Transitions between settings
Working as part of an “intensive care unit without walls,” critical care physicians (called intensivists) decide which patients require intensive care unit admission and oversee the care of all critically ill patients throughout the hospital, leading to declines in hospital and intensive care unit mortality, improved management of intensive care unit bed capacity, and low intensive care unit length of stay for terminally ill patients.
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.
Community-based clinic enhances access to medical care and reduces emergency department visits for chronically ill individuals who have recently been released from prison.
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 hospital links HIV-positive prisoners to medical care and other social services before and after release to enable successful reentry into the community, leading to enhanced access to these services and less recidivism.
A collaborative medication review process involving physicians, nurses, and pharmacists virtually eliminates medication errors and significantly reduces readmissions in patients discharged to a nursing home.
Community-based physicians send an electronic handoff note with pertinent information to Northwestern Memorial Hospital's emergency department personnel when referring patients for emergency care, leading to improvements in physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.
Culturally competent community liaisons help members of the Orthodox Jewish, Arab, and Chinese communities access health care and community-based services, leading to a better patient experience.