Transitions between settings

Innovations

Transition "Tickets" Reduce Adverse Events During Patient Transports 09/19/08

An intrahospital transport program, known as Ticket to Ride, standardizes the inpatient transport process by ensuring that critical information accompanies the patient at all times, leading to fewer off-unit adverse events.

Postdischarge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs 09/11/08

A chronic care coordination program employs coordinators to provide telephone-based support to recently discharged patients and other high-risk enrollees, leading to fewer hospitalizations and emergency department visits and lower costs.

Discharge Education Program Increases Patient Understanding of Treatment and Followup Care 09/09/08

The Patient Safe-D(ischarge) program uses standardized tools to educate patients about their discharge needs, assess their understanding of those needs, and improve medication reconciliation at admission and discharge.

Parent Consultants Help Families Who Have Children With Special Needs Access Needed Services, Leading to Lower Health Care Utilization and Costs 09/04/08

The Pediatric Practice Enhancement Project places parent consultants in primary care practices to help families with special needs children navigate the health care system and access community-based psychosocial and financial services.

Cardiac Unit Features Acuity-Adjustable Rooms and Other Patient-Centered Programs, Leading to Well-Above Average Outcomes and Patient Satisfaction 09/02/08

A cardiothoracic care unit uses a multifaceted approach to patient- and family-centered care, leading to a well-above-average performance with respect to patient outcomes and satisfaction.

Advocacy Firm Assists Patients in Choosing Providers/Treatments and Coordinating Care, Leading to Quick Access to Services and High Satisfaction 08/26/08

PinnacleCare provides individualized care management services that include an initial health assessment, an annual health plan/consultation, round-the-clock access to medical advocates and advisers, facilitated access to top specialists and medical institutions, and management of electronic medical records.

Redesign of Telemetry Unit Admission and Transfer Criteria Leads to Improved Patient Flow and Reduced Emergency Department Waiting Times 08/08/08

Grady Memorial Hospital created the Telemetry Urgent Matters Initiative to improve patient flow by redesigning the telemetry unit discharge criteria to ensure appropriate use of monitored beds.

Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits 08/08/08

Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.

Comprehensive Heart Failure Program Enhances Adherence to Recommended Care and Reduces Hospital Readmissions 07/25/08

Baystate Medical Center's comprehensive heart failure management program incorporates tools and processes that ensure the provision of all necessary components of care, leading to increased adherence to recommended care and reduced heart failure readmission rates.

Transition Home Program Reduces Readmissions for Heart Failure Patients 07/23/08

The Transition Home for Patients with Heart Failure program incorporates a number of components to ensure patients a safe transition to home or another health care setting, leading to fewer readmissions.

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