Transitions between settings
A partnership between a health plan and psychiatric hospitals focuses on sharing of quarterly data, case reviews, and deployment of specific strategies to improve postdischarge care, leading to significant reductions in readmissions, inpatient days, and costs.
A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.
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.
A rapid admission protocol streamlines the process between the decision to admit an emergency department patient and the arrival of the patient on the inpatient unit by reassigning care responsibilities and reducing process steps, leading to reduced emergency department boarding time.
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.
In instances of institutional overcrowding, a protocol allows patients admitted to the hospital but boarded in the emergency department to be transferred to beds located in inpatient unit hallways, leading to expedited patient placement in a room, lower length of stay, and higher patient and staff satisfaction.
A medical center added outpatient palliative services, including symptom management and holistic emotional, psychosocial, and spiritual care, to its comprehensive inpatient palliative care services, leading to improved access and high levels of patient, family, and provider satisfaction.
A trained nurse educated other nurses, physicians, and administrators on evidence-based heart failure treatment and provided disease management education and followup support to high-risk patients, leading to fewer readmissions and lower costs.
An intensive, nurse-led care management program provided during and after hospitalization reduced readmissions, inpatient days, and care costs for high-risk seniors.
Langley Porter Psychiatric Hospital and Clinics used Toyota Production System principles to streamline the process by which patients are transferred to outpatient clinics, significantly reducing scheduling time, time to the patient's first appointment, and communication errors, and leading to a near doubling in the number of patient transfers.