Discharge planning

Innovations

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.

Hospital Gain-Sharing Program Offers Incentives to Physicians Based on Their Efficiency, Producing Significant Cost Savings Without Decline in Quality 03/17/14

A group of 12 New Jersey hospitals offered upside incentives to individual physicians based on their performance on various efficiency metrics, leading to significant cost savings without negatively affecting quality of care.

Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies 03/17/14

After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital 01/14/14

Massachusetts banned ambulance diversions and helped hospitals respond to the ban by improving patient flow, leading to reductions in emergency department length of stay for admitted patients, shorter turnaround times for ambulances, and strong support from emergency department leaders who believe the ban has yielded multiple benefits.

Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes 12/20/13

With support from State funding, a community mental health center provides integrated mental health, primary care, care coordination, and wellness services to Medicaid beneficiaries with severe and persistent mental illness, leading to better chronic disease outcomes.

Comprehensive Program To Improve Discharge Process Reduces Readmissions 11/01/13

Project BOOST (Better Outcomes by Optimizing Safe Transitions) provides hospitals a comprehensive set of interventions to improve the care transition process after discharge, leading to a significant reduction in readmissions.

Hospital Uses Data Analytics and Predictive Modeling To Identify and Allocate Scarce Resources to High-Risk Patients, Leading to Fewer Readmissions 08/13/13

A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.

Voluntary Citywide Initiative To Support Mothers Who Choose To Breastfeed Attracts Many Hospitals, Wins Support of Medical Community 05/23/13

A city health department encourages public and private maternity hospitals to voluntarily adopt various policies to support new mothers who choose to breastfeed exclusively. The program has attracted many participating hospitals, won broad support within the medical community, and increased the proportion of new mothers who breastfeed exclusively during their hospital stay.

Hospital–Retail Pharmacy Partnership Provides Inhospital and Postdischarge Support to At-Risk Patients, Leading to Fewer Readmissions and High Patient Satisfaction 05/22/13

A partnership between a hospital and retail pharmacy company provides inhospital and postdischarge support to patients at high risk of readmission, leading to fewer readmissions and high levels of patient satisfaction.

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