Bridge to the Future provides nursing home visits to low-income families with medically fragile infants who have been discharged from the neonatal intensive care unit, thus ensuring a smooth transition to long-term care in the home.
Transitions coaches encourage recently hospitalized Medicare patients with complex care needs to assert a more active role in their posthospital care, leading to fewer readmissions and lower costs.
A nurse-guided, patient-centered approach combines ongoing peer support from a trained elder with home visits and followup phone calls from an advanced practice nurse for unpartnered, elderly patients who are discharged from the hospital after a heart attack or bypass surgery. The program is intended to encourage compliance with medication regimens and recommended lifestyle changes, with the goal of reducing hospital readmissions. A 247-patient randomized controlled trial found that the program improved adherence to medical recommendations and reduced hospitalizations due to cardiac-related complications but failed to reduce overall hospital readmissions.
Hospital at Home sm provides hospital-level care in a patient's home as a full substitute for acute hospital care for selected conditions common among seniors.
A county health department implemented disease management programs for uninsured and underinsured, low-income diabetes, asthma, and heart failure patients, leading to improved outcomes.
The Re-Engineered Discharge project at Boston Medical Center standardizes the hospital discharge process through use of 11 separate but mutually reinforcing steps that health care professionals follow from patient admission to postdischarge.
Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs over the phone, during office visits, and in group classes; the program reduced readmission rates and costs among elderly patients.
A partnership between a hospice organization and an 11-location multispecialty group practice places palliative care nurses in primary care clinics to monitor dying patients' medical and social care needs, coordinate community services, and discuss end-of-life issues.
A pediatric asthma management program led to a significant decline in the percentage of patients with moderate to severe asthma, improved quality of life, and sizable decreases in hospitalizations and costs.
The Marshfield Clinic is using electronic tools to facilitate care process redesign for patients with chronic illnesses, leading to enhanced quality and access to care, fewer hospitalizations and adverse events, and lower costs.