Transitions between settings
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.