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.

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

August 7, 2019

Promising Models of Care Coordination/care Management For Beneficiaries With Chronic Illnesses

Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare
Presentation Goals: • Define Care Coordination/Care Management • Identify proven care coordination/management interventions for beneficiaries with chronic illnesses • Describe key distinguishing features of these programs • Describe external and internal evaluation parameters • Suggest policy implications for Medicaid and Medicare
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http://socialwork.nyam.org/mwg-internal/de5fs23hu73ds/progress?id=1/DIeJ7cnT

August 7, 2019

Effect of a Hospitalist-Care Coordinator Team on a Nonteaching Hospitalist Service.

O’Leary K, Lindquist L, Colone MA, et al. Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service. J Hosp Med. 2008 Mar;3(2):103-9.http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract. Accessed December 11, 2014. BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to […]
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O'Leary K, Lindquist L, Colone MA, et al. Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service. J Hosp Med. 2008 Mar;3(2):103-9.http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract. Accessed December 11, 2014. BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to evaluate the impact of a hospitalist-care coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency. DESIGN AND PARTICIPANTS: During each of 12 weeks, hospitalists on a nonteaching hospitalist service were randomly assigned to work with a hospitalist care coordinator (HCC) or to work independently. MEASUREMENTS: Each week hospitalists completed a survey to assess their satisfaction and perceived work efficiency. Patient satisfaction with hospital discharge was assessed by telephone interviews. Hospital efficiency was analyzed with multivariate linear regression using log-transformed length of stay (LOS) and cost as dependent variables. RESULTS: The 356 patients cared for by hospitalist-HCC teams were similar to 337 patients cared for by control hospitalists. Twenty-eight of 31 hospitalists (90%) who worked with an HCC responded that the HCC improved their efficiency and job satisfaction. Seventy-one of 196 eligible patients (36%) completed the postdischarge interview. The mean ratings of overall satisfaction with hospital discharge on a scale of 10 were similarly high in both groups (8.57 vs. 8.37; P = .94). In multivariate regression analyses, LOS was 0.28 days shorter and cost was $585.62 lower for patients cared for by hospitalist-HCC teams; however, these results were not statistically significant (P = .17 and .15, respectively). CONCLUSIONS: Hospitalists working in a team approach with an HCC reported improved efficiency and job satisfaction compared with hospitalists working independently. These findings are important in light of growing concerns about hospitalist workload and job satisfaction.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.280/abstract

August 7, 2019

Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients

This special report is based on an in-depth analysis of responses from nearly 100 healthcare organizations to the 2009 Healthcare Intelligence Network Industry Survey, “Managing care Transitions,” as well as selected case studies of care transition management programs.
This special report is based on an in-depth analysis of responses from nearly 100 healthcare organizations to the 2009 Healthcare Intelligence Network Industry Survey, “Managing care Transitions,” as well as selected case studies of care transition management programs.
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http://hin.3dcartstores.com/Retooling-Care-Transitions-to-Reduce-Hospitalizations-in-Medicare-Patients_p_3925.html

August 7, 2019

Pharmacy Team Providing Enhanced Services to a Transitional Care Unit.

Boord A, Sanders S, Bass L, et al. Pharmacy Team Providing Enhanced Services to a Transitional Care Unit. Am J Health Syst Pharm. 2007;64(6):647-651. http://www.medscape.com/viewarticle/555610_1. Accessed December 11, 2014. The development of a pharmacy team to evaluate patients admitted to the TCU resulted in improved patient care and outcomes. One […]
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Boord A, Sanders S, Bass L, et al. Pharmacy Team Providing Enhanced Services to a Transitional Care Unit. Am J Health Syst Pharm. 2007;64(6):647-651. http://www.medscape.com/viewarticle/555610_1. Accessed December 11, 2014. The development of a pharmacy team to evaluate patients admitted to the TCU resulted in improved patient care and outcomes. One of the team's most important contributions is the virtual elimination of medication errors following the implementation of computerized transfer orders.
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http://www.medscape.com/viewarticle/555610_1

August 7, 2019

Quality Matters Newsletter: In Focus: Toward a System of Coordinated Care

Hostetter M. In Focus: Toward a System of Coordinated Care. Quality Matters. The Commonwealth Fund.http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june.Published May/June 2007. Accessed December 11, 2014. The care of many patients lacks necessary oversight and continuity, particularly during transitions among health care providers and settings. Current efforts to improve care coordination focus on patient coaching […]
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Hostetter M. In Focus: Toward a System of Coordinated Care. Quality Matters. The Commonwealth Fund.http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june.Published May/June 2007. Accessed December 11, 2014. The care of many patients lacks necessary oversight and continuity, particularly during transitions among health care providers and settings. Current efforts to improve care coordination focus on patient coaching and tracking of high-risk groups, but widespread reform will require changes to the financing of care delivery and other system-wide changes
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http://www.commonwealthfund.org/publications/newsletters/quality-matters/2007/may-june

August 7, 2019

Guided Care Patient-Centered Medical Home

Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is […]
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Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information technology to provide state-of-the-art care for 50-60 chronically ill Medicare beneficiaries. Following a comprehensive assessment and planning process, the Guided Care nurse educates and empowers patients and families, monitors their conditions monthly, and coordinates the efforts of health care professionals, hospitals and community agencies to be sure that no important health-related need slips through the cracks
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http://www.guidedcare.org/pdf/Guided%20Care%20summary%20and%20results.pdf