Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, a program called Transitions Home is addressing these concerns for patients with heart failure. By providing self-management support for patients at home, the hospital is reducing its rate of readmissions for heart failure patients. The program includes a combination of patient-friendly written information along with a home visit from a nurse, a physician office visit, and follow-up telephone calls. There are also weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support.

August 7, 2019

St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge

Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s […]
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Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, a program called Transitions Home is addressing these concerns for patients with heart failure. By providing self-management support for patients at home, the hospital is reducing its rate of readmissions for heart failure patients. The program includes a combination of patient-friendly written information along with a home visit from a nurse, a physician office visit, and follow-up telephone calls. There are also weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support.
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http://www.ihi.org/knowledge/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx

August 7, 2019

IHI Collaborative: Hospital to home, Optimizing the Transition

IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve […]
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IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve workflow using ideas that have been tested on the discharges of patients with heart failure (HF) on medical-surgical units. Upon completion of this Web&ACTION, participants will be able to: • Reduce unplanned admissions for patients with heart failure • Understand and collect key data regarding hospital readmissions • Describe and test top ideas for reducing heart failure readmissions to hospitals • Increase patient involvement in their care while in the hospital and after discharge
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http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx

August 7, 2019

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their […]
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The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2006.00791.x/abstract

August 7, 2019

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient’s care on an ongoing basis through regular telephone and in-person contact with both patients and […]
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Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits and hospital admissions; and generated high levels of physician and patient satisfaction. A recent analysis found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year three. Strong: The evidence consists of a randomized controlled trial (RCT) of 951 patients that compared results for program participants with patients receiving usual care on a variety of metrics (including functional status, activity of daily living status, ED and hospital use, and patient and physician satisfaction).
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http://www.innovations.ahrq.gov/content.aspx?id=2066

August 7, 2019

Groups Focus On Cutting Hospital Readmission Of Medicare Patients

Medicare Quality Improvement Organizations (QIOs) in the states began work last year on the three-year projects aimed at improving readmission rates. These organizations are the Alabama Quality Assurance Foundation, the Louisiana Health Care Review and the Georgia Medical Care Foundation. These QIOs are independent organizations that contract with CMS to […]
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Medicare Quality Improvement Organizations (QIOs) in the states began work last year on the three-year projects aimed at improving readmission rates. These organizations are the Alabama Quality Assurance Foundation, the Louisiana Health Care Review and the Georgia Medical Care Foundation. These QIOs are independent organizations that contract with CMS to improve care. They are examining hospital and community systemwide interventions, interventions that target specific diseases or conditions and interventions that target specific reasons for admission.
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http://www.eqhealthsolutions.com/LinkClick.aspx?fileticket=rJj5n1tRPXw%3D&tabid=99

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