2-11-2010%20(2).pdf

August 7, 2019

AARP: Talking About Your Final Wishes

AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do […]
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AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do I want to die? Who will take care of me? What do I have to do to achieve a "good death?" These questions raise just a few of the issues to be considered in deciding your care at the end of life.
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http://www.aarp.org/relationships/grief-loss/info-2003/endoflife-finalwishes.html

August 7, 2019

AARP: Advance Directives: Planning for the Future

AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one’s health care wishes are at the end of life? Find out how advance directives can help.
AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one's health care wishes are at the end of life? Find out how advance directives can help.
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http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html

August 7, 2019

Care Cooperation and Continuity Across Clinicians, Facilities and Systems: Massachusetts Strategic Plan for Care Transitions

Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and […]
Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and HIT strategies
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http://www.iom.edu/~/media/Files/Activity%20Files/Quality/VSRT/16-Care%20cooperation%20and%20continuity.ashx

August 7, 2019

Improving Chronic Illness Care

Improving Chronic Illness Care is dedicated to the idea that United States health care can do better. Over 145 million people – almost half of all Americans – suffer from asthma, depression and other chronic conditions. Over eight percent of the U.S. population has been diagnosed with diabetes. We believe […]
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Improving Chronic Illness Care is dedicated to the idea that United States health care can do better. Over 145 million people - almost half of all Americans - suffer from asthma, depression and other chronic conditions. Over eight percent of the U.S. population has been diagnosed with diabetes. We believe that people can lead better, healthier lives. Providers who care for chronically ill patients can be better supported with evidence-based guidelines, specialty expertise, and information systems. Overall health care costs can be lowered through better care delivery. All of this is possible by transforming what is currently a reactive health care system into one that keeps its patients as healthy as possible through planning, proven strategies and management.
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http://www.improvingchroniccare.org/

August 7, 2019

Guided Care Patient-Centered Medical Home

Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is […]
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Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information technology to provide state-of-the-art care for 50-60 chronically ill Medicare beneficiaries. Following a comprehensive assessment and planning process, the Guided Care nurse educates and empowers patients and families, monitors their conditions monthly, and coordinates the efforts of health care professionals, hospitals and community agencies to be sure that no important health-related need slips through the cracks
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http://www.guidedcare.org/pdf/Guided%20Care%20summary%20and%20results.pdf

August 7, 2019

Collaborative Management of Chronic Illness. Archives of Internal Medicine

In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health […]
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In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.
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http://www.annals.org/content/127/12/1097.abstract

August 7, 2019

Home Health Telemedicine

Home Health Telemedicine is a remote technology-enabled model in which nurses manage the care of chronic patients in their homes using video units and diagnostic devices.
Home Health Telemedicine is a remote technology-enabled model in which nurses manage the care of chronic patients in their homes using video units and diagnostic devices.
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http://www.innovativecaremodels.com/care_models/18