Transitions between settings

A partnership between local jails and community health providers facilitates the provision of appropriate health care to inmates and ensures continued, coordinated care upon their release, leading to reductions in jail violence and deaths and enhanced access to care.

A hospital created a new nursing position, the clinical resource nurse, to ensure continuity of care, facilitate care planning, coordinate with physicians, encourage adherence to evidence-based practices, and mentor less experienced nurses, leading to more timely discharges, fewer falls and pressure ulcers, lower nurse turnover, and higher patient, nurse, and physician satisfaction.

An information exchange system enabled clinicians serving Medicaid beneficiaries to immediately access patient-specific hospital discharge, laboratory test, and medication data from other providers, leading to enhanced efficiency and safety and lower costs.

A comprehensive program consisting of standardized protocols, an interdisciplinary team, a specialized inpatient unit, education and training support, and community outreach improves inpatient care for the elderly.

A nurse practitioner–led service to bridge the gap in care for recently discharged patients awaiting a followup appointment did not reduce the rate of unplanned readmissions.

A children's hospital empowers families to directly activate its pediatric rapid response team in case of a suspected emergency situation, leading to a significant increase in calls to the team by family and staff.

By “nesting” a weekly gynecologic clinic into their HIV program, Christiana Care reduces barriers to screening and preventive care for female patients.

An interdisciplinary, hospital-based outpatient clinic staffed by geriatricians and other health professionals cares for seniors with one or more chronic health conditions, leading to improved outcomes and lower costs.

The Hospital of the University of Pennsylvania's Transitions in Care program bridges the gap between hospital discharge and outpatient followup care for patients who are obese and/or have diabetes, leading to improvements in physical health status.

The West Los Angeles Healthcare Center implemented a program to improve nurses' and patients' awareness and reporting of medication allergies and adverse drug reactions. Key program elements include a training module for nurses, educational brochures for patients, and distribution of an allergy/adverse drug reaction questionnaire to patients.