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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.

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

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

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/

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/

August 8, 2019

Institute for Healthcare Improvement

The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for […]
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The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.
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http://www.ihi.org

August 7, 2019

Care Continuum Alliance

We believe the highest achievable health status is attained through the promotion and alignment of population health improvement by: • Promoting a proactive, patient-centric focus across the care continuum; • Convening health care professionals across the care continuum to share and integrate practice models; • Emphasizing the importance of both […]
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We believe the highest achievable health status is attained through the promotion and alignment of population health improvement by: • Promoting a proactive, patient-centric focus across the care continuum; • Convening health care professionals across the care continuum to share and integrate practice models; • Emphasizing the importance of both healthful behaviors and evidence-based care in preventing and managing chronic conditions; • Promoting high quality standards for and definitions of key components of wellness, disease and, where appropriate, case management, and care coordination programs as well as support services and materials; • Identifying, researching, sharing and encouraging innovative approaches and best practices care delivery and reimbursement models; • Establishing consensus-based outcomes measures and demonstrating health, satisfaction, and financial improvements achieved through wellness, disease and case management, and care coordination programs; • Supporting delivery system models that assure appropriate care for chronic conditions and coordination among all health care providers including strategies such as the Chronic Care Model, the physician-led medical home concept, and the disease management model; • Encouraging the widespread adoption and interoperability of health information technologies; • Advocating the principles and benefits of population health improvement to public health officials, including state and federal government entities; • Underscoring the level of commitment to population health improvement and timeframes necessary to realize the full benefits.
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http://www.carecontinuum.org/

August 7, 2019

Medicare Health Support

Section 721 of the Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary chronic care improvement programs, now called Medicare Health Support, to improve the quality of care and life for people living with multiple chronic illnesses. Chronic conditions are a leading cause of illness, disability, and […]
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Section 721 of the Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary chronic care improvement programs, now called Medicare Health Support, to improve the quality of care and life for people living with multiple chronic illnesses. Chronic conditions are a leading cause of illness, disability, and death among Medicare beneficiaries and account for a disproportionate share of health care expenditures. About 14 percent of Medicare beneficiaries have heart failure, but they account for 43 percent of Medicare spending. About 18 percent of Medicare beneficiaries have diabetes, yet they account for 32 percent of Medicare spending. The initiative assessed whether the benefits of better managing and coordinating the care of these beneficiaries would result in reduced health risks, an improved quality of life, and savings to the Medicare program and the beneficiaries. The programs were overseen by the Centers of Medicare and Medicaid Services (CMS) and operated by health care organizations chosen through a competitive selection process. Phase I program operations began between August 2005 and January 2006. Phase I ended on August 31, 2008 and CMS is assessing the results of this program.
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http://www.cms.gov/CCIP/

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