The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations–The Care Transitions Intervention–could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.

August 7, 2019

Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations–The Care Transitions Intervention–could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for […]
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The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations--The Care Transitions Intervention--could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.
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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20182958

August 7, 2019

Care Continuum Alliance

We believe the highest achievable health status is attained through the promotion and alignment of population health improvement by: • Promoting a proactive, patient-centric focus across the care continuum; • Convening health care professionals across the care continuum to share and integrate practice models; • Emphasizing the importance of both […]
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We believe the highest achievable health status is attained through the promotion and alignment of population health improvement by: • Promoting a proactive, patient-centric focus across the care continuum; • Convening health care professionals across the care continuum to share and integrate practice models; • Emphasizing the importance of both healthful behaviors and evidence-based care in preventing and managing chronic conditions; • Promoting high quality standards for and definitions of key components of wellness, disease and, where appropriate, case management, and care coordination programs as well as support services and materials; • Identifying, researching, sharing and encouraging innovative approaches and best practices care delivery and reimbursement models; • Establishing consensus-based outcomes measures and demonstrating health, satisfaction, and financial improvements achieved through wellness, disease and case management, and care coordination programs; • Supporting delivery system models that assure appropriate care for chronic conditions and coordination among all health care providers including strategies such as the Chronic Care Model, the physician-led medical home concept, and the disease management model; • Encouraging the widespread adoption and interoperability of health information technologies; • Advocating the principles and benefits of population health improvement to public health officials, including state and federal government entities; • Underscoring the level of commitment to population health improvement and timeframes necessary to realize the full benefits.
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http://www.carecontinuum.org/

August 7, 2019

The Patient Education Forum: Transitional Care—Eric Coleman

Q. What is transitional care? A. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. “Transitional Care” refers to when they move across settings. When they “transition” they often are treated by many different health care […]
Q. What is transitional care? A. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. “Transitional Care” refers to when they move across settings. When they “transition” they often are treated by many different health care professionals.
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http://eldercare.health-first.org/docs/forums/transitional_care.pdf

August 7, 2019

Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial; Journal of the American Geriatrics Society. 52:675–684, 2004

A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.
A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2004.52202.x/abstract

August 7, 2019

Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart Failure; JAMA. 2004;291:1358-1367

Conclusion Comprehensive discharge planning plus post-discharge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
Conclusion Comprehensive discharge planning plus post-discharge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
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http://jama.ama-assn.org/cgi/content/abstract/291/11/1358

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

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

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

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

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