Avoidable hospitalizations

Innovations

Enhanced Home Health Program Provides Remote Monitoring and Services, Leading to Fewer Hospitalizations and Increased Nurse Productivity 08/16/08

A home health program enhances services to congestive heart failure and other chronically ill patients by supplementing at-home visits with ongoing remote monitoring and services.

Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits 08/08/08

Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.

Comprehensive Heart Failure Program Enhances Adherence to Recommended Care and Reduces Hospital Readmissions 07/25/08

Baystate Medical Center's comprehensive heart failure management program incorporates tools and processes that ensure the provision of all necessary components of care, leading to increased adherence to recommended care and reduced heart failure readmission rates.

Transition Home Program Reduces Readmissions for Heart Failure Patients 07/23/08

The Transition Home for Patients with Heart Failure program incorporates a number of components to ensure patients a safe transition to home or another health care setting, leading to fewer readmissions.

Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays 07/04/08

Summa Health System's Care Coordination Network strives to ensure smooth transitions between the hospitals and 40 local skilled nursing facilities, leading to fewer readmissions and lower length of stay in the hospital.

Formalized Communication Between Rural Home Health Agency Nurses and Physicians Leads to Increased Use of Home Health Services, Fewer Inpatient Admissions 04/28/08

A rural home health agency formalized oral and written communication processes with physicians, using specific communication tools to ensure that ongoing patient needs are being met; the program led to an increase in the use of home health services and a concomitant decline in inpatient admissions among home health patients.

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors 04/25/08

As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.

Integrating Behavioral Health and Nutrition Services Into Primary Care Clinics Significantly Reduces Mental Health-Related Hospitalizations for Staff-Model Health Maintenance Organization 03/28/08

A health maintenance organization integrated mental and behavioral health care and nutrition services with primary care delivery, leading to a more than 50-percent reduction in mental health–related hospitalizations.

Enhancements to Interpreter Program Lead to Better Productivity for Interpreters, More Depression Screening, and Potential Reduction in Readmissions for Non–English-Speaking Patients 03/24/08

Cambridge Health Alliance enhanced its round-the-clock interpreter services by tracking key indicators that gauge the quality of these services; analyses of these data led to significant improvements in the program's telephone-based services and staff efficiency and the decision to implement depression screening in patients with limited English proficiency.

Disease Management Programs Improve Adherence to Evidence-Based Processes and Outcomes by Targeting Sickest Patients and Working Closely With Physicians 03/14/08

A hospital-based outpatient disease management program serves patients with asthma, chronic heart failure, and diabetes and offers smoking cessation services to smokers. Unlike traditional disease management programs, this initiative heavily involves physicians in the initial referral and throughout the process and targets services toward the sickest patients (rather than to all patients with the condition).

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