August 7, 2019

Hospital to Home (H2H): Excellence in Transitions

An initiative of the American College of Cardiology and the Institute for Healthcare Improvement, Hospital to Home (H2H) is a national improvement initiative that aims to reduce unnecessary readmissions and improve care transitions for cardiovascular patients. The goal is to reduce all-cause readmission rates among patients discharged with heart failure […]
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An initiative of the American College of Cardiology and the Institute for Healthcare Improvement, Hospital to Home (H2H) is a national improvement initiative that aims to reduce unnecessary readmissions and improve care transitions for cardiovascular patients. The goal is to reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction by 20 percent by December 2012.
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http://www.h2hquality.org/

August 7, 2019

Groups Focus On Cutting Hospital Readmission Of Medicare Patients

Medicare Quality Improvement Organizations (QIOs) in the states began work last year on the three-year projects aimed at improving readmission rates. These organizations are the Alabama Quality Assurance Foundation, the Louisiana Health Care Review and the Georgia Medical Care Foundation. These QIOs are independent organizations that contract with CMS to […]
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Medicare Quality Improvement Organizations (QIOs) in the states began work last year on the three-year projects aimed at improving readmission rates. These organizations are the Alabama Quality Assurance Foundation, the Louisiana Health Care Review and the Georgia Medical Care Foundation. These QIOs are independent organizations that contract with CMS to improve care. They are examining hospital and community systemwide interventions, interventions that target specific diseases or conditions and interventions that target specific reasons for admission.
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http://www.eqhealthsolutions.com/LinkClick.aspx?fileticket=rJj5n1tRPXw%3D&tabid=99

August 7, 2019

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient’s care on an ongoing basis through regular telephone and in-person contact with both patients and […]
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Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits and hospital admissions; and generated high levels of physician and patient satisfaction. A recent analysis found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year three. Strong: The evidence consists of a randomized controlled trial (RCT) of 951 patients that compared results for program participants with patients receiving usual care on a variety of metrics (including functional status, activity of daily living status, ED and hospital use, and patient and physician satisfaction).
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http://www.innovations.ahrq.gov/content.aspx?id=2066

August 7, 2019

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their […]
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The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2006.00791.x/abstract

August 7, 2019

IHI Collaborative: Hospital to home, Optimizing the Transition

IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve […]
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IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve workflow using ideas that have been tested on the discharges of patients with heart failure (HF) on medical-surgical units. Upon completion of this Web&ACTION, participants will be able to: • Reduce unplanned admissions for patients with heart failure • Understand and collect key data regarding hospital readmissions • Describe and test top ideas for reducing heart failure readmissions to hospitals • Increase patient involvement in their care while in the hospital and after discharge
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http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx

August 7, 2019

St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge

Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s […]
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Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, a program called Transitions Home is addressing these concerns for patients with heart failure. By providing self-management support for patients at home, the hospital is reducing its rate of readmissions for heart failure patients. The program includes a combination of patient-friendly written information along with a home visit from a nurse, a physician office visit, and follow-up telephone calls. There are also weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support.
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http://www.ihi.org/knowledge/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx

August 7, 2019

Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure

Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. http://www.ncbi.nlm.nih.gov/pubmed/15725981. Accessed August 13, 2014. BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to […]
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Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. http://www.ncbi.nlm.nih.gov/pubmed/15725981. Accessed August 13, 2014. BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to expand. Performance measurement is one potential strategy towards improving the quality of transitional care. A valid and reliable self-report measure of the quality of care transitions is needed that is both consistent with the concept of patient-centeredness and useful for the purpose of performance measurement and quality improvement.
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http://www.ncbi.nlm.nih.gov/pubmed/15725981

August 7, 2019

Guided Care: Better Care for Older People With Chronic Conditions

More than 125 million Americans have at least one chronic health condition, and 60 million have more than one. These people, many of them elderly, manage multiple conditions, treatments, medications, and doctors. Primary care doctors often don’t have the time or resources to properly manage these complex, chronic health problems. […]
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More than 125 million Americans have at least one chronic health condition, and 60 million have more than one. These people, many of them elderly, manage multiple conditions, treatments, medications, and doctors. Primary care doctors often don’t have the time or resources to properly manage these complex, chronic health problems. So these patients and the family members who care for them are often less healthy, confused by their treatments and medications, and overwhelmed by high health care costs. As the baby boomers age, this problem will multiply. In response, a multidisciplinary team of experts from the Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health designed Guided Care as a model of comprehensive health care by physician-nurse teams for people with several chronic health conditions, specifically focusing on the 25% of Medicare patients at highest risk for using health services heavily.
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http://www.guidedcare.org/pdf/Guided%20Care%20summary%20and%20results.pdf

August 7, 2019

Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure

Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx. 2008. Accessed August 7, 2014. Institute for Healthcare Improvement (in collaboration with […]
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Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx. 2008. Accessed August 7, 2014. Institute for Healthcare Improvement (in collaboration with the Robert Wood Johnson Foundation) Cambridge, Massachusetts, USA Launched in 2003, Transforming Care at the Bedside (TCAB) is a national program of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI). One of the most promising changes that has been developed within TCAB is “creating an ideal transition home” for patients who are being discharged from medical and surgical units within hospitals. This How-to Guide builds upon relevant research and published literature, and integrates what TCAB hospitals have learned as they strive to dramatically improve the quality of care for patients discharged from the hospital to home or to another health care facility.
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http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx

August 7, 2019

The Remington Report: Improving Outcomes Through Re-Engineered Care Transitions: The New York Experience

The Centers for Medicare & Medicaid Services (CMS) is funding an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test a variety of interventions and approaches to improving the quality of care for Medicare beneficiaries as they transition from one setting to another. A primary objective of the Care […]
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The Centers for Medicare & Medicaid Services (CMS) is funding an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test a variety of interventions and approaches to improving the quality of care for Medicare beneficiaries as they transition from one setting to another. A primary objective of the Care Transitions Theme is to reduce unnecessary hospital readmissions and the resultant morbidity, mortality and quality of life issues. The project began in August 2008 and will continue through July 2011. The structure of this CMS initiative provides QIOs the flexibility to develop approaches tailored to local needs, while using evidence-based interventions to target improvement across settings.
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http://www.cfmc.org/integratingcare/files/rem_mj10-care_transitions.pdf

August 7, 2019

The Care Transitions Intervention: Results of a Randomized Controlled Trial

Background: Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates. Methods: Randomized controlled trial. Between […]
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Background: Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates. Methods: Randomized controlled trial. Between September 1, 2002, and August 31, 2003, patients were identified at the time of hospitalization and were randomized to receive the intervention or usual care. The setting was a large integrated delivery system located in Colorado. Subjects (N=750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their preferences, and (3) continuity across settings and guidance from a “transition coach.” Rates of rehospitalization were measured at 30, 90, and 180 days. Results: Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P=.048) and at 90 days (16.7 vs 22.5, P=.04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P=.04) and at 180 days (8.6 vs 13.9, P=.046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P=.049). Conclusion: Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization. Trial Registration: clinicaltrials.gov Identifier: NCT00244491
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http://www.caretransitions.org/documents/The%20CTI%20RCT%20-%20AIM.pdf

August 7, 2019

Transitions of Care Consensus Policy Statement

Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives […]
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Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family-Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. Journal of Hospital Medicine 2009;4:364–370. © 2009 Society of Hospital Medicine.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.510/abstract

August 7, 2019

NQF: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination

Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated […]
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Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated care are particularly evident for people with chronic conditions, such as diabetes and hypertension, and those at high risk for multiple illnesses who often are expected to navigate a complex healthcare system. In this report, NQF has endorsed a portfolio of care coordination preferred practices and performance measures. These standards will provide the structure, process, and outcome measures required to assess progress toward care coordination goals and to evaluate access, continuity, communication, and tracking of patients across providers and settings. Given the high-risk nature of transitions in care, this work will build on ongoing efforts among the medical and surgical specialty societies to establish principles for effective patient hand-offs among clinicians and providers. Measurement and improvement efforts will be upgraded over time as interoperable health information technology (HIT) systems evolve.
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http://www.qualityforum.org/Publications/2010/10/Preferred_Practices_and_Performance_Measures_for_Measuring_and_Reporting_Care_Coordination.aspx

August 7, 2019

NQF Quality Connections, October 2010: Care Coordination

Abstract: Care coordination—a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time—is foundational to high-quality healthcare. All patients, but especially the growing num¬ber of Americans who suffer from multiple chronic con¬ditions, can benefit from […]
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Abstract: Care coordination—a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time—is foundational to high-quality healthcare. All patients, but especially the growing num¬ber of Americans who suffer from multiple chronic con¬ditions, can benefit from care coordination. Care coordi¬nation is an information-rich, patient-centric endeavor that seeks to deliver the right care (and only the right care) to the right patient at the right time. NQF has completed significant work to advance care coordination, including the endorsement of a definition and framework for care coordination; the NQF-convened National Priorities Partnership; the designation of care coordination as one of six “National Priorities” for national action; and the endorsement of preferred practices and performance measures for care coordination. Ultimately, achieving coordinated care will be possible only when healthcare entities collectively agree to place the patient at the center of care.
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http://www.qualityforum.org/Publications/2010/10/Quality_Connections__Care_Coordination.aspx

August 7, 2019

Health Care Leader Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
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http://www.commonwealthfund.org/Publications/Fund-Manuals/2010/Jan/Health-Care-Leader-Action-Guide.aspx

August 7, 2019

Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care JAMA February 28, 2007 297:831-841

Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: […]
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Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection: Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data Extraction: Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Data Synthesis: Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Conclusions: Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
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http://jama.ama-assn.org/cgi/content/abstract/297/8/831

August 7, 2019

Strengthening primary care with better transfer of information CMAJ November 4, 2008 179:987-988

The reality of modern health care is that patients commonly receive care from multiple providers, both physicians and nonphysicians, who often work in disconnected offices and facilities. This makes it a tremendous challenge to connect and integrate a patient’s care into a coherent whole. Widespread lack of information continuity is […]
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The reality of modern health care is that patients commonly receive care from multiple providers, both physicians and nonphysicians, who often work in disconnected offices and facilities. This makes it a tremendous challenge to connect and integrate a patient's care into a coherent whole. Widespread lack of information continuity is troublesome because of the unnecessary tests, medical errors and inconsistent treatment plans that can result.1 The transition from hospital to community care is a particularly vulnerable time when coordination lapses can result in serious adverse events.2
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http://www.cmaj.ca/cgi/content/full/179/10/987

August 7, 2019

Continuity of Care and Intensive Care Unit Use at the End of Life Arch Intern Med January 12, 2009 169:81-86

Background: There is increasing concern about discontinuity of care across transitions (eg, from home to the hospital) and how it might affect appropriate medical management. Methods: We examined changes over time in outpatient-to-inpatient continuity of care in individuals hospitalized with advanced lung cancer and its relationship to end-of-life intensive care […]
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Background: There is increasing concern about discontinuity of care across transitions (eg, from home to the hospital) and how it might affect appropriate medical management. Methods: We examined changes over time in outpatient-to-inpatient continuity of care in individuals hospitalized with advanced lung cancer and its relationship to end-of-life intensive care unit (ICU) use via retrospective analysis of the linked Surveillance, Epidemiology, and End Results–Medicare database. Patients were 21 183 Medicare beneficiaries 66 years or older and diagnosed as having stage IIIB or IV lung cancer between January 1, 1992, and December 31, 2002, who died within a year of diagnosis. Outpatient-to-inpatient continuity of care was defined as an inpatient visit by the patient's usual care provider during the last hospitalization. The primary outcome measure was ICU use during the last hospitalization. Results: Outpatient-to-inpatient continuity decreased from 60.1% in 1992 to 51.5% in 2002 (P < .001). Factors associated with decreased continuity included male sex, black race, low socioeconomic status, being unmarried, treatment by a hospitalist, and treatment in a teaching hospital. Use of the ICU increased by 5.8% per year from 1993 to 2002. After adjustment for patient characteristics, patients with outpatient-to-inpatient continuity of care had a 25.1% reduced odds of entering the ICU during their terminal hospitalization. Conclusions: Outpatient-to-inpatient continuity of care declined during the 1990s and early 2000s. Patients with terminal lung cancer who experienced outpatient-to-inpatient continuity of care were less likely to spend time in the ICU before death.
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http://archinte.ama-assn.org/cgi/content/abstract/169/1/81

August 7, 2019

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ, January 20, 2009; 180 (2). doi:10.1503/cmaj.081491.

Background: Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient’s home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring […]
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Background: Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care. Methods: We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.
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http://www.cmaj.ca/cgi/content/abstract/180/2/175

August 7, 2019

Coordination of Care for Persons With Disabilities Enrolled in Medicaid Managed Care Plans

The purpose of this document is to present a conceptual framework to guide the development of measures of care coordination that would be both feasible to apply and meaningful in assessing the performance of Medicaid managed care organizations (MCOs) that enroll people with disabilities. Although there are no explicitly required […]
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The purpose of this document is to present a conceptual framework to guide the development of measures of care coordination that would be both feasible to apply and meaningful in assessing the performance of Medicaid managed care organizations (MCOs) that enroll people with disabilities. Although there are no explicitly required care coordination systems now in place, some states are providing systems of coordination and doing it with existing resources. This document presents a structure for defining and measuring good care coordination for states that have systems and want to measure them, and for those who may wish to implement systems in the future.
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http://aspe.hhs.gov/daltcp/reports/carecoor.pdf