Transitions between settings

Innovations

Education and Reminder Card for Those on Multiple Medications Enhances Patient Understanding, But Not Satisfaction or Safety 07/18/08

The Mayo Clinic Department of Medicine developed a computer-generated, customized medication education and reminder card for patients discharged on multiple medications; the card was tested as an alternative to the medication discharge worksheet commonly used by nurses at Mayo.

Posting Expected Discharge Date Facilitates Communication, Leads to On-Time Patient Departures and High Levels of Satisfaction 07/10/08

The Mayo Clinic's Department of Medicine establishes and posts estimated discharge dates and times in patients' rooms to facilitate ongoing communication about discharge-related issues between patients/families, physicians, and nurses.

Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays 07/04/08

Summa Health System's Care Coordination Network strives to ensure smooth transitions between the hospitals and 40 local skilled nursing facilities, leading to fewer readmissions and lower length of stay in the hospital.

Michigan Pathways Project Links Ex-Prisoners to Medical Services, Contributing to a Decline in Recidivism 06/23/08

The Michigan Prisoner Reentry Initiative, in partnership with the Muskegon Community Health Project, helps newly released or paroled prisoners access needed health care, contributing to a decline in recidivism.

Low-Tech Medication Reconciliation Process Emphasizing Standardized, Easy-to-Execute Roles Significantly Reduces Rate of Unreconciled Medications 05/13/08

Contra Costa Health Services launched a medication reconciliation process at its county-owned hospital based on Institute for Healthcare Improvement concepts for redesigning work to achieve a high degree of reliability. The institution uses a process in which providers, pharmacy, and nursing staff have standardized, easy-to-understand, and easy-to-execute roles related to medication reconciliation.

Interim Methadone Maintenance Program Reduces Heroin Use and Increases Treatment Entry Rates for Addicts Awaiting Comprehensive Services 05/02/08

Operating within U.S. Federal regulations, the Baltimore Interim Methadone Maintenance program provides interim care (in the form of daily methadone with emergency counseling) to heroin addicts awaiting placement for comprehensive methadone treatment programs.

Formalized Communication Between Rural Home Health Agency Nurses and Physicians Leads to Increased Use of Home Health Services, Fewer Inpatient Admissions 04/28/08

A rural home health agency formalized oral and written communication processes with physicians, using specific communication tools to ensure that ongoing patient needs are being met; the program led to an increase in the use of home health services and a concomitant decline in inpatient admissions among home health patients.

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors 04/25/08

As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.

Hospital-Based Program Proactively Identifies, Addresses Delirium Risk Factors in Elderly, Leading to Less Cognitive/Functional Decline and Lower Nursing Home Costs 04/22/08

The Hospital Elder Life Program screens all patients aged 70 years and older at admission for the presence of six risk factors for delirium, and then implements targeted interventions to reduce these risks, leading to less cognitive and functional decline and lower costs.

Reconciliation of Patient and Provider Medication Lists Reduces Discrepancies and Enhances Medication Safety in Physician Clinics 04/02/08

Reconciling patient and provider medication lists reduces discrepancies, leading to enhanced medication safety and high levels of patient and provider satisfaction in the outpatient setting.

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