Transitions between settings

Innovations

Coordinated, Intensive Medical, Social, and Behavioral Health Services Improve Outcomes and Reduce Utilization for Frequent Emergency Department Users 03/04/13

Intensive, concurrent medical and behavioral health care, addiction services, and social service coordination improve patient outcomes and reduce health system use among patients who historically have been frequent users of emergency departments.

Statewide Health Information Exchange Generates High Levels of Participation and Many Reports of Improved Quality and Efficiency 02/26/13

The nation's first statewide health information exchange, the Delaware Health Information Network gives clinicians immediate access to patient-specific health data from other providers, leading to higher quality and more efficient care.

Nurse Case Managers Offer Low-Resource Transitional Care Services, Reducing Readmissions for At-Risk, Community-Dwelling Veterans in Remote Areas 01/25/13

Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.

Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes 12/06/12

A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.

Clinics and Hospitals Use Trained, Certified Community Members To Screen and Support Primary Care and Postdischarge Patients, Reducing Physician Visits and Costs 07/24/12

Specially trained and certified lay workers known as “Grand-Aides” use illness-specific protocols to ensure that patients receive appropriate treatment in primary care settings and to ease the transition from hospital to home after discharge. The primary care-based program has reduced unnecessary visits and demonstrated the potential to reduce costs. Early data from one hospital program show significant reductions in readmissions.

Managed Care Organization and Visiting Nurse Association Offer Standardized Education to Elderly Heart Failure Patients, Improving Self-Management and Reducing Readmissions 07/03/12

Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.

System-Integrated Program Coordinates Care for People With Advanced Illness, Leading to Greater Use of Hospice Services, Lower Utilization and Costs, and High Satisfaction 12/20/11

The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.

Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs 11/29/11

A partnership between a large health system and 512 churches supports the transition from the hospital back into the community, leading to lower mortality, health care utilization, and health care costs and to higher satisfaction with hospital care.

Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths 11/11/11

Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.

Patient Videos That Describe Care Experiences Spur Development of Many Successful Quality Improvement Initiatives 07/18/11

As part of Kaiser Permanente's Care Management Institute's video ethnography approach, provider teams interview patients about their care experiences, leading to the development of many quality improvement projects that have resulted in better care processes and outcomes.

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