Avoidable hospitalizations


Standardized Processes and Tools Significantly Enhance Provision of Recommended Care to Teens With Asthma 01/24/11

Teen Health Center providers use standardized processes and tools to enhance the provision of recommended care to teens with asthma.

Health Plan and Psychiatric Hospitals Reduce Readmissions by Reviewing Data and Developing Strategies to Improve Postdischarge Care 01/13/11

A partnership between a health plan and psychiatric hospitals focuses on sharing of quarterly data, case reviews, and deployment of specific strategies to improve postdischarge care, leading to significant reductions in readmissions, inpatient days, and costs.

Transitional Care Program With Advance Care Planning for Frail Elders Reduces Emergency Department Visits and Readmissions 11/29/10

A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.

Person-Centered Care for Residents with Dementia Exhibiting Aggressive Behavior Reduces Psychiatric Hospitalizations and Behavior-Related Medications 11/15/10

A dementia care facility takes a person-centered approach to caring for residents who exhibit challenging, aggressive behavior, leading to less need for psychiatric hospitalizations and behavior-related medications.

Telephone-Based Coaching on Shared Decisionmaking, Behavioral Change, and Health System Navigation Reduces Utilization and Cost 10/27/10

Health coaches work with at-risk individuals over the phone to develop skills and plans to participate effectively in shared clinical decisionmaking with physicians, self-manage their conditions, and navigate the health system, leading to reduced hospital admissions and medical costs when offered to a larger portion of the population.

Care Coordinators Remotely Monitor Chronically Ill Veterans via Messaging Device, Leading to Lower Inpatient Utilization and Costs 10/25/10

Care coordinators remotely monitor veterans with chronic medical conditions via home telehealth devices, leading to reductions in hospital admissions, bed days, and care costs and to high levels of patient satisfaction.

Pharmacist Provides Telephone-Based Medication Reconciliation and Education to Recently Discharged Patients, Leading to Fewer Readmissions 09/07/10

Health system pharmacists telephone recently discharged patients to complete medication reconciliation and provide medication-related education, leading to significant reductions in readmission rates and high levels of patient satisfaction.

Care Coordinators Support Individuals With Severe Mental Illness, Leading to Improved Quality of Life and Lower Costs 08/10/10

The seven-county New York Care Coordination Program offers comprehensive care coordination for individuals with severe mental illness through assessment, individualized goal setting, and access to social programs, leading to improved quality of life and coping skills, fewer emergency department visits and inpatient days, and lower costs.

Health Plan Uses Nurse Practitioners to Improve Outcomes for Seniors With Diabetes, Congestive Heart Failure, Hypertension, and Wounds 07/13/10

Supported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners run disease-specific clinics in which they educate patients about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease; the program has led to significant improvements in outcomes across targeted diseases/conditions.

Health Navigators Support Self-Management With Primary Care Patients, Leading to Improved Behaviors and Lower Utilization 07/13/10

Health navigators help primary care patients access medical and community resources, leading to significant improvements in health-related and self-management behaviors and health outcomes and to meaningful declines in emergency department and inpatient utilization.


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