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