Transitions between settings


Statewide Managed Care Plan for Foster Care Children Features Care Coordination and a Central Database, Leading to Improved Access and Mental Health Treatment 10/31/14

Supported by a central data repository, a statewide managed care plan for children and young adults in foster care provides ongoing care coordination, linkages to community-based services, and psychotropic drug utilization reviews, leading to better care access, better followup after mental illness hospitalization, and less use of psychotropic drugs.

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.

Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies 03/17/14

After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.

Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes 12/20/13

With support from State funding, a community mental health center provides integrated mental health, primary care, care coordination, and wellness services to Medicaid beneficiaries with severe and persistent mental illness, leading to better chronic disease outcomes.

Foundation Develops Community-Based HIV Testing and Partnerships With Medical Homes, Leading to More Timely Linkages to Care for Newly Diagnosed Patients 11/25/13

A local foundation developed community-based testing programs and partnerships with medical homes to provide real-time linkages to HIV care to newly diagnosed patients and to support these patients in transitioning to care, nearly doubling the number of patients initiating treatment.

Comprehensive Program To Improve Discharge Process Reduces Readmissions 11/01/13

Project BOOST (Better Outcomes by Optimizing Safe Transitions) provides hospitals a comprehensive set of interventions to improve the care transition process after discharge, leading to a significant reduction in readmissions.

Hospital Uses Data Analytics and Predictive Modeling To Identify and Allocate Scarce Resources to High-Risk Patients, Leading to Fewer Readmissions 08/13/13

A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.

Hospital–Retail Pharmacy Partnership Provides Inhospital and Postdischarge Support to At-Risk Patients, Leading to Fewer Readmissions and High Patient Satisfaction 05/22/13

A partnership between a hospital and retail pharmacy company provides inhospital and postdischarge support to patients at high risk of readmission, leading to fewer readmissions and high levels of patient satisfaction.

Short-Term Housing and Care for Homeless Individuals After Discharge Leads to Improvements in Medical and Housing Status, Fewer Emergency Department Visits, and Significant Cost Savings 03/13/13

A recuperative care program provides homeless clients with housing, food, medical care, case management, and connections to social services after hospital discharge, resulting in improvements in their medical and housing status, fewer emergency department visits, and meaningful cost savings for participating hospitals.


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