Avoidable hospitalizations

Innovations

Nurse Home Visitation Program Reduces Readmissions, Emergency Department Visits, Child Abuse, and Foster Home Placements for Medically Fragile Infants 02/25/08

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.

Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs 02/14/08

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.

Peer Coaching Combined With Nurse Outreach Improves Adherence to Medical Recommendations Among Elderly Cardiac Patients Who Live Alone Following Discharge 02/12/08

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℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients 01/30/08

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.

Public Health-Led Disease Management Programs Improve Outcomes for Individuals With Diabetes and Children With Asthma 01/25/08

A county health department implemented disease management programs for uninsured and underinsured, low-income diabetes, asthma, and heart failure patients, leading to improved outcomes.

Standardized Discharge Planning Focusing on Patient Education and Care Coordination Increases Understanding of Postdischarge Needs and Likelihood of Followup Care 01/25/08

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.

Health Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients 01/17/08

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.

Palliative Care Nurses in Primary Care Clinics Reduce Hospital Admissions, Increase Use of Hospice and Home Care for Patients Nearing End of Life 01/15/08

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.

Periodic Home Visits, Specialist Visits, and Followup Enhances Access and Improves Outcomes for Low-Income Children With Asthma 01/15/08

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.

Electronic Health Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses 01/08/08

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.

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