Physician Specialist

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 14, 2019

The geriatric floating interdisciplinary transition team

J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality […]
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J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02682.x/abstract

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

Guided Care: Care for the Whole Person, For Those Who Need It Most

Guided Care® is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality of life and make more efficient use of […]
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Guided Care® is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality of life and make more efficient use of health services. The nurse assesses patient needs, monitors conditions, educates and empowers the patient, and works with community agencies to ensure that the patient’s healthcare goals are met. In a pilot study, patients who received Guided Care rated their quality of care significantly higher than usual care patients. The average insurance costs for Guided Care patients were 25% lower over a six month period. The program is currently being tested at eight primary care sites in the Baltimore-Washington D.C. area in a randomized trial involving over 900 patients, 300 caregivers, and 48 primary care physicians. Click here for a summary of pilot outcomes and preliminary data from the trial. Guided Care is the winner of the American Public Health Association's 2008 Archstone Foundation Award for Excellence in Program Innovation, which recognizes a innovative care model for older Americans each year. Guided Care also won the 2009 Medical Economics Award for Innovation in Practice Improvement cosponsored by the American Academy of Family Physicians, the Society of Teachers of Family Medicine, and Medical Economics magazine. Guided Care was a finalist for the British Medical Journal's 2010 Getting Research into Practice Award. The Guided Care Program at Kaiser Permanente Mid-Atlantic States won the 2010 Case In Point Platinum Award for Case Management Provider Program.
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http://www.guidedcare.org/

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

Transitional Care Model

Transitional Care Model. Penn Nursing Science. Web Site. http://www.transitionalcare.info/home .2013. Accessed July 24, 2014. More than 10 million Medicare beneficiaries, approximately 20% of older Americans, are living with five or more chronic conditions. Effective care management of this population is often complicated by several other health and social risk factors. […]
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Transitional Care Model. Penn Nursing Science. Web Site. http://www.transitionalcare.info/home .2013. Accessed July 24, 2014. More than 10 million Medicare beneficiaries, approximately 20% of older Americans, are living with five or more chronic conditions. Effective care management of this population is often complicated by several other health and social risk factors. Unfortunately, multiple studies reveal that the health care needs of older adults are poorly managed, often with devastating human and economic consequences. The Transitional Care Model (TCM) is an evidence-based solution to these challenges. The TCM has consistently demonstrated improved quality and cost outcomes for high-risk, cognitively intact and impaired older adults when compared to standard care in: reductions in preventable hospital readmissions for both primary and co-existing health conditions; improvements in health outcomes; enhanced patient experience with care; and a reduction in total health care costs
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http://www.transitionalcare.info/