Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.
A rehabilitation center's recuperative services unit uses a three-part protocol consisting of standardized assessments, palliative care consults and care plans, and root-cause analysis to reduce readmissions and improve staff morale.
A collaborative telemedicine program between a hospital and 10 nursing homes in rural communities prevents unnecessary transports of residents to the emergency department.
A Native American tribe–owned skilled nursing facility provides culturally competent services using a holistic approach to health and well-being, leading to high patient and family member satisfaction and low staff turnover.
Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, leading to a significant reduction in readmissions and associated cost savings.
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.
An inpatient psychiatric unit holds regular 30-minute “community” meetings focused on violence prevention, with all on-duty unit staff and patients attending; the meetings—which serve as a forum for expressing concerns, reviewing recent episodes, and brainstorming prevention strategies—reduced violent episodes by 85 percent.
Liberty Country Living, a long-term care facility for people with dementia, offered nurse-managed care in a home-like setting, with a focus on supporting residents' capabilities. The facility had a high ratio of staff to residents and promoted social interaction, ambulation, and continence. The program helped residents stay ambulatory, maintain continence, avoid weight loss, avoid falls and disruptive behaviors, and reduce psychotropic medication use. After 5 years of operation, Liberty closed abruptly due to changes in State regulations.
A Medicare Advantage plan uses employed “extensivists” who perform traditional hospitalist functions for a smaller-than-average caseload of patients, and then continue to follow and care for these patients after discharge until their condition becomes stabilized, leading to low length of stay and fewer readmissions.
A three-agency partnership provides a one-stop resource for community-dwelling older adults to learn about and access available resources to help them remain independent, and proactively reaches out to these individuals to assess needs and connect them to services. The program has enhanced access to services and allowed the vast majority of nursing home–eligible individuals to improve or maintain the ability to remain in their home.