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.

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

Nursing Home Special Study: Reducing Avoidable Hospitalizations of Nursing Home residents—Framework for Pilot Testing Interventions to Reduce Acute Care Transfers of Nursing Home Residents

This pilot project is a part of a special study supported by CMS. The special study is being conducted by Georgia Medical Care Foundation (GMCF), the Medicare Quality Improvement Organization (QIO) for Georgia. The main goal of the special study is to develop and implement strategies and tools that will […]
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This pilot project is a part of a special study supported by CMS. The special study is being conducted by Georgia Medical Care Foundation (GMCF), the Medicare Quality Improvement Organization (QIO) for Georgia. The main goal of the special study is to develop and implement strategies and tools that will reduce potentially avoidable acute care transfers (ACT) from nursing homes. The INTERACT TOOL KIT (INTERventions to reduce Acute Care Transfers) will be implemented using a Collaborative Framework similar to the model developed by IHI. The tool kit will be refined as the result of this pilot project, and disseminated nationally to assist nursing homes in the U.S. to reduce potentially avoidable ACT.
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http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=3&ved=0CE0QFjAC&url=http%3A%2F%2Fwww.qualitynet.org%2Fdcs%2FBlobServer%3Fblobkey%3Did%26blobwhere%3D1228861423145%26blobheader%3Dapplication%252Fpdf%26blobheadername1%3DContent-Dispos

August 7, 2019

Patient Care Link: State Action on Avoidable Rehospitalizations Initiative (STARR)

The PatientCareLink Mission: To help participating hospitals provide transparent staffing and patient safety information to the public and other healthcare stakeholders, and also offer valid and reliable information on quality and safety to patients and healthcare workers alike. A multi-state project involving 53 hospitals, STARR was launched by the Institute […]
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The PatientCareLink Mission: To help participating hospitals provide transparent staffing and patient safety information to the public and other healthcare stakeholders, and also offer valid and reliable information on quality and safety to patients and healthcare workers alike. A multi-state project involving 53 hospitals, STARR was launched by the Institute of Healthcare Improvement (IHI) in May 2009 with grant funding from The Commonwealth Fund. 22 Massachusetts hospitals are enrolled in the initiative. To date, participating hospitals have formed cross-continuum teams and submitted baseline 30-day readmission rates. Now they are busy determining how to improve the patient's transition from hospital to post-acute setting.
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http://www.patientcarelink.org/improving-patient-care/readmissions/state-action-on-avoidable-rehospitalizations-initiative-staar.aspx

August 7, 2019

Project Boost: Reducing Unnecessary Readmissions and So Much More

Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a quality improvement toolkit, backed by evidence-based research, to enhance the care of patients transitioning from the hospital to home. Project BOOST helps hospitals better manage patient discharge—a chaotic process at most facilities— leading to better patient care by […]
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Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a quality improvement toolkit, backed by evidence-based research, to enhance the care of patients transitioning from the hospital to home. Project BOOST helps hospitals better manage patient discharge—a chaotic process at most facilities— leading to better patient care by reducing readmission rates, improving patient and family preparation for discharge, enhancing patient satisfaction, and much more.
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http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/BOOST_Presentation_St_Mary's_Handout.pdf

August 7, 2019

ABIM Summer Forum: Coordination of Care: Is There a Missed Opportunity?

ABIM. Coordination of Care. Missed Opportunity? The 2007 ABIM Foundation Summer Forum. http://www.abimfoundation.org/~/media/care_coordination.ashx. Published 2007. Accessed September 24, 2014. The 2007 ABIM Foundation Summer Forum , August 4 – 7, 2007, convened more than 130 healthcare leaders who addressed the topic Coordination of Care: Missed Opportunity? Presented here are illustrations […]
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ABIM. Coordination of Care. Missed Opportunity? The 2007 ABIM Foundation Summer Forum. http://www.abimfoundation.org/~/media/care_coordination.ashx. Published 2007. Accessed September 24, 2014. The 2007 ABIM Foundation Summer Forum , August 4 – 7, 2007, convened more than 130 healthcare leaders who addressed the topic Coordination of Care: Missed Opportunity? Presented here are illustrations to each of the Forum’s sessions. The illustrations graphically capture the key insights, observations and commentary shared by facilitators, moderators and participants during each of the Forum’s sessions.
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http://www.abimfoundation.org/~/media/care_coordination.ashx

August 7, 2019

PtC3: Patient-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. 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

Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program

The hospital discharge is nonstandardized and marked with poor quality. One in five hospital discharges is complicated by an adverse event (AE) within 30 days, many of which lead to emergency department visits and rehospitalizations. Methods: Using an iterative group process, we developed the principles and components of the ReEngineered […]
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The hospital discharge is nonstandardized and marked with poor quality. One in five hospital discharges is complicated by an adverse event (AE) within 30 days, many of which lead to emergency department visits and rehospitalizations. Methods: Using an iterative group process, we developed the principles and components of the ReEngineered Discharge (RED), a set of 11 distinct components designed to prepare patients for discharge. Three tools were created: a training manual used to train discharge nurses to provide the RED; an individualized, patient-friendly “After Hospital Care Plan” (AHCP), a booklet used to prepare patients for discharge; and a workstation to integrate all pertinent discharge information used to electronically create the AHCP. Outcomes: The RED was adopted by the National Quality Forum (NQF) as one of their “Safe Practices.” Among the intervention subjects, 89 percent were provided with an AHCP at discharge; it required approximately 1 hour for the discharge advocate to provide the RED intervention. Implications: Use of the AHCP tool can effectively prepare patients for discharge, as recommended by NQF 2006 Safe Practice number 11. These results have important implications for quality of care at discharge and for lowering costs.
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http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Jack_28.pdf

August 7, 2019

Shared Care Plan

Shared Care Plan.Sharedcareplan.org. [Tool]. https://www.sharedcareplan.org/OtherPages/Phms.aspx. Published [No Date Specified]. Updated 2013. Accessed December 11, 2014. The Shared Care Plan is a free, easy-to-use, Shared Care Plan record that lets you organize and store vital health information. You can share this information with your family, physicians and others you feel should […]
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Shared Care Plan.Sharedcareplan.org. [Tool]. https://www.sharedcareplan.org/OtherPages/Phms.aspx. Published [No Date Specified]. Updated 2013. Accessed December 11, 2014. The Shared Care Plan is a free, easy-to-use, Shared Care Plan record that lets you organize and store vital health information. You can share this information with your family, physicians and others you feel should have access to this information. The Shared Care Plan is also much more — it is a self-management care plan, improving your understanding of your own health. It can help you manage chronic conditions, coordinate the care of others, and improve your health. Whether you are living with a chronic condition or are a healthy athlete, the Shared Care Plan can benefit you.
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https://www.sharedcareplan.org/OtherPages/Phms.aspx

August 7, 2019

Administration On Aging

The mission of AoA is to develop a comprehensive, coordinated and cost-effective system of home and community-based services that helps elderly individuals maintain their health and independence in their homes and communities.
The mission of AoA is to develop a comprehensive, coordinated and cost-effective system of home and community-based services that helps elderly individuals maintain their health and independence in their homes and communities.
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http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/index.aspx

August 7, 2019

Organizing the U.S. Health Care Delivery System for High Performance

The Commonwealth Fund. Organizing the U.S. Health Care Delivery System for High Performance. http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf. Published August 2008. Accessed December 11, 2014. This report from The Commonwealth Fund Commission on a High Performance Health System examines fragmentation in our health care delivery system and offers policy recommendations to stimulate greater organization—established […]
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The Commonwealth Fund. Organizing the U.S. Health Care Delivery System for High Performance. http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf. Published August 2008. Accessed December 11, 2014. This report from The Commonwealth Fund Commission on a High Performance Health System examines fragmentation in our health care delivery system and offers policy recommendations to stimulate greater organization—established mechanisms for working across providers and care settings. Fragmentation fosters frustrating and dangerous patient experiences, especially for patients obtaining care from multiple providers in a variety of settings. It also leads to waste and duplication, hindering providers’ ability to deliver high-quality, efficient care. Moreover, our fragmented system rewards high-cost, intensive medical intervention over higher-value primary care, including preventive medicine and the management of chronic illness. The solutions are complex and will require new financial incentives, changes to the regulatory, professional, and educational environments, and support for new infrastructure. But as a nation, we can no longer tolerate the status quo of poor health system performance. Greater organization is a critical step on the path to higher performance.
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http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf