Transitions between settings

Innovations

Onsite Nurses Manage Care Across Settings to Increase Satisfaction and Reduce Cost for Chronically Ill Seniors 01/21/08

Specially trained nurses work with primary care physicians in their offices to improve the quality and efficiency of care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings.

Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients 01/16/08

An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.

Palliative Care Nurses in Primary Care Clinics Reduce Hospital Admissions, Increase Use of Hospice and Home Care for Patients Nearing End of Life 01/15/08

A partnership between a hospice organization and an 11-location multispecialty group practice places palliative care nurses in primary care clinics to monitor dying patients' medical and social care needs, coordinate community services, and discuss end-of-life issues.

24-Hour Mobile Mental Health Crisis Team Reduces Hospitalization for Children with Complex Behavioral and Emotional Needs 01/04/08

A rapid response team defuses crisis situations for children with complex behavioral needs.

Teamwork Enhancement Program Improves Obstetric Care in a Military Hospital 12/27/07

An evidence-based teamwork and communication program implemented in the labor and delivery unit of Madigan Army Medical Center led to an improved care process.

Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System 12/20/07

The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.

Bilingual, Culturally Competent Managers Enhance Access to Prenatal Care for Migrant Women, Leading to Potential for Improved Birth Outcomes 12/17/07

The Migrant Clinicians Network Prenatal Care Program seeks to ensure continuity of care for expectant mothers who begin prenatal care in one location and move for employment purposes during their pregnancy. Bilingual, culturally competent staff link migrant patients with prenatal services and manage their medical records throughout the pregnancy.

Comprehensive, Integrated Palliative Care Reduces Costs and Improves Satisfaction Among Patients and Their Families Within a Large Health System 12/05/07

Fairview Health Services' palliative care program offers palliative care clinical and support services to inpatients, outpatients, and home care patients to mitigate suffering and improve quality of life; the program is integrated into the care process to facilitate referrals and care coordination.

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