National Hospice and Palliative Care Organization. Caring Connections. [Web site]. Accessed July 31, 2014. Caring Connections provides people with information and support when they are planning ahead, caring for a loved one, living with an illness or grieving a loss.

August 7, 2019

Caring Connections

National Hospice and Palliative Care Organization. Caring Connections. [Web site]. Accessed July 31, 2014. Caring Connections provides people with information and support when they are planning ahead, caring for a loved one, living with an illness or grieving a loss.
National Hospice and Palliative Care Organization. Caring Connections. [Web site]. Accessed July 31, 2014. Caring Connections provides people with information and support when they are planning ahead, caring for a loved one, living with an illness or grieving a loss.
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http://www.caringinfo.org/

August 7, 2019

Transition Home Program for Patients with Heart Failure

AHRQ. Agency for Healthcare Research and Quality. Transition Home Program for Patients with Heart Failure http://innovations.ahrq.gov/content.aspx?id=2206. Accessed August 13, 2014. Summary The Transition Home for Patients with Heart Failure program at St. Luke’s Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to […]
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AHRQ. Agency for Healthcare Research and Quality. Transition Home Program for Patients with Heart Failure http://innovations.ahrq.gov/content.aspx?id=2206. Accessed August 13, 2014. Summary The Transition Home for Patients with Heart Failure program at St. Luke's Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to home or another health care setting. These components include an ongoing enhanced assessment of postdischarge needs, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handovers, and a standardized process for postacute care followup. The program reduced the 30-day heart-failure-to-heart-failure readmission rate for patients from 14 to 6 percent, and the all-cause heart failure readmission rate is 15 to 17 percent. See the Description section for several updates related to ongoing assessment and patient education; the Results section for updated data on readmission rate and patient satisfaction; and the Planning and Development section for new information about spread to other conditions and an Advance Medical Team pilot (updated February 2013).
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http://innovations.ahrq.gov/content.aspx?id=2206

August 7, 2019

What is the Patient-Centered Medical Home?

A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other […]
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A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.
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http://www.acponline.org/running_practice/pcmh/understanding/what.htm

August 7, 2019

Development and Testing of a Measure Designed to Assess the Quality of Care Transitions.

Coleman E, Smith J, Frank, J, et.al. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration.2002;2. http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf . Accessed August 1, 2014. Results: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct […]
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Coleman E, Smith J, Frank, J, et.al. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration.2002;2. http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf . Accessed August 1, 2014. Results: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct validity was assessed by comparing items from the CTM to selected items from a measure developed by Hendriks and colleagues (Medical Care 2001; 39(3): 270–283). Inter-item Spearman correlations ranged 0.388–0.594. No significant floor or ceiling effects were detected. Conclusions: The CTM was developed with substantial input from older patients and their caregivers. Psychometric testing suggested that the measure was valid. The CTM may serve to fill an important gap in health system performance evaluation by measuring the quality of care delivered across settings.
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http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf

August 7, 2019

New Design for Discharge: The Hospitalist, November 2010

Four-part process improves patient outcomes, lowers readmission rates With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower […]
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Four-part process improves patient outcomes, lowers readmission rates With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.
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http://www.the-hospitalist.org/details/article/182425/New_Design_for_Discharge.html

August 7, 2019

The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care

A policy paper providing proposals for resolving some of the major problems with the health care system in America was released today by The American College of Physicians (ACP) at its annual report on “The State of the Nation’s Health Care.” “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of […]
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A policy paper providing proposals for resolving some of the major problems with the health care system in America was released today by The American College of Physicians (ACP) at its annual report on "The State of the Nation's Health Care." "The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care," proposes a fundamental change in the way that principal - or primary care - is delivered and financed. "ACP proposals would provide patients with access to care that is coordinated by their own personal physician," explained C. Anderson Hedberg, ACP president. "The physicians will be working in a practice environment organized around patients' needs." The paper recommends voluntary certification and recognition of primary care and specialty medical practices that use health information technology, quality measurement and reporting, patient-friendly scheduling systems and other "best practices" to deliver better value and improve care coordination for patients, especially those with multiple chronic illnesses.
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http://www.acponline.org/pressroom/admed_home.htm

August 7, 2019

The Medicare Physician Group Practice Demonstration: Lessons Learned on Improving Quality and Efficiency in Health Care

ABSTRACT: In April 2005, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Group Practice demonstration, which offers 10 large practices the opportunity to earn performance payments for improving the quality and cost-efficiency of health care delivered to Medicare fee-for-service beneficiaries. This report is based on the proceedings […]
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ABSTRACT: In April 2005, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Group Practice demonstration, which offers 10 large practices the opportunity to earn performance payments for improving the quality and cost-efficiency of health care delivered to Medicare fee-for-service beneficiaries. This report is based on the proceedings of a 2006 site conference held in Baltimore and cosponsored by The Commonwealth Fund, CMS, and the Agency for Healthcare Research and Quality. The meeting provided a forum for PGPs to: 1) explore specific care management models, including methods for implementation and assessment of effectiveness; 2) accelerate learning across PGPs through information sharing; and 3) harvest knowledge and develop a plan for case studies and descriptive reports on successful care management models. A number of promising practice changes were discussed, such as increasing patient engagement, expanding care management, improving care transitions, and expanding non-physician roles.
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http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Feb/The-Medicare-Physician-Group-Practice-Demonstration--Lessons-Learned-on-Improving-Quality-and-Effici.aspx

August 7, 2019

Improving Care Transitions and Reducing Hospital readmissions: Establishing the Evidence for Community-Based Implementation Strategies Through the Care Transitions Theme

The Care Transitions Theme is a CMS-funded initiative for Medicare Quality Improvement Organizations (QIOs) to measurably improve the quality of care for Medicare Beneficiaries who transition among care settings through a comprehensive community effort. Fourteen QIOs began working with target communities within their respective States on August 1st, 2008, and […]
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The Care Transitions Theme is a CMS-funded initiative for Medicare Quality Improvement Organizations (QIOs) to measurably improve the quality of care for Medicare Beneficiaries who transition among care settings through a comprehensive community effort. Fourteen QIOs began working with target communities within their respective States on August 1st, 2008, and the project will be completed by August 2011. Each QIO selected a specific geographic area and a Medicare beneficiary population (as defined by beneficiary zip code of residence) where they are now working with the medical services providers, other community health support agencies, unpaid caregivers and patients to identify drivers of poor transitional care and to reduce their influence on patient outcomes. In other words, this work seeks to improve care quality by promoting seamless transitions among care settings, and thereby reduce readmissions to hospitals within 30 days of discharge.
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http://www.cfmc.org/integratingcare/files/Care_Transition_Article_Remington_Report_Jan_2010.pdf

August 7, 2019

Medicare Hospital Readmissions: Issues and Policy Options. A report by the Congressional Research Service.

This report is intended to help Congress address the complex issue of hospital readmissions. It is largely conceptual and does not track legislation moving through the House and Senate.4 After helping to define the issues, this report discusses some of the diverse causes of hospital readmissions. It also provides a […]
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This report is intended to help Congress address the complex issue of hospital readmissions. It is largely conceptual and does not track legislation moving through the House and Senate.4 After helping to define the issues, this report discusses some of the diverse causes of hospital readmissions. It also provides a summary of approaches used to distinguish which hospital readmissions might be preventable. Finally, to help Congress evaluate strategies to reduce readmissions, this report includes a discussion of various strategies to lower the incidence of Medicare-covered hospital readmissions.
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http://www.fah.org/fahCMS/Documents/On%20The%20Record/Research/2009/CRS_Medicare_Hospital_Readmissions_report.pdf

August 7, 2019

Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices

BACKGROUND Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination. OBJECTIVES We examine whether and how practices use commercial EMRs to […]
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BACKGROUND Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination. OBJECTIVES We examine whether and how practices use commercial EMRs to support coordination tasks and identify work-arounds practices have created to address new coordination challenges. DESIGN, SETTING Semi-structured telephone interviews in 12 randomly selected communities. PARTICIPANTS Sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders. RESULTS Six major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs’ potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity). CONCLUSIONS There is a gap between policy-makers’ expectation of, and clinical practitioners’ experience with, current electronic medical records’ ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.
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http://www.springerlink.com/content/j02w23143245j24r/