Non-Skilled LTC

Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a result of medical errors and unsafe situations. Care coordination has been emphasized recently as a strategy for enhancing the effectiveness of care during such necessary transitions. This article describes the issue of care transitions and suggests how case management, through care coordination, can play an important role in ensuring safe and effective care transitions.

August 13, 2019

One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management

Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are […]
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Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a result of medical errors and unsafe situations. Care coordination has been emphasized recently as a strategy for enhancing the effectiveness of care during such necessary transitions. This article describes the issue of care transitions and suggests how case management, through care coordination, can play an important role in ensuring safe and effective care transitions.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx

August 8, 2019

Integrating Care for Populations and Communities

Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers […]
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Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers for Medicare & Medicaid Services (CMS) looks to QIOs to implement community-based projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.
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http://www.cfmc.org/integratingcare/

August 8, 2019

Transitions of Care Performance Measures: Paper by the NTOCC Measures Work Group, 2008

The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality […]
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The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality of care transitions. The multi-disciplinary members of NTOCC work collaboratively to develop policies, tools, and resources as well as recommend actions and protocols to guide and support providers and patients in achieving safe and effective transitions of care.
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http://www.ntocc.org/Portals/0/TransitionsOfCare_Measures.pdf

August 8, 2019

Improving Transitions of Care: The Vision of the National Transitions of Care Coalition

The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient […]
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The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient safety while controlling costs.
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http://www.ntocc.org/Portals/0/PolicyPaper.pdf

August 8, 2019

Institute for Healthcare Improvement

The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for […]
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The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.
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http://www.ihi.org

August 7, 2019

Evercare Care Model

Evercare Care Model is a primary care team model in which nurse practitioners provide intensive primary and preventive care to individuals with long-term conditions or disabilities.
Evercare Care Model is a primary care team model in which nurse practitioners provide intensive primary and preventive care to individuals with long-term conditions or disabilities.
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http://www.innovativecaremodels.com/care_models/17

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

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

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

Improving the Quality of Transitional Care for Persons with Complex Care Needs. American Geriatrics Society (AGS) Position Statement.

American Geriatrics Society. Improving the Quality of Transitional Care for Persons with Complex Care Needs. American Geriatrics Society (AGS) Position Statement. Journal of the American Geriatrics Society. 2007;51(4): 556-557. http://www.caretransitions.org/documents/Improving%20the%20quality%20-%20JAGS. Pdf. Published March 2007. Accessed August 7, 2014. The assisted living (AL) setting is subject to multiple transitional care points. […]
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American Geriatrics Society. Improving the Quality of Transitional Care for Persons with Complex Care Needs. American Geriatrics Society (AGS) Position Statement. Journal of the American Geriatrics Society. 2007;51(4): 556-557. http://www.caretransitions.org/documents/Improving%20the%20quality%20-%20JAGS. Pdf. Published March 2007. Accessed August 7, 2014. The assisted living (AL) setting is subject to multiple transitional care points. Each transition is an opportunity for a collaborative, multidisciplinary process. Of course, this can only occur with careful planning at both ends of the transition. For this process to be successful, a coordinated system involving several members of the multidisciplinary team is required. One important component of ensuring a successful process is open, regular communication with all the critical channels. By having a point person in the AL facility serve as the liaison and educator between each channel, a successful transitional care process can be achieved.
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http://www.caretransitions.org/documents/Improving%20the%20quality%20-%20JAGS.pdf