August 7, 2019

NTOCC Transitions of Care Checklist

This list provides a detailed description of effective patient transfer between practice settings. Implementing this process developed by NTOCC can help to ensure that patients and their critical medical information are transferred safely, timely, and efficiently.
This list provides a detailed description of effective patient transfer between practice settings. Implementing this process developed by NTOCC can help to ensure that patients and their critical medical information are transferred safely, timely, and efficiently.
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http://www.ntocc.org/Portals/0/TOC_Checklist.pdf

August 7, 2019

NTOCC Taking Care of MY Health Care (French)

French Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved […]
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French Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and at the minimum to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
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http://www.ntocc.org/Portals/0/Taking_Care_Of_My_Health_Care_French.pdf

August 7, 2019

NTOCC Taking Care of MY Health Care (Spanish)

Spanish Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved […]
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Spanish Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and at the minimum to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
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http://www.ntocc.org/Portals/0/Taking_Care_Of_My_Health_Care_Spanish.pdf

August 7, 2019

PtC3: Centered Coordinated Care

The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in […]
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The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in America will soon become unsustainably expensive (Box 1).2 The answer may be Patient-Centered Coordinated Care (PtC3). PtC3 is an assessment-based interdisciplinary approach to integrating health care and social support services in which a patient’s individual needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored through a high touch approach.
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http://www.medicarepatientmanagement.com/issues/04-03/mpmMJ09-CareCoordination.pdf

August 7, 2019

NTOCC Taking Care of MY Health Care (English)

Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September […]
Read More
Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and at the minimum to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
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http://www.ntocc.org/Portals/0/Taking_Care_Of_My_Health_Care.pdf

August 7, 2019

Aging and Disability Resource Center (ADRC) Development and LTC Options

The Aging and Disability Resource Center Program (ADRC), a collaborative effort of AoA and the Centers for Medicare & Medicaid Services (CMS), is designed to streamline access to long-term care. The ADRC program provides states with an opportunity to effectively integrate the full range of long-term supports and services into […]
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The Aging and Disability Resource Center Program (ADRC), a collaborative effort of AoA and the Centers for Medicare & Medicaid Services (CMS), is designed to streamline access to long-term care. The ADRC program provides states with an opportunity to effectively integrate the full range of long-term supports and services into a single, coordinated system. By simplifying access to long-term care systems, ADRCs and other single point of entry (SEP) systems are serving as the cornerstone for long-term care reform in many states.
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http://www.aoa.gov/AoAroot/AoA_Programs/HCLTC/ADRC/index.aspx

August 7, 2019

NTOCC Informational Slidedeck

Download this presentation to learn more about how transitions of care impact your safety and how NTOCC is working to ensure improved transitions for you and your family.
Download this presentation to learn more about how transitions of care impact your safety and how NTOCC is working to ensure improved transitions for you and your family.
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http://www.ntocc.org/Portals/0/Consumer.pps

August 7, 2019

Chronic care Coordination Program

The Chronic Care Coordination (CCC) program has resulted in significant cost savings for KP Colorado. An analysis of services and care costs for patients in the six months prior to enrolling in CCC and in the six months following enrollment in CCC yielded $1900 savings per patient per year (as […]
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The Chronic Care Coordination (CCC) program has resulted in significant cost savings for KP Colorado. An analysis of services and care costs for patients in the six months prior to enrolling in CCC and in the six months following enrollment in CCC yielded $1900 savings per patient per year (as a result of decreased hospitalizations, SNF admissions, and ED visits).
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http://www.innovativecaremodels.com/care_models/13/results

August 7, 2019

Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up

BACKGROUND The transition between the inpatient and outpatient setting is a high-risk period for patients. The presence and role of the primary care provider (PCP) is critical during this transition. This study evaluated characteristics and outcomes of discharged patients lacking timely PCP follow-up, defined as within 4 weeks of discharge. […]
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BACKGROUND The transition between the inpatient and outpatient setting is a high-risk period for patients. The presence and role of the primary care provider (PCP) is critical during this transition. This study evaluated characteristics and outcomes of discharged patients lacking timely PCP follow-up, defined as within 4 weeks of discharge. METHODS This prospective cohort enrolled 65 patients admitted to University of Colorado Hospital, an urban 425-bed tertiary care center. We collected patient demographics, diagnosis, payer source and PCP information. Post-discharge phone calls determined PCP follow-up and readmission status. Thirty-day readmission rate and hospital length of stay (LOS) were compared in patients with and without timely PCP follow-up. RESULTS The rate of timely PCP follow-up was 49%. For a patient's same medical condition, the 30-day readmission rate was 12%. Patients lacking timely PCP follow-up were 10 times more likely to be readmitted (odds ratio [OR] = 9.9, P = 0.04): 21% in patients lacking timely PCP follow-up vs. 3% in patients with timely PCP follow-up, P = 0.03. Lack of insurance was associated with lower rates of timely PCP follow-up: 29% vs. 56% (P = 0.06), but did not independently increase readmission rate or LOS (OR = 1.0, P = 0.96). Index hospital LOS was longer in patients lacking timely PCP follow-up: 4.4 days vs. 6.3 days, P = 0.11. CONCLUSIONS Many patients discharged from this large urban academic hospital lacked timely outpatient PCP follow-up resulting in higher rates of readmission and a non-significant trend toward longer hospital LOS. Effective transitioning of care for vulnerable patients may require timely PCP follow-up.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.666/abstract

August 7, 2019

Transition of care for hospitalized elderly patients–development of a discharge checklist for hospitalists

BACKGROUND Discharge from the hospital is a critical transition point in a patient’s care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of […]
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BACKGROUND Discharge from the hospital is a critical transition point in a patient's care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of the discharge process may help to address the gaps in quality and safety that occur when patients transition from the hospital to an outpatient setting. METHODS The Society of Hospital Medicine's Hospital Quality and Patient Safety committee assembled a panel of care transition researchers, process improvement experts, and hospitalists to review the literature and develop a checklist of processes and elements required for ideal discharge of adult patients. The discharge checklist was presented at the Society of Hospital Medicine's Annual Meeting in April 2005, where it was reviewed and revised by more than 120 practicing hospitalists and hospital-based nurses, case managers, and pharmacists. The final checklist was endorsed by the Society of Hospital Medicine. RESULTS The finalized checklist is a comprehensive list of the processes and elements considered necessary for optimal patient handoff at hospital discharge. This checklist focused on medication safety, patient education, and follow-up plans. CONCLUSIONS The development of content and process standards for discharge is the first step in improving the handoff of care from the inpatient to the posthospital setting. Refining this checklist for patients with specific diagnoses, in specific age categories, and with specific discharge destinations may further improve information transfer and ultimately affect patient outcomes.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.129/abstract