Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and HIT strategies

August 7, 2019

Care Cooperation and Continuity Across Clinicians, Facilities and Systems: Massachusetts Strategic Plan for Care Transitions

Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and […]
Purpose: To create a “living document” that: – Creates a vision for optimal transitions in care for everyone in Massachusetts – Sets broad goals and actionable steps that will lead to implementation To ensure that this work is aligned with related state and federal health care, payment reform efforts and HIT strategies
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http://www.iom.edu/~/media/Files/Activity%20Files/Quality/VSRT/16-Care%20cooperation%20and%20continuity.ashx

August 7, 2019

AARP: Advance Directives: Planning for the Future

AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one’s health care wishes are at the end of life? Find out how advance directives can help.
AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one's health care wishes are at the end of life? Find out how advance directives can help.
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http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html

August 7, 2019

AARP: Talking About Your Final Wishes

AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do […]
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AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do I want to die? Who will take care of me? What do I have to do to achieve a "good death?" These questions raise just a few of the issues to be considered in deciding your care at the end of life.
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http://www.aarp.org/relationships/grief-loss/info-2003/endoflife-finalwishes.html

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

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

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