Transitions between settings

Innovations

Community Health Center-Jail Partnerships Improve Care During and After Incarceration, Reduce Jail-Based Violence and Deaths and Enhance Access to Community-Based Care 09/08/09

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.

Creation of Unit-Based, Clinically Focused Nurse Leader Position Expedites Discharge, Improves Quality, and Reduces Turnover 07/14/09

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.

Instant Access to Clinical Information From Other Providers Leads to Reports of Higher Quality and Lower Costs for Medicaid Beneficiaries 06/30/09

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.

Comprehensive Program Including Specialized Inpatient Unit, Standardized Protocols, and Interdisciplinary Team Improves Care Quality for Geriatric Patients 05/18/09

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.

Nurse Practitioner–Led Transitional Care Program Does Not Reduce Readmissions During Period Between Discharge and Followup Appointment 01/16/09

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.

Family-Activated Pediatric Rapid Response Team Increases Calls From Both Families and Staff, Supports Improvements in Outcomes 12/23/08

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.

Co-Locating Gynecologic Services Within an HIV Clinic Increases Cervical Cancer Screening Rates, Leading to Identification and Treatment of Many Cancer Cases 11/19/08

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

Interdisciplinary Clinic Using Team-Based Approach Improves Outcomes and Reduces Costs for Frail, Vulnerable Elderly 11/17/08

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.

Inpatient Education and Counseling and Postdischarge Followup Lead to Improved Health for Patients With Diabetes and/or Obesity 10/01/08

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.

Increasing Patient Health Literacy Leads to Improved Reporting of Medication Allergies 09/24/08

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.

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