Transitions between settings
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.
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 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.
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.
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.
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.
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.
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 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.
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.