Stroke

The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission. The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts. This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care. The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.

August 16, 2019

Improving Care Transitions: A Key Component of Health Reform

The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk […]
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The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission. The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts. This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care. The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.
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https://www.healthaffairs.org/do/10.1377/hblog20100429.004893/full/

August 13, 2019

Principles of the Patient-Centered Medical Home and Preventive Services Delivery

Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF.Principles of the Patient-Centered Medical Home and Preventive Services Delivery. Annals of Family Medicine.2010.8(2): 108-116.http://www.annfammed.org/content/8/2/108.abstract. Accessed April 26, 2013. PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed […]
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Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF.Principles of the Patient-Centered Medical Home and Preventive Services Delivery. Annals of Family Medicine.2010.8(2): 108-116.http://www.annfammed.org/content/8/2/108.abstract. Accessed April 26, 2013. PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services. METHODS We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling. RESULTS Higher global PCMH scores were associated with receipt of preventive services (β=2.3; P <.001). Positive associations were found with principles of personal physician (β=3.7; P <.001), in particular, continuity with the same physician (β=4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (β=5.6; P <.001), particularly, having a well-visit within 5 years (β=12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (β = 8.0; P <.001) and use of clinical decision-support tools (β = 5.0; P = .04) were also associated with receipt of preventive services. CONCLUSIONS Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.
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http://www.annfammed.org/content/8/2/108.abstract

August 13, 2019

One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management

Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are […]
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Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a result of medical errors and unsafe situations. Care coordination has been emphasized recently as a strategy for enhancing the effectiveness of care during such necessary transitions. This article describes the issue of care transitions and suggests how case management, through care coordination, can play an important role in ensuring safe and effective care transitions.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx

August 8, 2019

Transforming Care at the Bedside: She’s Got a Ticket to Go Home

Institute for Healthcare Improvement. She’s Got a Ticket To Go Home. http://www.ihi.org/resources/Pages/ImprovementStories/ShesGotaTicketToGoHome.aspx . Updated 2014. Accessed July 25, 2014. In March 2004, the staff at Virginia Mason Medical Center (VMMC) in Seattle, Washington, decided there was a better way to keep patients and families informed and engaged with the discharge […]
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Institute for Healthcare Improvement. She's Got a Ticket To Go Home. http://www.ihi.org/resources/Pages/ImprovementStories/ShesGotaTicketToGoHome.aspx . Updated 2014. Accessed July 25, 2014. In March 2004, the staff at Virginia Mason Medical Center (VMMC) in Seattle, Washington, decided there was a better way to keep patients and families informed and engaged with the discharge planning. Most of the 23 patients in VMMC’s Acute Care for the Elderly (ACE) unit receive a “Ticket Home” in the form of a white laminated board that’s placed in front of each patient’s bed.
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http://www.ihi.org/resources/Pages/ImprovementStories/ShesGotaTicketToGoHome.aspx

August 8, 2019

Project RED (Re-Engineered Discharge)

Boston University Medical Center. Project RED (Re-Engineered Discharge). http://www.bu.edu/fammed/projectred/. Published 2007. Updated 2014. Accessed July 25, 2014. Project Re-Engineered Discharge is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization […]
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Boston University Medical Center. Project RED (Re-Engineered Discharge). http://www.bu.edu/fammed/projectred/. Published 2007. Updated 2014. Accessed July 25, 2014. Project Re-Engineered Discharge is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates. The RED (re-engineered discharge) intervention is founded on 12 discrete, mutually reinforcing components and has been proven to reduce rehospitalizations and yields high rates of patient satisfaction. Virtual patient advocates are currently being tested in conjunction with the RED. In addition, Project RED has started to implement the re-engineered discharge at other hospitals serving diverse patient populations. We are also looking at the transitional needs from inpatient to outpatient care of specific populations (i.e., those with depressive symptoms). Finally, we are about to start a patient-centered project to create a tool that hospitals can use to discover factors (i.e., medical legal, social, etc.) in patients' readmission
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http://www.bu.edu/fammed/projectred/

August 8, 2019

Interventions to Reduce Acute Care Transfers (INTERACT)

Florida Atlantic University. INTERACT. Interventions to Reduce Acute Care Transfers. Commonwealth Fund. http://interact2.net/. Updated February 7, 2011. Accessed July 25, 2014. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal […]
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Florida Atlantic University. INTERACT. Interventions to Reduce Acute Care Transfers. Commonwealth Fund. http://interact2.net/. Updated February 7, 2011. Accessed July 25, 2014. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.
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http://interact2.net/#

August 8, 2019

Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization.

West Virginia Medical Institute. Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization. http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf. Published January 2010. Accessed July 25, 2014. Why is the Home Health Quality Improvement (HHQI) National Campaign so Important? It is a grassroots, cross-setting, patient-centered movement with stakeholders, designed to improve […]
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West Virginia Medical Institute. Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization. http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf. Published January 2010. Accessed July 25, 2014. Why is the Home Health Quality Improvement (HHQI) National Campaign so Important? It is a grassroots, cross-setting, patient-centered movement with stakeholders, designed to improve the quality of care home health patients receive. A special project funded by Centers for Medicare & Medicaid Services (CMS).
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http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf

August 8, 2019

Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program

Society of Hospital Medicine. Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program. Http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx. Updated 2014. Accessed July 25, 2014. The BOOSTing (Better Outcomes by Optimizing Safe Transitions) Care Transitions implementation toolkit provides a wealth of materials to help you optimize the discharge process at your institution. The […]
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Society of Hospital Medicine. Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program. Http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx. Updated 2014. Accessed July 25, 2014. The BOOSTing (Better Outcomes by Optimizing Safe Transitions) Care Transitions implementation toolkit provides a wealth of materials to help you optimize the discharge process at your institution. The tools and approach are based on principles of quality improvement (QI), evidence-based medicine, as well as personal and institutional experiences. Originally, the BOOST Implementation toolkit was developed in 2008 through support from the John A. Hartford Foundation and has been continued to be revised and improved over the years. In 2014, SHM developed a revised 2nd edition of the guide that incorporated the latest literature on transitions of care as well as the experiences of lessons learned from the Project BOOST mentoring program's mentors (faculty experts) and participating BOOST hospitals (more than 180 in US and Canada). The Guide is laid out in a user-friendly, step by step method with explicit instructions and worksheets to help new sites engage with Project BOOST, build effective QI teams, and improve the care of their patients as they transition out of the hospital.
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http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx

August 8, 2019

The Care Transitions Program

Coleman E. The Care Transitions Program®. Http://www.caretransitions.org/ Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program® is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level […]
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Coleman E. The Care Transitions Program®. Http://www.caretransitions.org/ Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program® is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level interventions to improve quality and safety; develop performance measures and public reporting mechanisms; and influence health policy at the national leve
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http://www.caretransitions.org/

August 8, 2019

Integrating Care for Populations and Communities

Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers […]
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Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers for Medicare & Medicaid Services (CMS) looks to QIOs to implement community-based projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.
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http://www.cfmc.org/integratingcare/